Deep peroneal nerve palsy with isolated lateral compartment syndrome secondary to peroneus longus tear: a report of two cases and a review of the literature
© The Author(s) 2015
Received: 7 October 2014
Accepted: 8 August 2015
Published: 11 September 2015
Drop foot is typically caused by neurologic disease such as lumbar disc herniation, but we report two rare cases of deep peroneal nerve palsy with isolated lateral compartment syndrome secondary to peroneus longus tears. Both patients developed mild pain in the lower legs while playing sport, and were aware of drop foot. As compartment pressures were elevated, fasciotomy was performed immediately, and the tendon of the peroneus longus was completely detached from its proximal origin. The patients were able to return their original sports after 3 months, and clinical examination revealed no hypesthesia or muscle weakness in the deep peroneal nerve area at the time of last follow-up. The common peroneal nerve pierced the deep fascia and lay over the fibular neck, which formed the floor of a short tunnel (the so-called fibular tunnel), then passed the lateral compartment just behind the peroneus longus. The characteristic anatomical situation between the fibular tunnel and peroneus longus might have caused deep peroneal nerve palsy in these two cases after hematoma adjacent to the fibular tunnel increased lateral compartment pressure.
Compartment syndrome of the lower extremity is a rare event and can occur with trauma or occasionally with a sports injury. The diagnosis needs to be established early in its course to avoid disabling sequelae, such as neurologic disorders. The most frequent location of compartment syndrome in the lower extremity is the anterior compartment. Looking at the literature, lateral compartment syndrome of the lower leg is quite rare. Lateral compartment syndrome occurs due to inversion ankle injuries [1, 2], exertion [3, 4], horseback riding [5, 6], a prolonged lithotomy position in general surgical, urologic, and gynecologic procedures , peroneus longus muscle tears or avulsion [8–12].
Early diagnosis and treatment of lateral compartment syndrome secondary to peroneus longus tear is difficult due to the lack of characteristic clinical symptoms [3, 13]. To the best of our knowledge, deep peroneal nerve palsy with lateral compartment syndrome secondary to complete avulsion of the proximal origin of the peroneus longus has not been reported. Two rare cases of deep peroneal nerve palsy with isolated lateral compartment syndrome secondary to peroneus longus tear are reported herein.
The proximal lower leg was exposed through a longitudinal incision above the lateral compartment. Hematoma within the lateral compartment was evacuated. The tendon of the peroneus longus was found to be completely detached from its proximal origin. Although the hematoma was evacuated, lateral compartment pressure remained elevated (120 mmHg). The distal lower leg was exposed through an incision above the lateral compartment. The peroneus muscle was ischemic and swollen, but not necrotic. The skin was closed, because the skin was not tense. Reduced lateral compartment pressure was confirmed, and the operation was finished. The day after the operation, the patient complained of right lower leg pain. The wound was opened because lateral compartment pressure was again increased (120 mmHg). After the wound was opened, the patient noted pain relief.
Fourteen days later, he was taken back to the operating room for delayed primary closure. At the time of primary closure, tibialis anterior strength had recovered to 3/5, and extensor hallucis longus and peroneus strengths were 1/5. The patient was discharged 18 days after fasciotomy, requiring an ankle–foot orthosis for ambulation. Three months after fasciotomy, he was able to return to play baseball with almost complete recovery of muscle strength in the tibialis anterior (5/5) and extensor hallucis longus/peroneus (4/5). Clinical examination after 2 years revealed no hypesthesia and no muscle weakness in the territory of the deep peroneal nerve.
A 16-year-old boy with no history of pain in the leg, muscle weakness, or other disorders developed pain in the right lower leg after playing soccer. Sixteen days later, he presented to the orthopedic department complaining of swelling, pain, and numbness in the right leg. The initial clinical examination revealed swelling of the right lower leg, and manual muscle testing showed 4/5 muscle strength of the anterior muscle group (tibialis anterior and extensor hallucis longus), 5/5 muscle strength of the posterior muscle group, and 3/5 muscle strength of the peroneus muscle. Sensation was decreased in the deep peroneal nerve area, but normal in the superficial peroneal nerve area. Anterior compartment pressure was 42 mmHg, but that of the lateral compartment was 100 mmHg. The results of these clinical examinations led to the definitive diagnosis of anterior and lateral compartment syndromes, and fasciotomy was immediately performed.
This is the first case report of deep peroneal nerve palsy with isolated lateral compartment syndrome secondary to peroneus longus tears. In both cases, it was difficult to diagnose because of the few and complex symptoms, such as drop foot, which often occur in lumbar disc herniation.
Although the most frequent presentation of compartment syndrome of the lower extremity involves the anterior compartment, lateral compartment syndrome of the leg is rare. In addition, as injury to the peroneal muscle–tendon unit tends to occur more distally, reports of acute rupture of the peroneus longus muscle from its proximal origin are very rare . To the best of our knowledge, only four cases of isolated lateral compartment syndrome secondary to peroneus longus tear have been described [9–12]. In those previous reports, the pathological processes causing the peroneus longus to tear from its proximal origin were initiated by overuse of muscles, but the situations of injury remained unclear [10, 11]. As in previous cases, the present two cases did not show the injury situations clearly. From these perspectives, peroneus muscle tear should be included in the differential diagnosis for patients who play sports intensely and develop lateral lower leg pain.
In conclusion, we have reported two rare cases of deep peroneal nerve palsy with isolated lateral compartment syndrome secondary to peroneus longus tear. In both cases, diagnosis was difficult due to the few and complex symptoms, such as drop foot, which often occurs with lumbar disc herniation. Although rare, isolated lateral compartment syndrome secondary to peroneus longus tear should be considered in patients who play sports intensely and develop leg pain with peroneal nerve palsy.
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Conflict of interest
All patients gave informed consent to publish the present report.
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