RESULTS

OF
THE
COMMON

THE

TO

J.
From

Platt

(1928)

the Department

described

paralysis

with

severe

peroneal

nerve

syndrome.

the tibia!
margin,
cruciate
ligaments,
the

common

continuity

WHITE,

TRACTION
PERONEAL

GLASGOW,

SCOTLAND

of Orthopaedic

the

Surgery,

association

adduction

injury
The

of
of

knee

knee,

peroneal

nerve

from

disruption

traction,
of the

the
nerve

(lateral

injury

he

of rupture

popliteal)

called

of the

the

lateral

nerve

ligamentous

capsule

close

to

of the lateral
ligament
and of both
This is accompanied
by paralysis
of

injury

varying

in severity

from

a lesion

in

1).

Mitchell
(1930)
complicated

Glasgow

rupture
tract.
(Fig.

the knee
recorded

Infirmary,

peroneal
an

consists

avulsion
of the biceps
tendon,
and rupture
of the ilio-tibial

to complete

Royal

common

the

injury

INJURIES
NERVE

over

reported
two cases ofdislocation
by foot drop.
No recovery

three

of the

end-result.
in which
the nerve

months

but

Watson
recovered

there

was

of
was

no indication

Jones
(1931)
reported
a case
within ten weeks.
Ferguson

and Allan (1939) studied

the anatomy
of the syndrome
at necropsy,
and Novich
(1960) reported
a patient
with
complete
rupture
of the nerve, which was resected
and
sutured : no motor
function
was regained
but some
sensory
recovery
was
recorded-this
was
possibly
because
of sensory overlap
from neighbouring
nerves.
Two small series of this uncommon
lesion have
been
published,
prognosis
may
cases

which

complete
with

from
which
some
impression
be gained.
Platt
(1940)
reported
he

collected

ruptures

complete

treated

recovery

in continuity,
in four

over

were
one

weeks.

was

In the

in

twenty

years.

by resection

two

cases.

four

which

remaining

cases

the
nine
Five

and

Of

a neuropraxia

of

suture,
lesions

recovered

there
was little
nerve trunk:
spontaneous

or no naked-eye
evidence
of a lesion in the
there
was failure
to recover
in two and
recovery
in one.
Highet
and

.
.
An

FIG.

of

the

Illustration

peroneal
carried

six cases
recovery.
extent

out

in all.

of the

the

common

In two,

the

damage

in the

reported
rupture

.
trunk.
The other
four
considerable
macroscopic
resection
was so extensive
that

peroneal

nerve

trunk,

gained
nerve

prompted
to record
a personal
series
there
were two complete
346

Holmes
(1943)
had a complete

whom

eight patients,
of the nerve

had

leslons
changes.
repair
was

ln

not

.
contlnulty
Resection
feasible.

wlth
was
In the

the nerve was sutured

there were five complete
failures
and one incomplete
(1960)
had come
to the conclusion
that owing
to the great
longitudinal

attempting
in any situation.
It is on the impressions
of

of

hgamentous

nerve syndrome.

in which
Seddon

four

#{149}

from
have

surgical
the
earned

repair

report
their

of these

of Highet
evil

injuries

and

Holmes

reputation.

is hardly

that

ever

traction

Because

of

this

worth
lesions
I was

series of six cases collected

over the past eight years.
In this
ruptures
of the nerve
trunk,
both
treated
by resection
and
THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

THE

suture.

The

have

RESULTS

first

gained

patient

a good

full sensory

OF TRACTION

and

in Glasgow

resected,

and

considerable

functional

motor

Meeting

had

result.

The

(this

patient

recovery
in 1960).

all recovered

INJURIES

Of the

fully.

The

motor

and

second

case

was

shown

four

lesions

fourth

two

cases

of rupture

with

PERONEAL

sensory
was

recovery

not

and

is considered

in that

at the British

Orthopaedic

three

explored

and

347

NERVE

exceptional

in continuity,

was

CASE

The

TO THE COMMON

were

the

to

patient

had

Association
explored

recovered

but

not

spontaneously.

REPORTS

resection

and

suture

are

detailed

below.

Case 1-A
crane slinger aged twenty
was struck
on the right knee by a heavy load.
At primary
operation
the cruciate
ligaments,
lateral
ligament
and lateral
capsule
were repaired
and the
nerve
ends were approximated
with one suture
(Fig. 2). Four
months
after the injury
eight
centimetres
of nerve
were
marker
system
was thought
and the
continued

nerve
for

sensory

loss

was
two
was

resutured
with
years after the

heavier
operation

regained

3).

(Fig.

I . Figure
recovery.

Research

Council
muscles

extensor

digitorum

require

grading),
at

is such

Case

2-A

4 and

(Figs.

There

4.

He did

motor

cyclist

tibialis

anterior

of the common
the long extensors

extensor

There

The

a disadvantage

accident.
On admission,
the lateral
ligament
and
The common
peroneal
approximated.
nerve
suture

the

force
brevis.

an appliance.

which

The

were
was

contracted

patient

not

have

partial
a typical

the lateral
the ilio-tibial
nerve
was

able

in

to extend

the

extensor

his foot

force

5 (Medical

3-Showing
the sensory
to be contracting.

contracted

of the peronei

recovery

at

force

hallucis

to a right

as described

4 and

longus

angle

and

by Seddon

the

or

the

did

not

(1960),

is achieved.

ligamentous

side of the
tract were
found
to

Three
months
later, seven
done.
Full recovery,

was

longus

recovery

overaction

when
sustained

was

no

Recovery
Most
of the

peroneal
nerve.
Figure
of the toes can be seen

digitorum

was

because
the
come apart

inserted.
good.
at

FIG.

2-The
complete
disruption
The peroneal
muscles
and

peroneal

material
and new markers
and the functional
result

FIG.

Case

resected.
Six months
later the nerve
was re-explored
to be inaccurate.
The suture
line was found
to have

peroneal

nerve

syndrome

in a road

knee was exposed,

and the cruciate
repaired
after removal
of the lateral
be completely
ruptured
and
the

centimetres
motor
and

of the nerve were

sensory,
occurred

resected
and
in eighteen

ligaments,
meniscus.
ends
were
a formal
months

5).

were

four

traction

lesions

in continuity

and

in none

of these

cases

was

the

nerve

resected.
Case
3-A
exploration
VOL.

crane
slinger
aged
twenty
four days later the cruciate

50 B, NO. 2.

MAY

1968

sustained
ligaments

an adduction
and the lateral

injury
ligament

to his left knee.

At
were found
ruptured

348

J. WHITE

and were
the nerve
began

repaired
sheath

to recover

Case

4-A

man

complete
in

of the lateral
centimetres.

meniscus.
The texture

at six months

and

recovered

aged

nineteen

dislocation

a plaster

for

months

after

patchy

fibrosis

was

after removal
over about
ten

ten

the

nerve

five

centimetres.

recovered

crane

5-A
of

the

strain

to

intact

cruciate

to

slinger

lateral
the

recover

aged

iron

and

the

peroneal

explored.

There

nerve

nerve

was

started

girder,

sustaining

knee
was

was
still

a lesion

protected

present

five

in continuity

to recover

FIG.

thirty-nine
and

under

anaesthesia

ligaments.
in six

common

The

by an

with

at five months

and

and

a dislocation

of the

knee

ligaments,

demonstrated

by

applying

; the

was

was

recovery
in
completely.

sustained

cruciate

Treatment

weeks

dorsiflexion
of the foot illustrates
the excellent
show the original
sensory
loss which recovered

ligament

knee

was

knee

months.

reduced

FIG.

tear

left
was

bruising
of
Paralysis

in a year.

Case 2. Figure 4--Active

all muscles.
Figure 5-To
Case

the

was considerable
nerve
felt normal.

at nine

the

dislocation
of

so the

about

across

The

Paralysis

injury,

fully

struck

knee.

weeks.

over

completely

was

of the

was

There
of the

degree

of

tilt

obtained
of the

by immobilisation

completely

recovered

in four

was
knee.

with

a complete
an

adduction

not compatible
The drop foot

months.

The

nerve

with
began
was

not

explored.
Case

6-A

child

Her knee
lesion.
fibrotic
at

aged

six years

was shattered

and

was

widely

struck

on

the

adducted

knee

; the

by a piece

common

Three
months
later
there
was no recovery
so the
area about
a centimetre
in extent
was discovered.

four

traction

months

or coal dust

and
lesion

nerve
was

found

was

completely

well

removed

anywhere

recovered
from
in the

the
region

in
point

one
of

of the

ofcoal

peroneal

when

nerve

a fire

sustained

a traction

nerve
was exposed.
The drop
foot started
year.

entry

This

was

exploded.

A localised
to recover

thought

of the

coal

certain

observations

to

because

no

be

debris

nerve.

DISCUSSION

From
considered
secondary

returned

a review

of the

pertinent.
Highet
traction
lesion which

to the extended

three

series

and Holmes
they believed

position.

From

of cases

described,

(1943)
attributed
was produced

my experience

their
disappointing
when the flexed knee

with
THE

the first case

JOURNAL

OF

BONE

could

of complete
AND

be

results
to a
was gradually

JOINT

nerve
SURGERY

THE

disruption,

RESULTS

some

of

OF TRACTION

these

failures

early
stage,
from
In fact, separation

tension
of less

case,

is directly

the

problem

INJURIES

TO

the

repair

peroneal

nerve

of a mixed

nerve

Finally,
the
On

has

would

to

the

and

to cause

it seems

the

months,
best
the

the

when

were

is between

the

easily

nerve

here.

his

was

because
early,

the

to

which

makes

may

be added

before

the

nerve

of two

As will
two

be seen

x-ray

from

give

the

position

the

system

on the

other

merely

from

of the

to approximate

The

the

nerve

the

at the

right

after

three

repaired
It appears

of the

nerve

hip,

that

intraneural

the

fibrosis

have
made

reported

is

more

this

time,

more

secure.

is less

to start

____________

_______

It

liable

to

recovering

if the

suture

I found

the

YY

-Y
line

usual

inadequate.

6, the

on

the

can

distance

distance

the

this

markers

the

two

marker

accuracy

between

of the

x-ray

____________
FIG.

Diagram

showing
described

measurement,

the marker
in the text.

system

are in the same

nerve

is placed

of this

on a constant

_____________
i-Yu1

I have shown
that
in the distance
of the

distort

fact
one

may
was

the

in lesions
extent

of the

injuries

of

at

recover.

that

some

nerve

that

Figure

nerve

the

the

lesion

Experimentally
centimetres

in which

depends

at an

prognosis

separation
nerve

to be the case.

when

material
a little

not

that

that,

this

in continuity,

damage

that

heavier

to be

in actual

side.

the

in order

to explore

said

find

months,

in continuity

however,

impression

whereas

marker

lesion

not

This

of the

is dependent
the nerve.
of a few

and

have

with

peroneal

and

said

as it appears

will

tube from
a difference
tube

also

neuropraxic

markers

markers

fifth

in lesions

anastomosis

the third month.

It must
be agreed,

system

ends

fibrils.

connected

common

It is important

normal.

first

unnecessarily,

separates

the

were

with
the

all

I did

and

I believe

that

not

sensory

has to be mobilised

is also

of

exploration

Platt

in the

the

be explored

third

apparently

suturing

limb

repair

early

series

Furthermore,

amenable

the

assessment

as it was

it should
some

the nerve

disappointing.

assessed.
in

although

be immobilised.

advocated

results

the

been

should

results

most
bad

size

it has

the more

in

(1940)

the
time

that

ankle

Platt

time.

nerve

increased
likelihood
of impairment
of its blood
supply.
with
lesions
in continuity
up to five centimetres
the
It therefore
seems
that
inadequate
resection
of the nerve
failure
of recovery
than a painstaking
attempt
to get above
and

recovered.

liable

and

knee

and

the gap,

of the

breakdown
of the anastomosis.
any chance
of recovery.
In either
of the gap left after
the nerve
has been

be the difference
in diameter
of the two nerve
nerve fibrils
difficult.
It must
be remembered

and,

median,

a lesion
of over ten centimetres.
The problem
of immobilising
the

endings,

too

motor,

as the

to separation

349

NERVE

the consequent
in some
cases

eventually

be less

below

is

the greater

nerve
ends,
with
the other
hand,

nerve

such

PERONEAL

with consequent
could
vitiate

proportional

is mainly

COMMON

be attributed

could

on the sutures
than a centimetre

resected.
Also, the greater
the gap, the greater
will
ends,
which
makes
accurate
apposition
of the
that

THE

method

distance

ends

have

on

one

of the

is independent

between

I therefore

separated.
side

of the

each

lateral

devised

anastomosis

and

position

marker

of the

and

the

the threetwo

markers

x-ray

central

tube,

one.

CONCLUSIONS

Considering

the ligamentous
in three months.
VOL.

50

B,

NO.

my

series

peroneal
Although
2, MAY

1968

and

that

of

Platt,

it appears

that

nerve syndrome
must be explored
traction
lesions
can be extensive,

all common

peroneal

nerves

if there is no evidence
of recovery
they seem to vary considerably.

in

350

J. WHITE

It seems
that in some there
fingers
with a snapping-like

is an

action

analogy
which

with the
produces

way
only

a draper
can break
string
with
a localised
lesion
in the string;

his
so

that

not all lesions

are as extensive
as is often supposed
even though
they are complete
ruptures.
Salvage
procedures
such as the Lambrinudi
triple
fusion
and the posterior
bone block
are not without
their
disadvantages
and are no substitute
for successful
nerve
recovery.
Furthermore,
there
is no disadvantage
in delaying
these procedures
until the nerve has been

given

a chance

to recover.

However,

posterior
muscle
through
same
time as the common
recovery
were first rate.
lesions,

there

may

the interosseous
peroneal
nerve

be a good

membrane
is repaired,

reason

for transplanting

I would
like therefore
to make
a plea for a more
conservative
as it is better
to leave some parts of the nerve in which damage

may recover
approximate
prognosis
without
that the
worth

as some lesions
in continuity
the nerve
ends,
especially

the

tibialis

on to the dorsum
of the foot at the
as it could
be replaced
if the nerve
resection
of complete
is very slight and which

do, rather
than have too big a gap
because
Highet
and Holmes
(1943)

in extensive
resection
as very disappointing.
On the whole,
severe
changes
should
not be resected.
No doubt
some
lesions
results
will be disappointing
but I cannot
subscribe
to the view

with
have

inability
shown

to
the

lesions
in continuity
will be so extensive
that the lesion
is not

treating.
SUMMARY

A series

of

adduction
2.

The

six

force

traction

lesions

to knee

reasons

for

of the

common

peroneal

nerve

in association

with

failure

of the

nerve

repair

are

discussed.

3. A new system
of radiological
marking
of the anastomosis
is described.
4. A less pessimistic
view of the prognosis
is taken
than
heretofore,
and
of the injury
is discussed
with a recommendation
that a more
conservative
three

months

I would
advice.

after

the

like to thank
I would also

a severe

is described.

the management
resection
be done

injury.

Sir Herbert
like to thank

Seddon
for the interest
Miss J. M. Macdonald,

he has shown
the medical

in these
artist.

cases

and

for

his very

with

Division

helpful

REFERENCES

J.

FERGUSON,
HIGHET,

W.

and
Peroneal

A.,

Common
B.,

to Peripheral

Nerve.

HOLMES,

Nerves

J. 1. (1930):

MITCHELL,
12,

and

ALLEN,

L. (1939):

Journal
W. (1943):

after Suture.
Dislocation

Complete
of Bone
Traction
British

Medial
and Joint
Injuries

Journal

of the Knee.

Dislocation

of Surgery,

Report

of the Knee Joint

Surgery,
21, 1012.
to the Lateral
Popliteal
of Four

30,

Nerve

and Traction

of the
Injuries

212.

Cases.

Journal

of

Bone

and

Joint

Surgery,

640.

M. M. (1960):
Adduction
Injury of the Knee with Rupture
of the Common
Peroneal
Nerve.
Report
of a Case.
Journal
of Bone
and Joint
Surgery,
42-A,
1372.
PLAIT,
H. (1928):
On the Peripheral
Nerve
Complications
of Certain
Fractures.
Journal
of Bone
and Joint
Surgery,
10, 403.
PLAIT,
H. (1940):
Traction
Lesions
of the External
Popliteal
Nerve.
Lancet, ii, 612.
SEDDON,
H. J. (1960):
Personal
communication.
WATSON
JONES,
R. (1931):
Styloid
Process
of the Fibula
in the Knee Joint with Peroneal
Palsy.
Journal
of
N0vICH,

Bone

and Joint Surgery,

13,

258.

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY