Authors: U¨mu¨t Gu¨zelku¨c¸u¨k, MD Dimitrios Skempes, MPH Wipoo Kumnerddee, MD
Management
Affiliations: From the Gulhane Military Medical Academy, Department of Physical Medicine and Rehabilitation, Turkish Armed Forces Rehabilitation Center, Ankara, Turkey (U¨G); Department of Health Sciences and Health Policy, University of Lucerne and Swiss Paraplegic Research, Nottwil, Switzerland (DS); and Department of Rehabilitation Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand (WK).
CASE REPORT
Common Peroneal Nerve Palsy Caused by Compression Stockings After Surgery
Correspondence: All correspondence and requests for reprints should be addressed to U¨mu¨t Gu¨zelku¨c¸u¨k, MD, Gulhane Military Medical Academy, Department of Physical Medicine and Rehabilitation, Turkish Armed Forces Rehabilitation Center, Ankara 06800, Turkey.
Disclosures: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
0894-9115/14/9307-0609 American Journal of Physical Medicine & Rehabilitation Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/PHM.0000000000000086
www.ajpmr.com
ABSTRACT Gu¨zelku¨çu¨k U¨, Skempes D, Kumnerddee W: Common peroneal nerve palsy caused by compression stockings after surgery. Am J Phys Med Rehabil 2014;93:609Y611. Peroneal nerve palsy is one of the more common entrapment neuropathies of the lower limb and can be a result of a multitude of causes. Compression stockings are commonly used for prophylaxis of deep venous thromboembolism after surgery. The entrapment on the head and the neck of the fibula caused by compression stockings is uncommon. In this article, the authors report a 46-yr-old male patient who was operated on for postauricular squamous cell carcinoma of the skin. On the third postoperative day, it was noticed that compression stockings had rolled down, and a linear impression mark was observed under its upper edge at the proximal part of the left cruris. He had left foot drop and difficulty in walking during gait assessment. The needle electromyography confirmed total axonal degeneration of the left peroneal nerve with denervation potentials. The aim of this report was to emphasize the importance of the size and length of the compression stockings and regular skin control in avoiding the risk for peroneal nerve palsy. Key Words: Peroneal Nerve Palsy, Compression Stockings, Foot Drop, Total Axonal Degeneration
Reducing the Risk of CPN Palsy Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
609
T
he common peroneal nerve (CPN) is one of the most frequently entrapped peripheral nerves. Several anatomic factors predispose the CPN to both compression and trauma. The CPN wraps around the fibular head and neck, at which point it is rather superficial and relatively fixed with little soft tissue protection.1Y3 Foot drop is a common and distressing manifestation of peroneal nerve injury. This condition may lead to significant gait impairment and disability. Pain, numbness, and dysesthesia may also be seen. Compression stockings (CSs) are commonly prescribed to prevent venous thromboembolic events in the postoperative period or during immobilization. In this report, the authors present a case of unilateral peroneal nerve palsy after CSs use.
CASE REPORT A 46-yr-old man (height, 177 cm; weight, 64 kg) had been operated on for left postauricular squamous cell carcinoma of the skin. Subsequently, the patient was prescribed thigh-length CSs bilaterally for prophylaxis of venous thromboembolism. During the first 2 days, findings of routine daily clinical examinations were normal. On the third day, in the morning, ankle dorsiflexion weakness was noted, and the left CS was found rolled down (Fig. 1). A linear impression mark
FIGURE 1 Left foot drop and rolled-down above-knee CSs. Informed consent was obtained for publication of this figure.
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Gu¨zelku¨c¸u¨k et al.
FIGURE 2 Linear impression mark secondary to CSs on the posterolateral aspect of the left knee. Informed consent was obtained for publication of this figure.
was observed under its upper edge at the proximal part of the left cruris (Fig. 2). The patient was referred to the authors’ rehabilitation clinic with foot drop. He had no history of similar symptoms or trauma and neurologic disease before the surgery. On physical examination, a line of ecchymosis on the posterolateral aspect of the left knee was observed. No mass lesions were identified around the knee joint. The neurologic examination revealed steppage gait pattern and foot drop on the left. Manual muscle testing revealed 0 of 5 strength in the left ankle dorsiflexors, ankle evertors, and long toe extensors. The strength of the plantar flexors and invertors was normal. The Achilles reflex was normal. There was also sensory loss on the anterolateral side of the cruris and the dorsal aspect of the foot with normal sensation on the plantar surface. In the third week of the postoperative period, the patient underwent electrodiagnostic testing. With the stimulation of the left peroneal nerve at the ankle site, the amplitude of compound muscle action potential recorded from the extensor digitorum brevis muscle was 2.6 mV, and distal motor latency was 26.00 milliseconds. In addition, the compound muscle action potential was recorded from the tibialis anterior muscle, the compound muscle action potential amplitude was 2.3 mV, and distal motor latency was 16.85 milliseconds with the stimulation of the peroneal nerve at the fibular head site. Needle electromyography findings were normal in the short head of the left biceps femoris muscle. Denervation potentials were observed in the left peroneus longus and tibialis anterior muscles. Peroneal nerve palsy was diagnosed by clinical and electrophysiologic testing eventually. The patient did not accept surgery as a treatment alternative, and an ankle-foot orthosis combined
Am. J. Phys. Med. Rehabil. & Vol. 93, No. 7, July 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
with an active assisted exercise program was planned. At the 6-mo follow-up, almost full recovery was obtained clinically and electrophysiologically.
DISCUSSION Peroneal nerve injury occurs secondary to a wide variety of etiologies including trauma, surgery, or entrapment. CPN may be entrapped along their course internal and external compression. Intrinsic sources of compression include bony spurs, tumors, ganglions, synovial cysts, hematoma, vascular abnormality, fibrous bands, or muscles. Extrinsic sources of compression include improper leg cast, leg orthoses and pneumatic compression, postural causes such as pressure caused by prolonged positioning in bedridden patients, poor patient positioning during surgery, prolonged squatting, and leg crossing.1Y5 In this case, entrapment was secondary to the CSs externally. Entrapment neuropathy depends on factors such as location, severity, and chronicity.6 At the neck and head of the fibula point, the peroneal nerve became more sensitive to compression because of thinning of the protective subcutaneous tissue as it happens especially in thin and slender people.1,3 Nerve compression causes decreased microvascular blood flow and impaired axonal transport and can disrupt the nerve structure and function within hours.5 Acute compression leads to focal demyelination, and if compression is prolonged, it causes perineural edema and permanent fibrosis.5,6 Delays in detection of compression caused by CSs may lead to irreversible axonal injury and foot drop. In this case, a compression caused by rolled-down CSs caused severe peroneal nerve entrapment. Perhaps the long duration (approximately 24 hrs) of the compression played the critical role in the severe nerve entrapment findings.
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To the best of the authors’ knowledge, peroneal nerve palsy secondary to CSs has been reported only once previously, but in that case, the patient was prescribed below-knee stockings, whereas the patient in this study was prescribed above-knee stockings.2 Incorrectly sized CSs can potentially lead to peroneal nerve palsy. For avoiding such risk, stocking size should be selected according to length and diameter of the leg. The authors believe that above-knee should be preferred vs. below-knee stockings for deep venous thrombosis prophylaxis to protect the neck of the fibula. An effective strategy for early detection of peroneal nerve palsy would require, among other measures, clinicians to account for the potential side effects of CSs especially in patients with one or more related risk factors. Frequent postoperative skin control and selection of properly sized CSs on the basis of patients’ individual characteristics should be considered for the prevention of peroneal nerve palsy. REFERENCES 1. Stewart JD: Foot drop: Where, why and what to do? Pract Neurol 2008;8:158Y69 2. O’Brien CM, Eltigani T: Common peroneal nerve palsy as a possible sequelae of poorly fitting below-knee thromboembolic deterrent stockings (TEDS). Ann Plast Surg 2006;57:356Y7 3. Ramanan M, Chandran KN: Common peroneal nerve decompression. ANZ J Surg 2011;81:707Y12 4. Flanigan RM, DiGiovanni BF: Peripheral nerve entrapments of the lower leg, ankle, and foot. Foot Ankle Clin 2011;16:255Y74 5. Thompson AT, Gallacher PD, Rees R: Lateral meniscal cyst causing irreversible peroneal nerve palsy. J Foot Ankle Surg 2013;52:505Y7 6. Arnold WD, Elsheikh BH: Entrapment neuropathies. Neurol Clin 2013;31:405Y24
Reducing the Risk of CPN Palsy Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
611
Management
Affiliations: From the Gulhane Military Medical Academy, Department of Physical Medicine and Rehabilitation, Turkish Armed Forces Rehabilitation Center, Ankara, Turkey (U¨G); Department of Health Sciences and Health Policy, University of Lucerne and Swiss Paraplegic Research, Nottwil, Switzerland (DS); and Department of Rehabilitation Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand (WK).
CASE REPORT
Common Peroneal Nerve Palsy Caused by Compression Stockings After Surgery
Correspondence: All correspondence and requests for reprints should be addressed to U¨mu¨t Gu¨zelku¨c¸u¨k, MD, Gulhane Military Medical Academy, Department of Physical Medicine and Rehabilitation, Turkish Armed Forces Rehabilitation Center, Ankara 06800, Turkey.
Disclosures: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
0894-9115/14/9307-0609 American Journal of Physical Medicine & Rehabilitation Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/PHM.0000000000000086
www.ajpmr.com
ABSTRACT Gu¨zelku¨çu¨k U¨, Skempes D, Kumnerddee W: Common peroneal nerve palsy caused by compression stockings after surgery. Am J Phys Med Rehabil 2014;93:609Y611. Peroneal nerve palsy is one of the more common entrapment neuropathies of the lower limb and can be a result of a multitude of causes. Compression stockings are commonly used for prophylaxis of deep venous thromboembolism after surgery. The entrapment on the head and the neck of the fibula caused by compression stockings is uncommon. In this article, the authors report a 46-yr-old male patient who was operated on for postauricular squamous cell carcinoma of the skin. On the third postoperative day, it was noticed that compression stockings had rolled down, and a linear impression mark was observed under its upper edge at the proximal part of the left cruris. He had left foot drop and difficulty in walking during gait assessment. The needle electromyography confirmed total axonal degeneration of the left peroneal nerve with denervation potentials. The aim of this report was to emphasize the importance of the size and length of the compression stockings and regular skin control in avoiding the risk for peroneal nerve palsy. Key Words: Peroneal Nerve Palsy, Compression Stockings, Foot Drop, Total Axonal Degeneration
Reducing the Risk of CPN Palsy Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
609
T
he common peroneal nerve (CPN) is one of the most frequently entrapped peripheral nerves. Several anatomic factors predispose the CPN to both compression and trauma. The CPN wraps around the fibular head and neck, at which point it is rather superficial and relatively fixed with little soft tissue protection.1Y3 Foot drop is a common and distressing manifestation of peroneal nerve injury. This condition may lead to significant gait impairment and disability. Pain, numbness, and dysesthesia may also be seen. Compression stockings (CSs) are commonly prescribed to prevent venous thromboembolic events in the postoperative period or during immobilization. In this report, the authors present a case of unilateral peroneal nerve palsy after CSs use.
CASE REPORT A 46-yr-old man (height, 177 cm; weight, 64 kg) had been operated on for left postauricular squamous cell carcinoma of the skin. Subsequently, the patient was prescribed thigh-length CSs bilaterally for prophylaxis of venous thromboembolism. During the first 2 days, findings of routine daily clinical examinations were normal. On the third day, in the morning, ankle dorsiflexion weakness was noted, and the left CS was found rolled down (Fig. 1). A linear impression mark
FIGURE 1 Left foot drop and rolled-down above-knee CSs. Informed consent was obtained for publication of this figure.
610
Gu¨zelku¨c¸u¨k et al.
FIGURE 2 Linear impression mark secondary to CSs on the posterolateral aspect of the left knee. Informed consent was obtained for publication of this figure.
was observed under its upper edge at the proximal part of the left cruris (Fig. 2). The patient was referred to the authors’ rehabilitation clinic with foot drop. He had no history of similar symptoms or trauma and neurologic disease before the surgery. On physical examination, a line of ecchymosis on the posterolateral aspect of the left knee was observed. No mass lesions were identified around the knee joint. The neurologic examination revealed steppage gait pattern and foot drop on the left. Manual muscle testing revealed 0 of 5 strength in the left ankle dorsiflexors, ankle evertors, and long toe extensors. The strength of the plantar flexors and invertors was normal. The Achilles reflex was normal. There was also sensory loss on the anterolateral side of the cruris and the dorsal aspect of the foot with normal sensation on the plantar surface. In the third week of the postoperative period, the patient underwent electrodiagnostic testing. With the stimulation of the left peroneal nerve at the ankle site, the amplitude of compound muscle action potential recorded from the extensor digitorum brevis muscle was 2.6 mV, and distal motor latency was 26.00 milliseconds. In addition, the compound muscle action potential was recorded from the tibialis anterior muscle, the compound muscle action potential amplitude was 2.3 mV, and distal motor latency was 16.85 milliseconds with the stimulation of the peroneal nerve at the fibular head site. Needle electromyography findings were normal in the short head of the left biceps femoris muscle. Denervation potentials were observed in the left peroneus longus and tibialis anterior muscles. Peroneal nerve palsy was diagnosed by clinical and electrophysiologic testing eventually. The patient did not accept surgery as a treatment alternative, and an ankle-foot orthosis combined
Am. J. Phys. Med. Rehabil. & Vol. 93, No. 7, July 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
with an active assisted exercise program was planned. At the 6-mo follow-up, almost full recovery was obtained clinically and electrophysiologically.
DISCUSSION Peroneal nerve injury occurs secondary to a wide variety of etiologies including trauma, surgery, or entrapment. CPN may be entrapped along their course internal and external compression. Intrinsic sources of compression include bony spurs, tumors, ganglions, synovial cysts, hematoma, vascular abnormality, fibrous bands, or muscles. Extrinsic sources of compression include improper leg cast, leg orthoses and pneumatic compression, postural causes such as pressure caused by prolonged positioning in bedridden patients, poor patient positioning during surgery, prolonged squatting, and leg crossing.1Y5 In this case, entrapment was secondary to the CSs externally. Entrapment neuropathy depends on factors such as location, severity, and chronicity.6 At the neck and head of the fibula point, the peroneal nerve became more sensitive to compression because of thinning of the protective subcutaneous tissue as it happens especially in thin and slender people.1,3 Nerve compression causes decreased microvascular blood flow and impaired axonal transport and can disrupt the nerve structure and function within hours.5 Acute compression leads to focal demyelination, and if compression is prolonged, it causes perineural edema and permanent fibrosis.5,6 Delays in detection of compression caused by CSs may lead to irreversible axonal injury and foot drop. In this case, a compression caused by rolled-down CSs caused severe peroneal nerve entrapment. Perhaps the long duration (approximately 24 hrs) of the compression played the critical role in the severe nerve entrapment findings.
www.ajpmr.com
To the best of the authors’ knowledge, peroneal nerve palsy secondary to CSs has been reported only once previously, but in that case, the patient was prescribed below-knee stockings, whereas the patient in this study was prescribed above-knee stockings.2 Incorrectly sized CSs can potentially lead to peroneal nerve palsy. For avoiding such risk, stocking size should be selected according to length and diameter of the leg. The authors believe that above-knee should be preferred vs. below-knee stockings for deep venous thrombosis prophylaxis to protect the neck of the fibula. An effective strategy for early detection of peroneal nerve palsy would require, among other measures, clinicians to account for the potential side effects of CSs especially in patients with one or more related risk factors. Frequent postoperative skin control and selection of properly sized CSs on the basis of patients’ individual characteristics should be considered for the prevention of peroneal nerve palsy. REFERENCES 1. Stewart JD: Foot drop: Where, why and what to do? Pract Neurol 2008;8:158Y69 2. O’Brien CM, Eltigani T: Common peroneal nerve palsy as a possible sequelae of poorly fitting below-knee thromboembolic deterrent stockings (TEDS). Ann Plast Surg 2006;57:356Y7 3. Ramanan M, Chandran KN: Common peroneal nerve decompression. ANZ J Surg 2011;81:707Y12 4. Flanigan RM, DiGiovanni BF: Peripheral nerve entrapments of the lower leg, ankle, and foot. Foot Ankle Clin 2011;16:255Y74 5. Thompson AT, Gallacher PD, Rees R: Lateral meniscal cyst causing irreversible peroneal nerve palsy. J Foot Ankle Surg 2013;52:505Y7 6. Arnold WD, Elsheikh BH: Entrapment neuropathies. Neurol Clin 2013;31:405Y24
Reducing the Risk of CPN Palsy Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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