Deep Peroneal Nerve Palsy Due to Osteochondroma Arising From Fibular Head and Proximal Lateral Tibia

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InternationalJournalofSurgeryCaseReports31(2017)200–202

ContentslistsavailableatScienceDirect

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

Deep

peroneal

nerve

palsy

due

to

osteochondroma

arising

from

fibular

head

and

proximal

lateral

tibia

Murat

Demiro˘glu

_,

_Korhan

_Özkan

_,

_Bulent

_Kılıc¸

_,

_Akif

_Akc¸

_al

_,

_Mesut

_Akkaya

_,

Feyza

Ünlü

Özkan

a_{IstanbulMedeniyetUniv.GoztepeEAH,Orthopaedics,Turkey} b_{IstanbulGelisimUniv.HealthSciences,Turkey}

c_{AntalyaAtaturkStateHospital,Orthopaedics,Turkey}

d_{FatihSultanMehmetStateHospiatal,PhysicalMedicine,Istanbul,Turkey}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received10January2017

Receivedinrevisedform18January2017 Accepted19January2017

Availableonline24January2017

Keywords: Peronealnerve Osteochondroma Fibularhead

a

b

s

t

r

a

c

t

Followingmedianandulnarnerves,peronealnerveentrapmentisthemostfrequentnerveinvolvement

inthebodyKatirjiandWilbourn(1998)[1].

Osteochondromasarethemostcommonbenignbonetumorscomprising9%ofallbonetumorsand

35%ofbenignbonetumorsPorter(2000)[2].

Hereditaryexostoses(HME)isanautosomaldominantdisorderwithvariablepenetrance

character-izedbymultipleosteochondromasnearjoints.Itisoneofthemostcommonskeletaldysplasiaswitha

frequencyofabout1.18%.

Inthisstudy,weaimedtopresentacasewithadropfootresultingfromosteochondromasofproximal

tibiaandfibulaandhelptoguidethecliniciansindifferentialdiagnosisaccordingtoSCAREcriteriaAgha

(2016)[3].

©2017TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen

accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Osteochondromasare a relatively common imaging finding, accountingfor10–15%ofallbonetumoursand35%ofallbenign bonetumours[2]5.Althoughusuallythoughtofasabenignbone tumour,theymaybethoughtofasadevelopmentalanomaly.They arefrequentlyasymptomaticandhaveverylowmalignant poten-tialifsporadicandsolitary.Weaimedtopresentacasewithadrop footresultingfromosteochondromasofproximaltibiaandfibula andhelptoguidethecliniciansindifferentialdiagnosisaccording toSCAREcriteriaAgha(2016)[3].

2. Casereport

A13yearoldmalepatientattendedourorthopaedicdepartment andtraumatologyasanoutpatientwithcomplaintsofdifficultyin walking,liftinghisrightfootforthelast6months,andpainfulhard lumpsonthemedialsideofproximaltibiaanddistalthigh.

∗ Correspondingauthorat:Dr.ErkinCaddesiGöztepeE˘gitimAras¸tırmaHastanesi, Kadikoy,IstanbulTurkey.

E-mailaddresses:drmuratdemiroglu@gmail.com(M.Demiro˘glu),

korhanozkan76@gmail.com(K.Özkan),drbulentk@hotmail.com(B.Kılıc¸),

mehmetakifakcal@yahoo.com(A.Akc¸al),mesutakkaya2010@hotmail.com

(M.Akkaya),feyzamd@yahoo.com(F.Ü.Özkan).

On physical examination, there were multiple hard lumps aroundboththekneejoints,proximalhumerus,andontheleft dis-talulnaandradius.Thereweremildvalgusdeformitiesofboththe rightandleftanklejointsandgrowthdisturbanceofleftforearm withdeformity.Hisneurologicalexaminationrevealed1/5tibialis anterior,0/5extensordigitorumlongus,and0/5extensorhalluces longus muscle power—according tothe manual muscle testing grading system. Sensationwas not improved. Peroneal muscle powerwas5/5.Electrophysiologicalstudyconfirmeddenervation ofthenervemusclesuppliedbythedeepperoneal.

Roentgenographicevaluationrevealedmultiplebonyexostosys arisingfromtheproximalendofbothtibiaandfibula,distalfemur, proximalhumerus,andtheleftforearm.The

diagnosiswasconsistentwithhereditarymultiple osteochon-dromasanddeepperonealnervepalsyduetocompressionofthe osteochondromasattheproximaltibiaandfibula.

Extractionofthetwoosteochondromasoriginatingfromright proximalfibulaandoneosteochondromafromrightproximaltibia wasdonewithperonealnerveneurolysis(Figs.1and2)

Also,symptomaticosteochondromasoriginatingfrommedial side of right distal femur and right proximal tibia were also removed.

Pathologicspecimendepictedosteochondromas.

Tibialisanteriormusclepowerreturnedto4/5,extensor digito-rumlongusmuscle3/5andextensorhalluceslongusto2/5,48h

http://dx.doi.org/10.1016/j.ijscr.2017.01.050

2210-2612/©2017TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

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M.Demiro˘gluetal./InternationalJournalofSurgeryCaseReports31(2017)200–202 201

Fig.1.Peronealnervelooksedematousandinflamedwithtibialostechondromaat

theleveloffibularneck.

Fig.2. Twofibularandonetibialosteochondromacompressingperonealnerve.

aftersurgery.Patientisunderfollow-upand aphysicaltraining program.

Sixweekshavepassedsinceoperation.Asclinicalimprovement isobserved,controlEMGhasbeenplannedatthirdmonth postop-eratively.

3. Discussion

Peronealnerveislocatedbehindthebonyprominenceofthe fibularneck.Itis coveredprimarilybysubcutaneoustissueand skin.Thissuperficialanatomicalcoursemakesthenerveextremely susceptibletoinjury[1,4,5].

Commoncausesofdamagetoperonealnerveincludethe follow-ing:Blunttraumatotheknee,fractureoftheneckofthefibula,use oftightplastercast,prolongedsquatting,regularlywearinghigh boots,iatrogenicinjuryduringsurgery(kneearthroplasty,high tib-ialosteotomy),pneumaticcompression,andpressuretotheknee frompositionduringsleeporcoma[6,7].

Multiplehereditaryosteochondroma,alsoknownasmultiple hereditaryexostosis,isaninheritedskeletaldysplasiawithan auto-somal dominant pattern mainlyaffecting theepiphysis of long bones[8].

About40%percentofthecasesaresporadic[2].

Thosepatientshaveskeletaldeformitiesandshortstature clin-ically. Thelesions areradiologicallyand are histopathologically similar to solitary osteochondromas. Severe HMO may lead to majorspinaldeformitiesandscoliosis[9].

These patients, however, have a risk for malignant transformation—5–10%[10].

Deformitiesoccurduetodisorganizedendochondral ossifica-tioninthegrowthplateandmayrequiresurgicalcorrection[11].

Diseaseaffectingthekneejointhasbeendescribedin94%of allcases[12].Nervecompressioncausedby osteochondromais extremelyrareandpresentinonly≤1ofallcases[13]. Osteochon-dromasarecomposedofosseoztissue,whichissurroundedbya capofcartilage.Theselesionsmaybesolitaryormultiple,asin hereditarymultipleosteochondromas.

Theselesionsmaycompressthenerve—especiallyinthefibular neckarea—andcausetotalperonealpalsyorisolateddeepperoneal nerve,asinourcase[14].Althoughtherearefewcasereportsof commonperonealnervepalsyduetoproximalfibular osteochon-dromasintheliteratureinEnglish,thiscaseisuniquebecauseof anisolateddeepperonealnervepalsyduetoosteochondromaof proximalfibulaandtibia.

Neurologicalimprovementmaybeachievedifsurgeryis per-formedbeforenervedamagebecomesirreversible.

Electrophysiologicaltestscanhelptolocalizethelesionsalong thecourseofthenerveandcanhelptodistinguishentrapment oftheperonealnervefromsciaticneuropathyorL5radiculopathy

[15–17].

Ifwedonotoperatethepatient,nervedamagemaybecome irreversibleandinvolvementofsuperficialperonealnervebesides deepperonealnervemayensue.

4. Conclusion

Mostperonealnervetraumaorcompressionduetomassoccurs atthefibularhead-neckarea,wherethecommonperonealnerve hasnotyetdividedintoitsdeepandsuperficialperonealbranches; thusmostnervelesionsinvolvebothbranches,althoughisolated casesasinourreportmayoccur.Cliniciansdealingwithdropfoot etiologyshouldbeawareofthepossiblemasstumorallesions,such asosteochondromasandsynovialcysts,compressingtheperoneal nerve[18,19].

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Conflictofinterest

None.

Funding

Thereisnosourceoffunding.

Ethicalapproval

Itisretrospectivecasereportandnonecessaryethicalapproval.

Consent

Writtenconsentwasprovidedfrompatientforthepublication ofthiscasereport.

Contributions

MDandKOconceivedofthestudyandparticipatedinits coor-dination.BK,MA,AA,FUOcontributedtotheacquisitionofclinical data, its analysis and interpretation and to the preparation of images.KO,FUOcarried outtheliteraturereview.MD, BK con-tributedtothepreparationofthemanuscript.MA,AA,contributed totherefinementofthecasereport.Allauthorshaveapprovedthe finalarticle.

Guarantor

MuratDemiroglu,KorhanOzkan.

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