Common Fibular Nerve Lesion Following a Tibial and Fibular Spiral Fracture: a Case Report
Common Fibular Nerve Lesion Following a Tibial and Fibular Spiral Fracture: a Case Report
By: Jose Shimokawa SPT
Introduction
Tibial fractures are the most common long bone fractures and frequently associated with fibular fractures—in part, due to forces being transmitted across the interosseous membrane to the fibula.1 Fractures are generally managed by closed reduction or open reduction internal fixation (ORIF), 2 which is usually followed by a period of immobilization. The most common impairments associated with this type of injury include impaired muscle strength and limitations in joint range of motion (ROM).3
Impairments in strength can be addressed with therapeutic exercises, while joint mobilizations and ROM activities are used to restore joint mobility. However, this type of fractures can be aggravated by disruption of the soft tissues such as nerve and muscle injuries, all of which may slow the progress of recovery.3, 4, 5
Peripheral nerve injury, particularly the common fibular nerve is predisposed to injury caused by fractures of the tibia or fibula, especially at the proximal fibular region, where the common fibular nerve winds around to cross the fibular neck.5 If the nerve is damage, the potential for recovery is possible as long as the nerve cell body remains viable; new axons can sprout from the proximal end of damaged axons. However, successful functional regeneration requires that the proximal and distal ends of the connective tissue tube are aligned.6 Peripheral nerve regeneration occurs at a rate of 1mm/d, so patients with peripheral nerve injury may demonstrate functional limitations that persist for long periods of time.7
In the case of muscle injury, they are more common with tibial shaft fracture, particularly in muscles that originate near or pass by a fracture site. As the tissues heal, adhesions may form and depending on the severity could interfere with the muscle gliding, shortening, and force transmission, particularly in
By: Jose Shimokawa SPT
Introduction
Tibial fractures are the most common long bone fractures and frequently associated with fibular fractures—in part, due to forces being transmitted across the interosseous membrane to the fibula.1 Fractures are generally managed by closed reduction or open reduction internal fixation (ORIF), 2 which is usually followed by a period of immobilization. The most common impairments associated with this type of injury include impaired muscle strength and limitations in joint range of motion (ROM).3
Impairments in strength can be addressed with therapeutic exercises, while joint mobilizations and ROM activities are used to restore joint mobility. However, this type of fractures can be aggravated by disruption of the soft tissues such as nerve and muscle injuries, all of which may slow the progress of recovery.3, 4, 5
Peripheral nerve injury, particularly the common fibular nerve is predisposed to injury caused by fractures of the tibia or fibula, especially at the proximal fibular region, where the common fibular nerve winds around to cross the fibular neck.5 If the nerve is damage, the potential for recovery is possible as long as the nerve cell body remains viable; new axons can sprout from the proximal end of damaged axons. However, successful functional regeneration requires that the proximal and distal ends of the connective tissue tube are aligned.6 Peripheral nerve regeneration occurs at a rate of 1mm/d, so patients with peripheral nerve injury may demonstrate functional limitations that persist for long periods of time.7
In the case of muscle injury, they are more common with tibial shaft fracture, particularly in muscles that originate near or pass by a fracture site. As the tissues heal, adhesions may form and depending on the severity could interfere with the muscle gliding, shortening, and force transmission, particularly in
References: 1. Norvell JG. Tibia and Fibular Fracture. Medscape Reference [online]. 2011. Available at: http://emedicine.medscape.com/article/826304-overview#showall. Accessed on July 1, 2012. 2. Poduval M. Diaphyseal Tibial Fractures. Medscape Reference [online]. 2010. Available at: http://emedicine.medscape.com/article/1248857-overview. Accessed on July 1,2012. 3. Gupta S. Traumatic anterior knee dislocation and tibial shaft fracture: a case report. J Orthop Surg. 2007; 15(1):81-3. 4. Hey, HWG. Deep Peroneal Nerve Entrapment by Spiral Fibular Fracture: A Case Report. J Bone Joint Surg Am. 2011; e113(1) 5 6. Goodman CC, Fuller KS. The Peripheral Nervous System. Pathology: implications for the physical therapist. 3rd ed. St. Louis, Mo.: Saunders/Elsevier, 2009. 7. Ehni BL. Treatment of traumatic peripheral nerve injury. Am Fam Physician. 1991;43:897-905. 8. Alba CD, LaStayo P. Postoperative management of functionally restrictive muscular adherence, a corollary to surgical tenolysis: a case report. J Hand Ther. 2001;14:43-50. 9. Drake RL, et al. Gray’s Anatomy for Students. 2nd ed. Philadelphia, PA.: Elsevier, 2010 10 11. Boone DC, et al. Reliability of goniometric measurements. Phys Ther. 1978;58:1355-1390. 12. Bolgla LA, et al. Vastus Medialis Activation During Knee Extension Exercises: Evidence for Exercise Prescription. J Sport Rehabil. 2008, 16, 1-10. 13. Bjordal JM, et al. Transcutaneous electrical nerve stimulation (TENS) can reduce postoperative analgesic consumption. A meta-analysis with assessment of optimal treatment parameters for postoperative pain. Eur J Pain, 2003. 7(2): p. 181-8. 15. Malone T, et al. Knee Rehabilitation. Phys Ther. 1980; 60:1602-1610. 16. Algalfy AA, George KP. The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. Br J Sports Med. 2007; 41:365-369 17