Compression neuropathy of the common peroneal nerve caused by an intraosseous ganglion cyst of fibula

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InternationalJournalofSurgeryCaseReports40(2017)10–12

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International

Journal

of

Surgery

Case

Reports

jo u r n al ho me p a g e :w w w . c a s e r e p o r t s . c o m

Compression

neuropathy

of

the

common

peroneal

nerve

caused

by

an

intraosseous

ganglion

cyst

of

fibula

Adnan

Kara

_,

_Sercan

_Yalc¸

_ın

_,

_Haluk

_C¸

_elik

_,

_Ersin

_Kuyucu

_,

_Ali

_S¸

_eker

a_{˙IstanbulMedipolUniversity,Dept.ofOrthopaedicsandTraumatology, ˙Istanbul,Turkey} b_{ZonguldakAtatürkStateHospital,Dept.ofOrthopaedicsandTraumatology,Zonguldak,Turkey}

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l

e

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n

f

o

Articlehistory: Received3June2017

Receivedinrevisedform26August2017 Accepted27August2017

Availableonline8September2017

Keywords: Casereport Ganglioncystoffibula

Commonperonealnerveneuropathy Compressionneuropathy

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b

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Wepresentacaseofacompressionneuropathyofthecommonperonealnervecausedbyanintraosseous Ganglioncystoffibula.

©2017TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Ganglioncystsarecysticlesionssurroundedbysofttissues.They originatefromtendonsheathorjointcapsule[1];andaremostly foundonhand,wristandankle.Theyarecommonlyseeninpatients between30and50yearsofage.Afewauthorsreported Neuropa-thyrelatedtoganglion cystsin currentliterature.However;we couldfindonlyonecasereportonintraosseousganglioncyst caus-ingsymptomsintheliterature[2].Sultanet.alfirstreportedacase ofcompressionneuropathyrelatedtoasynovialcystin1921[3](C, 1921).Bassettetal.describedthecharacteristicsofgangliaonMRI; onT1weightedimagesthesignalintensityislowtointermediate andonT2weightedimagestheyappearhomogenousandwithhigh signalintensity[4].Synovialcystsconsistoftwolayers.Theouter layerconsistsoffibrouscoatandinnerlayerissynovialliningand containsaclear,lucent,gelatinousfluid[5].Thiscasereporthas beenreportedinlinewiththeSCAREcriteria[6].

2. Presentationofcase

A61-yearoldfemalepresentedwithpainandnumbnessinthe leftlowerlimb.Thephysicalexaminationrevealedlossof sensa-tiononlateralsideofthefoot.Plainradiographsoflowerextremity wereobtained.X-rayshowedalucencyinthemedullaofthehead ofthefibula(Fig.1).FurtherinvestigationwasperformedbyMRI

∗ Correspondingauthorat: ˙IstanbulMedipolUniversity,Dept.ofOrthopaedics andTraumatology,Ba˘gcılar, ˙Istanbul,34214,Turkey.

E-mailaddress:seralple@gmail.com(S.Yalc¸ın).

whichrevealed ahyperdenselesion atthesameplaceasX-ray (Fig.2a,b).Thiswasfollowedbysurgicalexcisionofthecyst.The peronealnervewasexposedanddetectedasswollenand edema-tous(Fig.3).Duringsurgicalexplorationwefoundthatthecyst waswellsurroundedbyintramedullaryspongiousbone.Thecyst wascompletelyintramedullaryandnocorticalboneerosionwas detected(Fig.4).Itwasassedtobe25*34mminsize.Gross exami-nationofthecystrevealedlobulated,lucent,serousgelatinousfluid (Fig.5).

3. Discussion

Thecommonperonealnerveisthemostcommonlydamaged nerveofthelowerextremity.Thecommonreasonsarefractureof theheadoffibula,compressionduetothesplintorcast, compres-sionduringsleep,traumatickneedislocation,gunshotinjuriesand iatrogenicinjury[7,8].Rarecausesincludetractionapplications, ganglioncyst,fabella,hematomaduetohemophilia,compression ofcallus,tumorsoftheheadofthefibulaornervesheath.

Spjutetal.classifiedthesecystsasseparatedistinctentitiesof “subchondralbone”and“synovialcystofbone”bothseparatefrom degenerativesubchondralcysts[9].Thehistologicalfeaturesofthe intraosseousgangliaareessentiallythesameasthoseofasoft tis-sueganglion“cyst”withinternalmucoidgelatinouscontent,and fibrouslining[3,9].Sinceitlacksanepitheliallining,itistherefore notatruecyst[3,10].

Lipoma,fibroma,osteoma,sarcoma,tuberculosis,rheumatoid tenosynovitisandaneurysmshouldbeconsideredinthe differen-tialdiagnosis[11].Differentrecurrencesvariesbetween%10and40

[11,12].

http://dx.doi.org/10.1016/j.ijscr.2017.08.050

2210-2612/©2017TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

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A.Karaetal./InternationalJournalofSurgeryCaseReports40(2017)10–12 11

Fig.1. X-Rayofganglioncystintheheadofrightfibula.

Fig.2.a:CoronalviewoftheganglioncystonT2weightedMRI.b:axialviewofthe

ganglioncystonT2weightedMRI.

Fig.3. Swollencommonperonealnerve.

Fig.4.Intramedullaryganglioncyst.

Fig.5.Viewoftheganglioncystafterremoval.

Radiologicalstudiesandelectromyography(EMG)areusedin establishingthediagnosis[7].EMGmaydemonstratethesiteand severityofalesion,whichisparticularlyimportantinthe pres-enceofanon-palpablemass.Plainradiographsareoflittlevalue althoughtheymayruleoutabonyabnormalityorfractureatthe neckofthefibulaofthiscasewhichcausedsuspicionofasofttissue

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12 A.Karaetal./InternationalJournalofSurgeryCaseReports40(2017)10–12

mass[7].Ultrasonographyhasbeensuccessfullyusedto demon-strateoccultgangliaatthewrist.Itmayconfirmcysticnatureof themassandthereforedistinguishitfromsolidtumors[13].In doubtfulcases,acombinationofMRIandultrasonographywould improvediagnosticaccuracy.

4. Conclusion

Compressionneuropathyofthecommonperonealnervecaused byanintraosseousGanglioncystoffibulaisarareentity.Webelieve thatthiscasereportwouldcontributetotheliteratureby present-ingthisrareentity.

Conflictofinterest

I,onbehalfofallauthors,confirmthatthereisnoconflictof interest.

Funding

Thereisnofundingsource.

Ethicalapproval

Sinceitwasacasereporttherewasnoneedtoobrainethics committeeapproval.

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontribution

AdnanKara:Surgery,Photographing,Writing. SercanYalym:CollectionofinformationandWriting. ErsinKuyucu:ReviewofthemanuscriptAlieker:Writing. HalukC¸elik:Writing.

Guarantor

AdnanKara,amtheguarantorofthiscasereport.

Acknowledgement

Weobtainedconsentfromthispatientintermsofpublishingof photosandinformation.

References

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[7]J.D.EvansM.B.,B.S.,L.NeumannM.D.,SimonP.FrostickD.M.,F.R.C.S., Compressionneuropathyofcommonperonealnevrecausedbyaganglion,» Microsurgery,cilt15,pp.193–195,1994.

[8]K.F.K.Ü.Ö.I.,Y.Kabukc¸uo˘glu,Compressionneuropathyoftheperoneal nervecausedbyaganglion,AmJOrthop,cilt26,pp.700–701,1997. [9]H.J.Spjut,Fasc.5.,Tumorsofboneandcartilage.Atlasoftumorpathology,

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[11]W.E.Barnes,R.D.Larsen,J.L.Posch,Reviewofgangliaofthehandandwrist

withanalysisofsurgicaltreatment,Plast.Reconstr.Surg.34(1964)570–578.

[12]R.F.Santore,F.R.DiMaio,Alargeganglioncystinapatientwithhipdysplasia,

Orthopedics20(1997)650–652.

[13]K.Fukada,T.Sakuma,H.Kato,T.Ogino,A.Mirani,Thedorsaloccultganglion

ofthewristandultrasonography,J.HandSurg.13B(1988)181–183.

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