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Nerve injuries of the lower limbs
Foot and Ankle Surgery 1998
4:109-117
Review article Nerve injuries of the lower limbs R. BIRCH Peripheral Nerve Injury Unit, Royal National Orthopaedic Hospital Trust, Middlesex, UK
Introduction It is a remarkable fact that the fundamental principles in the treatment of divided nerves, and of reconstruction or palliative work for paralysis have been drawn largely from experience in the lower limbs - for the treatment of the missile injuries of wars, for poliomyelitis, and cerebral palsy - and this foundation largely preceded equivalent work in the upper limbs. Yet the plethora of publications relating to this field is far greater in the upper than in the lower limbs. Injuries to nerves of the upper limbs exceed those of the lower by a factor of 5:1 in larger civilian series; but there are a significant number of injuries to the lumbo-sacral plexus and the major trunk nerves in the lower limbs and the toll from road traffic accidents, knife and missile wounds, or surgery are substantial. Since this review is concerned with nerve injuries that affect the ankle and foot discussion will be confined to the lumbo-sacral plexus, the sciatic nerve and its divisions and cutaneous nerves such as the sural and long saphenous. It must be noted that injuries in the lower limbs, unlike the upper, are more often 'compound', i.e. the damage to a nerve or nerves is associated with major damage to other tissues such as skin, muscle, the skeleton and major vessels at the same site. One must consider first the associated arterial injury (and the consequence of neglect of that injury), the particular difficulties attending a missile injury and some difficulties of reconstruction within the growing limb.
Arterial injury Eastcott [1] regarded the popliteal artery as the 'life line of the leg', perhaps reflecting on the findings of Correspondence: Mr Rolfe Birch, MChir, FRCS, Consultant Orthopaedic Surgeon, Peripheral Nerve Injury Unit, Royal National Orthopaedic Hospital Trust, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK. © 1998 Blackwell Science Ltd
De Bakey and Simeone [2, 3] who, in reviewing nearly 2500 arterial war injuries, found that a total of 346 of 502 lower limbs were amputated after ligation of the popliteal artery. Barros d'Sa [4, 5] achieved an amputation rate of 5% in cases of popliteal artery injury caused by missile injury treated in Northern Ireland, the lowest of any civilian or military series published. The principles of treatment in 188 major vascular injuries in the lower limbs of 118 patients included: revascularisation within 4h, fasciotomy of all compartments, vein grafting for the artery, and repair of at least one major vein. After the 'knee-capping injury' in which a close range shotgun blasts the contents of the popliteal fossa, tibia and femur, intraluminal shunts were shown to revolutionise the treatment of vascular injuries complicating fractures of the lower limbs. Two aspects are of particular interest: the effect of aneurysms and arterio-venous fistulae on nerve function and the consequences of post ischaemic fibrosis. Fifty-nine of our cases of post-ischaemic contracture in the lower limbs required operation. Twenty-one of these followed arterial injury, 34 were true compartment syndromes and four more occurred in crushed limbs or in patients in coma. The most common deformity was equinovarus and correction of the deformity was by simple elongation of the tendo-achilles and long flexor tendons but what was remarkable was the regular relief of pain, with improvement in sensation achieved by decompression of the tibial nerve. McQueen and Court-Brown [6] have closely defined the indications for fasciotomy in impending compartment syndrome and have clarified the long debate about the role of monitoring of compartmental pressure by defining the pressure threshold for intervention as the difference between diastolic pressure and compartment pressure. Fasciotomy is indicated when this difference falls below 30 mm of mercury (which is less than the critical closing pressure of muscle arterioles).
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Table 1
Arterial injuries, traumatic false aneurysms and arterio-venous fistulae in association with nerve lesions: 1975-1996" Common femoral Superficial femoral Profunda femoris Inferior gluteal Popliteal Posterior tibial Anterior tibial
3 11 6 4 33 1.2 13
*Arterial lesions complicated nearly 25% of injuries to major trunk nerves, or caused those lesions.
Holden's [7] review is particularly good, as he rightly condemns sympathetic block in i m p e n d i n g ischaemic contracture, and defines clinical criteria for action: first, and foremost, pain persisting after reduction of fracture refractory to m o d e r a t e analgesia, and second tense swelling of the afflicted compartments. The remarkable resistance of nerves to ischaemia is s h o w n b y some of these cases. A patient presented to us after primary treatment of an open fractured femur complicated b y a sciatic palsy. The skin had been closed b y the time he reached us and there was gas in the muscles of the thigh. The flexor c o m p a r t m e n t was excised, the sciatic nerve lay isolated over a length of 25 cm. There was useful recovery over the course of 2 years (Table 1). We have seen a n u m b e r of iatrogenic cases. One patient presented in severe pain after a poorly p e r f o r m e d tibial osteotomy. There was a complete lesion of the tibial nerve with sympathetic paralysis in the foot. Repair of the false a n e u r y s m of the posterior tibial artery was followed b y rapid and complete pain relief. In another case a false expanding a n e u r y s m of the lateral genicular artery was caused b y an arthroscopic meniscectomy. The diagnosis was not m a d e until it was too late to p r e v e n t massive ischaemic fibrosis of all muscles in the leg.
Penetrating missile injuries Delorme in 1915 [8], then Inspector General of the Medical Services of the Armies of France, outlined a m e t h o d for the treatment of shell and bullet w o u n d s based on three principles: resection of scar until a healthy bed is obtained, excision of a d a m a g e d nerve until healthy faces are seen, and tension-free suture
b y adequate immobilisation and flexion of the adjacent joints or b y grafting. Tinel [9] s u p p o r t e d this adding ' w h e n the distance b e t w e e n the segments of the nerve trunk is too great to permit direct suture the only legitimate operation is nerve grafting...'. Stewart and K i n n i n m o n t h [10] treated 23 patients with shotgun w o u n d s to limbs over 4 years. This valuable paper used the Red Cross W o u n d Classification [11]. N o limbs were a m p u t a t e d for vascular injury alone, but three amputations in the lower limbs were indicated because of injury to the sciatic or tibial nerves. S e d d o n [12] described 240 cases of missile injury to the sciatic nerve and its divisions, commenting: patients w h o present with complete paralysis require exploration anyway, because there is no other means of knowing w h e t h e r the nerve has been completely severed. Discovering it to be in continuity is fortuitous. The debate then centres on finding the reason w h y resection and suture should not be p e r f o r m e d ... Kline and H u d s o n [13] describe over 150 cases of w o u n d s to the lUmbo-sacral plexus, the femoral and sciatic nerve and its divisions confirming the value of recording nerve action potentials (NAPs) demonstrating lesions in continuity because spontaneous recovery usually occurred. We have operated in 33 patients with penetrating missite injuries to t r u n k nerves in the lower limbs. The indications for operations included: fracture, bleeding, aneurysm, arterio-venous fistula, severe pain and a nerve defect. Thirty-eight nerves were repaired and an arterial injury complicated 10. Demonstrating NAPs from indirect injury from traction or h a e m a t o m a was certainly useful in the u p p e r limbs but we f o u n d them unreliable in the analysis of sciatic nerve lesions. It seems that the appearance and texture of the nerve is a better guide to resection as S e d d o n [12] found. I therefore think that a vigorous approach is justified in the treatment of nerve d a m a g e in penetrating missile injuries of the lower limbs. The nerve lesion m a y be the first sign of a false a n e u r y s m or arterio-venous fistula. In 25% of our cases the two distinct pain syndromes, causalgia and neurostenalgia, regularly respond to operative treatment. Results of repair are b y no means bad and are better than in traction lesions. © 1998 Blackweli ScienceLtd, Footand Ankle Surgery,4, 109-117
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Fractures or dislocations Watson-Jones [14] described nerve palsies caused by fractures or dislocations; this was amongst the earliest, the largest, and the best of such reports. His precise description of the mechanisms of injury to the nerves included an analysis of the common peroneal nerve lesion from fractures of the fibular neck. Both he and Platt [15] favoured early exploration of nerves injured by fractures; others have taken a more cautious view. Siegel and Gelberman [16] found that 85% of nerves injured in closed fractures recovered spontaneously; and in 65-70% of nerves injured in open fractures, 90% destined to recover had done so by 4 months. On the other hand, Seddon [12] found spontaneous recovery in less than 50% of his 57 cases of nerve palsies after lower limb fractures. About the sciatic nerve palsy associated with fracture of the femur he wrote 'it is wise always to explore the nerve'. We believe that the nerves damaged in skeletal injury in the lower limbs should be explored when: the fracture needs internal fixat~ion;there is a vascular injury; wound exploration is necessary; the fracture or dislocation is irreducible; the neurological lesion becomes more dense whilst under observation; and the injury to the nerve occurred during operation. Neurophysiological studies should be interpreted with caution. The distinction between a degenerative lesion (axonotmesis and neurotmesis) and the conduction block (neurapraxia) is often obvious from clinical examination. In conduction block (neurapraxia) some modalities of function are usually preserved: deep pressure sense conveyed by somatic afferents; vaso and sudo motor function through the post-ganglionic efferents of the sympathetic system. Another difficulty is that electrical phenomena characteristic of denervated muscle, such as insertional activity and fibrillation potentials, will not be seen for some days after the nerve lesion. Furthermore, axonotmesis in which the prognosis for recovery is good if the cause of the lesion is removed cannot be distinguished from neurotmesis save by the passage of time or exposure of the nerve. However, the informed surgeon co-operating with an advised neurophysiologist will always find useful evidence from such studies.
The lumbo-sacral plexus This is protected by the stability of the pelvic girdle, in distinction to the brachial plexus which has the © 1998BlackwellScienceLtd, Footand Ankle Surgery, 4, 109-117
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mobility of the forequarter on the trunk. This is one reason for the relatively scanty literature and rare report of repairs to the lumbo-sacral plexus. Such injuries occur only from massive violence of a lifethreatening nature. London [17] described cases emphasising the vulnerability of the nervi errigente. R~f [18] noted the high incidence of nerve injuries in displaced shear fractures of the pelvis. Huittinen and Slatis [19] found 31 cases of nerve injury in a series of 68 unstable pelvic fractures; L5 and $1 roots were most commonly damaged and six patients were incontinent. Huittenen [20] performed post mortem examinations in 42 pelvic fracture and found damage to the lumbo-sacral plexus in 20 subjects. Hemi-pelvic dislocation damaged the lumbo-sacral trunk and superior gluteal nerve and comminution of the lateral sacral mass was associated with compression of the sacral nerves, and intradural injuries were caused by comminution and displacement of the sacro-iliac joints. In Stoehr's [21] series of 53 cases no less than 40% occurred in the course of operations. Moossy et al. [22] made the important observation that the characteristic pain following avulsion of spinal nerves from the conus could be relieved by dorsal root entry zone (DREZ) coagulation. They are very few reports of successful repair in these injuries. Meyer [23] achieved function close to normal after he grafted the third and fourth lumbar nerves which had been severed by glass. Carlstedt repaired the lumbo-sacral plexus in three cases of closed traction injury to the pelvis (personal communication, 1996). In one the repair was intra-spinal (pre-ganglionic) of $1, $2 and $3 roots. Functional recovery occurred in all three patients. It seems that these results justify a more vigorous approach in the treatment of patients with severe neural deficit in severe pain notwithstanding the difficulties in diagnosis and the forbidding surgical technical problems.
The hip The sciatic nerve is particularly at risk in posterior column fractures. Epstein [24] found 68 nerve injuries in his series of 830 cases and the outcome was poor in 32%. Letournel and Judet [25] found a pre-operative incidence of 12% which rose to 17.5% in the posterior column group from their series of 469 patients. Badger [26] commented: 'sciatic nerve damage is an indication for early manipulation followed
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immediately by open reduction of the fracture and repair of the sciatic nerve if practicable'. It seems hard to add to this. Our experience is limited to 19 cases. In some, release of the nerve from entanglement about a bone fragment, entrapment within the joint, or compression by callus was followed by early relief of pain and improvement of function. The outlook for nerves violently stretched is much worse and only one of our four patients who underwent repair of ruptures of the trunk gained useful recovery.
The knee Damage to the common peroneal nerve at the knee, from fracture dislocations or severe varus injuries, is frequently complicated by arterial injury. The outcome is bad not only because of the extensive longitudinal damage to the nerve but also from ischaemic injury to muscles and to end organs. Sunderland [27] made interesting observations to explain the selective vulnerability of this division of the sciatic nerve: i.e. it is superficial; tethered to the main trunk above the neck of the fibula below; and has less connective tissue and a smaller proportion of autonomic fibres than the tibial division, so that the brunt of the injury is borne by the larger motor and sensory fibres. This is also true at the level of the hip and sciatic notch. The traction lesion has a particularly bad reputation but Sedel and Nizard [28] achieved useful results in 12 of 17 such cases repaired by graft, with gaps ranging from 7 to 20 cm. Posterior tibialis transfer improved function in five of these. They recommended adequate resection of the scarred nerve and found that the length of the graft was not critical. Wilkinson and Birch [29] recorded a series of 27 repairs of the common peroneal nerve excluding those associated with arterial injury (all of which did badly). Results were broadly similar to those achieved by Sedel and Nizard [28]. Wilkinson and Birch [29] emphasised the harmfulness of delay. Four cases of primary grafting at the time of emergency ligament reconstruction did well. I have seen a particularly significant result by Mr D. Roussow (London) who grafted a 15-cm defect in the common peroneal nerve at the same time as emergency repair of the lateral ligament complex. The patient had excellent function 22 months after the nerve graft.
Iatrogenic nerve injuries Accidental damage to nerves in the lower limbs is common and is distressing both to the patient and the clinician. The frequency with which the pain and loss of function exceeds that provoked by the disorder requiring active treatment is depressing. Nerves are injured by doctors in many ways: by drugs causing neuropathy; by anticoagulants causing intra- or extraneural haemorrhage; by intraneural injection of drugs; in neglected ischaemia; by pressure or traction in the anaesthetised patient; by ionising radiation; and by direct injury in the field of surgery. In the last 15 years we operated in 150 cases of such lesions of trunk nerves in the lower limbs and in 50 more cases of cutaneous nerves. One particularly risky operation is that undertaken for a 'cyst' or 'ganglion', often performed through a short incision. Examples include excision of the common peroneal nerve mistaken for the biceps femoris tendon; the sciatic nerve for a 'ganglion'; the tibial nerve for the plantaris tendon; and the common peroneal and sural nerve in varicose vein surgery. During hip arthroplasty the sciatic nerve is particularly at risk. Ratliff [30] reported a series of 50 patients with this complication. Schmalzreid and Amstutz [31] found an incidence of 0.7% in their series of over 3000 hip replacements: the incidence was highest in operations for arthritis after congenital dislocation of the hip (5.8%). We have seen over 100 such cases. Surgery was performed in 54 to establish the cause, relieve pain and restore function. It seems convenient to separate 'direct' injury, from cement, knife or scissor, or ligation (17 cases) from 'indirect' causes, i.e. extra- and intra-neural bleeding, ischaemia, and traction and compression (37 cases). Lengthening of the leg by 2 cm or more causes attenuation of longitudinal blood supply and partial epineurial rupture of the sciatic nerve. This makes the case for urgent revision of the arthroplasty where lengthening is associated with nerve lesion to remove strain on the nerve. It is significant that in those cases where colleagues urgently drained haematoma, either outside or within the nerve trunk, early relief of pain and recovery of function followed in every case. In one case the sciatic nerve was cut during exploration of a complex proximal fracture at the hip. The nerve was immediately sutured and 2 years later there was recovery of both motor power and © 1998 BlackwelIScienceLtd, Footand Ankle Surgery, 4, 109-117
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sensibility in both components of the nerve. It seems best to give a formal warning when recommending arthroplasty of the hip to patients where the risk is significant, as in revision arthroplasty or arthroplasty for congenital dislocation of the hip. The case for urgent re-exploration in cases of severe pain or a dense lesion is amply confirmed by the promising outcome in some cases where this was undertaken. Amongst the most serious consequences of accidental damage to nerves are those following lesions of the slender cutaneous nerves, e.g. to the long saphenous, sural and plantar nerves. We consider the pain following damage to such nerves as post-traumatic neuralgia, which is not sympathetically maintained and does not respond to sympatholytic treatment. It is insensitive to transcutaneous nerve stimulation. It is strange that deliberate section of, e.g. the sural nerve, is hardly ever attended by pain when that operation has been performed for the purpose of nerve grafting but accidental damage so often is. When such nerves are divided the only treatment with any prospect of success is the restoration of neural continuity by direct suture or by interposition of a freeze thawed muscle graft [32, 33]. However, Thomas et al. [34] showed that results for this technique are worse in the lower limbs than in the upper. Prevention is better than cure. Knowledge of the topographical disposition of nerves to the foot and ankle, and respect for them in placing and developing incisions, is the only way forward.
Results of nerve repair in the lower limb It is clear that the sciatic nerve has an undeservedly bad reputation: we have seen four impressive results from primary repair of stab wounds at the hip, three were performed by colleagues on the day of injury. Sunderland et al. [35] present a detailed study of one such case. Seddon [12] commented, in discussing a very large series of injuries to the sciatic nerve and its divisions, that there was a marked lack of correlation between neurological and functional recovery: one of our patients with total sciatic paralysis continued rock climbing. Another, with complete common peroneal paralysis pilots jet aircraft and is playing 18 holes of golf. These patients are not wildly exceptional. By contrast there was a few who, with only a slight © 1998 Blackwell Science Ltd, Foot and A n k l e Surgery, 4, 109-117
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Table 2 Results of repair in c o m m o n peroneal a n d tibial divisions: children a n d adults 1975-1995
Good Fair Poor
Common peroneal rzerve *
Tibial nerve ~-
25 17 28
11 23 18
• n - 7 0 ; ~-n =52.
neurological deficit, were themselves.
very
sorry
for
We follow Seddon [12] in classifying results according to the strength of muscle and recovery of sensation for each of the divisions of sciatic trunk. A good result means power at least 4/5, protective sensation with no more than mild hypersensitivity and no spontaneous pain; a fair result implies motor power of 3/5, protective sensation and hypersensitivity not so bad as to interfere with daily activities. Poor or bad results imply muscle recovery less than 3/5, with or without fixed deformity, trophic changes, and poor sensation with spontaneous pain or hypersensitivity interfering with function. The results from 122 repairs of the common peroneal and tibial divisions between the hip and the knee are shown in Table 2. Assuming acceptable conditions for both patient and surgeon the general conditions for exploration of nerves include: a dense or a painful partial lesion in open wounds from whatever cause, and it must be said that when a nerve stops working after a surgeon has been near it with knife or scissors, is such a case; the sciatic palsy associated with closed fractures of the shaft of the femur; when the nerve palsy is associated with an arterial injury; and when the nerve lesion develops or progresses in the possible presence of such an injury. The factors which limit recovery after repair of the nerve are fully described by Seddon [12]. These include the age of the patient, the level of the injury, and the violence of the injury. We should add that associated injury to a major artery is a bad feature even when the vessel is promptly repaired. The treating surgeon can modify only two conditions which determine outcome. The first of these includes the proper treatment of the associated injuries to skeleton, muscle and skin and in particular of the vessels. The next is to minimise the interval
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between injury and repair. We have already noted good outcome following primary suture of the sciatic nerve at the hip. Repair of that nerve after 12 months is scarcely worthwhile. Most of our late repairs of the common peroneal nerve failed to restore function. Every week counts. Carefully considered neurophysiological investigations are undoubtedly useful in following the course of nerve recovery, or the lack of it, in closed lesions and these should be matched with the clinical evidence. To take the example of the common peroneal palsy from closed fracture of the distal femur or proximal tibia in which there is no clinical evidence of recovery of sensation or of muscle power, one in which the Tinel sign remains static and does not progress distally. Electromyographic confirmation of complete paralysis of t h e relevant muscles by 6 weeks from injury, is a good indication for recommending exploration of the nerve; such findings at 3 months from the injury constitute an overwhelming indication for exploration. The decision becomes more difficult when neurophysiological evidence suggests that the lesion is incomplete or that there is even some regeneration. A surgeon's judgement may become clouded when faced with a nerve lesion after his or her operation. It is, too often, tempting to iake an optimistic view - of waiting and seeing, in expectation of recovery; an expectation which is dashed with depressing frequency. The factors that affect the outcome include age (children usually doing better); the violence of the injury (traction lesions doing much worse than stab wounds or those from penetrating missile injury or from open fractures); and delay between injury and repair, which is particularly significant for high injuries to the sciatic nerve and for the tibial division. Pain
characteristics
Dissatisfaction with the terms 'reflex sympathetic dystrophy' (RSD), with 'sympathetically maintained pain' (SMP) and 'sympathetically independent pain' (SIP) led to the adoption by the International Association for the Study of Pain (IASP) of the proposal of Stanton-Hicks et al. [36], who wrote that 'SMP' can be associated with a number of diseases and a positive response to a sympathetic block should neither be a factor in the nomenclature of the disease nor define the disease'. Thomas and Ochoa [37] severely cautioned against the too easily labelling of
pains as SMP or not; they pointed out that the 'syndrome' of RSD might be no more than a group of symptoms provoked by a wide range of causes, each demanding accurate diagnosis and treatment: While sympathetic events might well influence the abnormal sensory physiology in some of these patients, it is not scientifically rigorous to assume that the sympathetic nervous system has a pathogenic role in determining pain, or the weakness of the subjective response of a patient to a ritualistic medical intervention. Verdugo and Ochoa [38] suggested that pain relief in the absence of successful sympathetic block is in fact a placebo effect. Bonney [39] added that, unfortunately, relief after successful block might also be a placebo effect! These are serious criticisms and must be acknowledged in any classification of pain following injury to peripheral nerves. The classification that follows has the apparent merit of making some sense of pain states after injury, by relating clinical presentation to method of treatment (Birch et al. [40]). 1. Causalgia (IASP Complex regional pain syndrome Type 2). This most severe pain state is uncommon. In most of our cases the provoking lesion was a partial w o u n d to the sciatic nerve, usually from a penetrating missile injury and often with an associated vascular injury. The combination of allody=nia, hyperpathia, extending beyond the territory of the afflicted nerve combined with clinical evidence of vaso and sudo motor instability, and relief of pain by sympathetic block is diagnostic. 2. Reflex Sympathetic Dystrophy (IASP CRPS Type 1). Sympathetically maintained pain in the absence of damage to a trunk nerve. 3. Post-traumatic neuralgia, which can be divided between that following major injury to a major nerve trunk and that following injury to a nerve of cutaneous sensation. A sympathetic manipulation does not affect this and it remains amongst the most resistant of all pain states. 4. Pain due to persistent compression, distortion or ischaemia, which we term neurostenalgia. This group undoubtedly contains many examples of Seddon's 'irritative' lesions [12]. 5. Central pain. This can be divided between that following rupture of spinal nerves at the transitional © 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 109-117
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zone or peripheral to it leading to pure deafferentation, and that following avulsion of the roots of the limb plexus from the spinal cord itself, a lesion which is truly an injury of the central nervous system. 6. Pain maintained either deliberately or subconsciously by the patient in response to a challenge such as a wish to obtain compensation, or resentment against a public body such as an Insurance Company, or other provocation. Causalgia and neurostenalgia respond well to decisive surgical intervention, directed towards relief of the cause, repair of an associated arterial injury and, in causalgia itself, some form of sympathetic blockade which need not necessarily be a formal open sympathectomy. In neurostenalgia the nerve trunk is intact, the lesion is neurapraxia, prolonged conduction block or at worst axonotmesis and the nerve is in some way irritated, tethered, compressed or ischaemic. Treatment of the cause relieves the pain. A 43-year-old woman went through operation of ligation of the short saphenous vein. This was complicated by intense pain and foot drop. A striking feature was the intensity of the pain and its relation to the posture of the leg. She found comfort by lying immobile with the knee and ankle flexed, any attempt to stretch the leg brought on agonising pain. The nerve was re-explored at 7 days from the first operation, and we found the common peroneal nerve encirled by a suture which had reduced its diameter to about one-half of normal. The epineurial vessels in the distal trunk were empty. The suture was removed, the epineurium had not been breached, the suture had been passed around the nerve not through it. This patient was free of pain on awakening, and recovery of nerve lesion was complete at 12 months; it was axonotmesis. Central pain is very much more common, of course, after traction injuries of the brachial plexus but there is the occasional case of pain relief after successful repair of proximal injuries of the lumbo-sacral plexus or following DREZ lesion. Moossy et al. [22] does offer, at last, some hope for the treatment of this particularly severe pain state.
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deformity; transfer of musculo-tendinous units to restore balance across joints; similar transfer to restore loss of active movements; and, on occasion, arthrodesis. These interventions are palliative, often due to the failure of primary treatment, and no musculo-tendinous transfer matches the result of good nerve regeneration. The most common indications in the world remain poliomyelitis and leprosy. Our own experience of some 200 cases is drawn largely from lesions of the lower motor neurone. Pulvertaft's [41] classification of causes of paralysis is good. The precepts of reconstructive work were defined by, amongst others, Nicoladoni [42], Vulpius [43] and Codavilla [44] whose work was largely directed towards treatment of the lower limbs afflicted by poliomyelitis. The reviews of Sharrard [45] and Huckstep [46] are also excellent. The prerequisites for success include: clear definition of loss of function which can be remedied only by transfer; the prognosis for neural function being known; strong motivation on the part of the patient; and the absence of severe pain. Sensation in the body part is desirable. Two essential requirements include the absence of fixed deformity; and, in dynamic deformity, re-alignment or modification of the causal force so that the affected joints are rebalanced. This last is of utmost importance in a growing child. Fixed equinovarus is a common deformity of the ankle and foot, it is often the result of post-ischaemic fibrosis. A 34-year-old man presented with pain, degenerative lesion of the tibial nerve and severe equino varus deformity after fracture of the tibia. At operation the tibial nerve and artery were exposed and decompressed, the tendo-calcaneus and tendons of tibialis posterior, flexor hallucis longus and flexor digitorum profundus were widely lengthened bringing the foot into a plantigrade position. There was early relief of pain and functional plantar flexion of the heel and toes were regained by I year. Similarly useful results have been seen in 18 other patients and a notable feature was the relief of pain with recovery of some sensation in the sole of the foot.
Reconstruction
C o m m o n peroneal n e r v e palsy
Reconstructive surgery signifies operations other than nerve repair designed to restore function. It includes: the release or correction of a fixed
The first method of treatment, by arthrodesis, seems to have fallen into disfavour. Angus and Cowell [47] found a large number of unsatisfactory results after
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triple arthrodesis. N o t all of their patients h a d c o m m o n p e r o n e a l palsy. L a m b r i n u d i ' s m o r e elegant o p e r a t i o n [48] is technically v e r y difficult to d o a n d w h e n d o n e in the y o u n g w a s often f o l l o w e d b y d e g e n e r a t i v e c h a n g e s in the ankle. The idea of restoring active dorsiflexion c o m e s f r o m O b e r [49] w h o r e c o m m e n d e d f o r w a r d transfer of the tibialis p o s t e r i o r m u s c l e b y a superficial route. Watkins et al. [50] r e v i e w e d 25 cases f o l l o w i n g Putti's idea of t r a n s f e r r i n g the m u s c l e t h r o u g h the i n t e r o s s e o u s m e m b r a n e ; g o o d results w e r e seen in 17 cases. L i p s c o m b e a n d S a n c h e z [51] a n d T u r n e r a n d C o o p e r [52] w e r e g u a r d e d l y optimistic. L a r g e r series of m o d i f i e d transfers in the t r e a t m e n t of l e p r o s y c o m e f r o m S r i n a v a s s a n et al. [53], R i c h a r d s [54] a n d S o a r e z [55]. R i c h a r d s e m p h a s i s e d that the tendo-achilles m u s t be l e n g t h e n e d if p a s s i v e dorsiflexion is less t h a n 20 °. Soares [55] s h o w e d that p a s s a g e of the tibialis p o s t e r i o r t h r o u g h the i n t e r o s s e o u s m e m b r a n e is better t h a n w h e n the c i r c u m tibial r o u t e is used. We h a v e u s e d A d a m s ' [56] technique, p r e f e r r i n g t e n d o n to t e n d o n s u t u r e o v e r s u t u r e into bone. Active dorsiflexion w a s r e g a i n e d in one-half of the 51 cases: in s o m e others the tenodesis effect u s e f u l l y corrected deformity.
The growing foot
We h a v e seen v e r y severe p r o g r e s s i v e d e f o r m i t i e s in c h i l d r e n w i t h failure of r e c o v e r y t h r o u g h either the c o m m o n p e r o n e a l n e r v e or the tibial trunk. It is v e r y i m p o r t a n t to r e m e m b e r that n o a r t h r o d e s i s s h o u l d ever be p e r f o r m e d in the g r o w i n g limb unless the m u s c u l a r i m b a l a n c e p r o v o k i n g that d e f o r m i t y has b e e n corrected. The s u r g e o n s h o u l d be alert to the n e e d for a r e - b a l a n c i n g o p e r a t i o n to p r e v e n t fixed d e f o r m i t y of the skeleton. E a c h case m u s t be t a k e n o n its merits b u t p r o g r e s s i v e d e f o r m i t y will e n s u e if care is n o t t a k e n to m a i n t a i n a b a l a n c e b e t w e e n e v e r s i o n a n d inversion. C a l c a n e u s d e f o r m i t y is n o w u n c o m m o n b u t w e h a v e seen cases of it in children w i t h d a m a g e d tibial d i v i s i o n a n d h a v e f o u n d the o p e r a t i o n of posterior transfer of tibialis anterior ( H e r n d o n et al. [57]) to be valuable. We t h i n k it is i m p o r t a n t first to b a l a n c e the forces of i n v e r s i o n a n d e v e r s i o n b e f o r e directing attention to the p o s i t i o n of the heel.
Conclusion In this r e v i e w I h a v e a t t e m p t e d to e m p h a s i s e the c o n t i n u i n g clinical significance of injuries to nerves in the l o w e r limbs a n d the c o n s e q u e n c e s of those injuries. It is s a l u t o r y to recollect the great c o n t r i b u t i o n s m a d e b y those w h o w e n t before 'Verachtet m i r die Meister nicht!'
References 1 Eastcott HHG, Blaisdell FW, Silver D. Acute ischaemia. In: Eastcott HHG, ed., Arterial Surgery, 3rd edn. Edinburgh: Churchill Livingstone, 1992: 31-54. 2 De Bakey ME, Simeone FA. Battle injuries of the arteries in World War II. Ann Surg 1946; 123: 534-579. 3 De Bakey ME, Simeone FA. Acute battle incurred arterial injury. In: Surgery and World War Two, Vascular Surgery. Washington: Medical Department US Army, US Government Printing Office, 1955: 60-148. 4 Barros d'Sa AAB. A decade of missile-induced vascular trauma. Ann Roy Coll Surg Engl 1982; 64: 37M4. 5 Barros d'Sa AAB. Arterial injuries. In: Eastcott HHG, ed., Arterial Surgery, 3rd edn. Edinburgh: Churchill Livingstone, 1992; 355-413. 6 McQueen MM, Court-Brown C-M. Compartment monitoring in tibial fractures. J Bone Joint Surg 1996; 78B: 99-104. 7 Holden CEA. The pathology and prevention of Volkmann's ischaemic contracture. J Bone Joint Surg 1979; 618: 296-299. 8 Delorme E. The treatment of gunshot wounds of nerves. Br ivied J 1915; 1: 853-855. 9 Tinel J. In: Joll CA, ed., Nerve Wounds. rev. edn. London: Balli6re Tindall and Cox. 10 Stewart MPM, Kinninmonth A. Shotgun wounds of the limbs. Injury 1993; 10: 667-670. 11 Coupland RM. War Wounds of Limbs. Oxford, London: Butte!;worth Heinemann, 1993. 12 Seddon HJ. Surgical Disorders of Peripheral Nerves, 2nd edn. Edinburgh, London, New York: Churchill Livingstone, 1975. 13 Kline DG, Hudson AR. Lower extremity nerves. Nerve Injuries Philadelphia: W B Saunders Company, 289-344. 14 Watson-Jones R. Styloid process of the fibula in the knee joint with peroneal palsy. J Bone Joint Surg 1931; 13: 158-260. 15 Platt H. On the peripheral nerve complications of certain fractures. J Bone Joint Surg 1928; 10: 403-414. 16 Siegel DB, Gelberman RG. Peripheral nerve injuries associated with fractures and dislocations. In: Gelberman RH, ed., Operative Nerve Repair and Reconstruction. Philadelphia: JB Lippincott, 1991; 619-633. 17 London PS. A Practical Guide To The Care Of The Injured. Edinburgh: E and S Livingstone, 1967. 18 R~ifL. Double vertical fractures of the pelvis. Acta Chir Scand 1966; 131: 298-305. 19 Huittinen V-M, Sl~itis P. Nerve injury in double vertical pelvic fractures. Acta Chir Scand 1972; 138: 571-575. 20 Huittinen V-M. Lumbosacral nerve injury in fracture of the pelvis: a post-mortem radiographic and patho-anatomical study. Acta Chir Scand 1972; 429 (Suppl.): 7-43. 21 Stoehr M. Traumatic and postoperative lesions of the lumbosacraI plexus. Arch Neurol 1978; 35: 757-760. © 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 109-117
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22 Moossy JJ, Nashold BS, Osborne D et al. Conus medullaris root avulsions. J Neurosurg 1987; 66: 835-841. 23 Meyer VE. Langzeit result nach Nervenrekonstrucktion. Bereich des Plexus Lumbalis: Ein Fallbericht. Hand Chirurgie Mikrochirurgie Plastiche Chirurgie. 14, 1982; 11-13. 24 Epstein HC. Traumatic Dislocation of the Hip. Baltimore: Wilkins and Wilkins, 1980. 25 Letournel E, Judet R. Fractures of the Acetabulum. New York: Springer Verlag, 1981. [Translated by Elsoo RA]. 26 Badger FG. Fractures near or involving joints of the lower limb. In: Ruscoe Clarke, Badger FG, Sevitt S eds., Modern Trends in Accident Surgery and Medicine. London: Butterworth and Co., 1959; 176-195. 27 Sunderland S. Nerve and Nerve Injuries, 2nd edn. Edinburgh: Churchill Livingstone, 1978. 28 Sedel L, .Nizard RR. Nerve grafting for traction injuries of the common peroneal nerve: a report of 17 cases. J Bone Joint Surg 1993; 75B: 772-774. 29 Wilkinson MCP, Birch R. Repair of the common peroneal nerve. 1 Bone Joint Surg 1995; 77B: 501-503. 30 Ratliff AHC. Neurological complications. In: Ling RSM, ed., Complications of Total Hip Replacement. Churchill Livingstone, 1984; 23-29. 3I Schmalzried TP, Amstutz HC. Nerve injury and total hip arthroplasty. In: Gelberman RH ed., Operative Nerve Repair and Reconstruction, Philadelphia: JB Lippincott Company, 1991; 1245-1254. 32 Gattuso JM, Davies AH, Glasby MA et al. Peripheral nerve repair using muscle autografts. J Bone Joint Surg 1988; 70B: 524-529. 33 Glasby MA. Nerve growth in matrices of orientated muscle basement membrane: developing a new method of nerve repair. CIin Anat 1990; 3: 161-182. 34 Thomas M, Stirratt A, Birch R et al. Freeze thawed muscle grafting from painful cutaneous neuromas. J Bone Joint Surg 1994; 76B: 474-476. 35 Sunderland S, McArthur RA, Nam DA. Repair of a transected sciatic nerve. J Bone Joint Surg 1993; 75A: 911-914. 36 Stanton-Hicks M, J~inig W, Hassenbusch S e t al. Reflex sympathetic dystrophy: changing concepts and taxonomy. Pain 1995; 63: 127-133. 37 Thomas PK, Ochoa J. Clinical features and differential diagnosis. In: Dyck PJ, Thomas PK eds., Peripheral Neuropathy, Vol. 3. 1993: Philadelphia: WB Saunders Co., 749-774.
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38 Verdugo R, Ochoa J. Sympathetically maintained pain: I. Phentolamine block questions the concept. Neurology 1994; 44: 1003-1010. 39 Bonney G. Causalgia. Br J Hosp Med 1973; 9: 593-596. 40 Birch R, Bonney G, Wynn Parry CB. Surgical Disorders of Peripheral Nerves. Edinburgh, London, New York: Churchill Livingstone: 1998. 41 Pulvertaft RG. Report of the Committee on Paralytic Diseases including Leprosy and Paralytic Diseases Committee of the International Federation of Societies for Surgery of the Hand. J Hand Surg 1983; 8: 745-748. 42 Nicoladoni C. Ein Vorschlag zur Sehennaht. Wiener Medizinische Wochenschrift; 1880; 30: 1413-I417. 43 Vulpius O. Der Heutige Stand der Sehnenplastik. Zeits Orthop Chir 1904; 1. 44 Codavilla A. Tendon transplants in orthopaedic practice. Clin Orthop 1976; 118: 2. [Translated by Ferrara JD]. 45 Sharrard WJW. Paediatric Orthopaedics and Fractures, 2rid edn. Blackwell, London, Edinburgh, Melbourne: Blackwell, 1971. 46 Huckstep RL. Poliomyelitis. Edinburgh, London, New York: Churchill Livingstone, 1975. 47 Angus PD, Cowell HR. Triple arthrodesis: a critical long-term review. J Bone Joint Surg 1986; 68B: 260-265. 48 Lambrinudi C. New operation on drop foot. Brit J Surg 1927; 15: 193-200. 49 Ober FR. Tendon transplantation in the lower extremity. New Eng J Med 1933; 209: 52-59. 50 Watkins MB, Jones JB, Ryder CT et al. Transplantation of the posterior tibial tendon. J Bone Joint Surg 1954; 36A: 1181-1189. 51 Lipscomb PR, Sanchez JJ. Anterior transplantation of the posterior tibial tendon for persistent palsy of the common peroneal nerve. J Bone Joint Surg 1961; 43A: 60-66. 52 Turner JW, Cooper RR. Anterior transfer of the tibialis posterior through the interosseous membrane. Clin Orthop 1972; 83: 241-244. 53 Srinavasan H, Mukherjee SM, Supramanian RA. Two tail transfer of tibialis posterior for correction of dropped foot in leprosy. J Bone Joint Surg 1968; 50B: 623~28. 54 Richards BM. Interosseous transfer of tibialis posterior for common peroneal palsy. J Bone Joint Surg 1989; 71B: 834-837. 55 Soares D. Tibialis posterior transfer for the correction of foot drop in leprosy. J Bone Joint Surg 1996; 78B: 61-62. 56 Adams JC. Standard Orthopaedic Operations, 2nd edn. Edinburgh, London, New York: Churchill Livingstone, 1980. 57 Herndon CH, Strong JM, Heyman CH. Transposition of the tibialis anterior in the treatment of paralytic talipes calcaneus. J Bone Joint Surg 1956; 38A: 751-760.
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Review article Nerve injuries of the lower limbs R. BIRCH Peripheral Nerve Injury Unit, Royal National Orthopaedic Hospital Trust, Middlesex, UK
Introduction It is a remarkable fact that the fundamental principles in the treatment of divided nerves, and of reconstruction or palliative work for paralysis have been drawn largely from experience in the lower limbs - for the treatment of the missile injuries of wars, for poliomyelitis, and cerebral palsy - and this foundation largely preceded equivalent work in the upper limbs. Yet the plethora of publications relating to this field is far greater in the upper than in the lower limbs. Injuries to nerves of the upper limbs exceed those of the lower by a factor of 5:1 in larger civilian series; but there are a significant number of injuries to the lumbo-sacral plexus and the major trunk nerves in the lower limbs and the toll from road traffic accidents, knife and missile wounds, or surgery are substantial. Since this review is concerned with nerve injuries that affect the ankle and foot discussion will be confined to the lumbo-sacral plexus, the sciatic nerve and its divisions and cutaneous nerves such as the sural and long saphenous. It must be noted that injuries in the lower limbs, unlike the upper, are more often 'compound', i.e. the damage to a nerve or nerves is associated with major damage to other tissues such as skin, muscle, the skeleton and major vessels at the same site. One must consider first the associated arterial injury (and the consequence of neglect of that injury), the particular difficulties attending a missile injury and some difficulties of reconstruction within the growing limb.
Arterial injury Eastcott [1] regarded the popliteal artery as the 'life line of the leg', perhaps reflecting on the findings of Correspondence: Mr Rolfe Birch, MChir, FRCS, Consultant Orthopaedic Surgeon, Peripheral Nerve Injury Unit, Royal National Orthopaedic Hospital Trust, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK. © 1998 Blackwell Science Ltd
De Bakey and Simeone [2, 3] who, in reviewing nearly 2500 arterial war injuries, found that a total of 346 of 502 lower limbs were amputated after ligation of the popliteal artery. Barros d'Sa [4, 5] achieved an amputation rate of 5% in cases of popliteal artery injury caused by missile injury treated in Northern Ireland, the lowest of any civilian or military series published. The principles of treatment in 188 major vascular injuries in the lower limbs of 118 patients included: revascularisation within 4h, fasciotomy of all compartments, vein grafting for the artery, and repair of at least one major vein. After the 'knee-capping injury' in which a close range shotgun blasts the contents of the popliteal fossa, tibia and femur, intraluminal shunts were shown to revolutionise the treatment of vascular injuries complicating fractures of the lower limbs. Two aspects are of particular interest: the effect of aneurysms and arterio-venous fistulae on nerve function and the consequences of post ischaemic fibrosis. Fifty-nine of our cases of post-ischaemic contracture in the lower limbs required operation. Twenty-one of these followed arterial injury, 34 were true compartment syndromes and four more occurred in crushed limbs or in patients in coma. The most common deformity was equinovarus and correction of the deformity was by simple elongation of the tendo-achilles and long flexor tendons but what was remarkable was the regular relief of pain, with improvement in sensation achieved by decompression of the tibial nerve. McQueen and Court-Brown [6] have closely defined the indications for fasciotomy in impending compartment syndrome and have clarified the long debate about the role of monitoring of compartmental pressure by defining the pressure threshold for intervention as the difference between diastolic pressure and compartment pressure. Fasciotomy is indicated when this difference falls below 30 mm of mercury (which is less than the critical closing pressure of muscle arterioles).
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Table 1
Arterial injuries, traumatic false aneurysms and arterio-venous fistulae in association with nerve lesions: 1975-1996" Common femoral Superficial femoral Profunda femoris Inferior gluteal Popliteal Posterior tibial Anterior tibial
3 11 6 4 33 1.2 13
*Arterial lesions complicated nearly 25% of injuries to major trunk nerves, or caused those lesions.
Holden's [7] review is particularly good, as he rightly condemns sympathetic block in i m p e n d i n g ischaemic contracture, and defines clinical criteria for action: first, and foremost, pain persisting after reduction of fracture refractory to m o d e r a t e analgesia, and second tense swelling of the afflicted compartments. The remarkable resistance of nerves to ischaemia is s h o w n b y some of these cases. A patient presented to us after primary treatment of an open fractured femur complicated b y a sciatic palsy. The skin had been closed b y the time he reached us and there was gas in the muscles of the thigh. The flexor c o m p a r t m e n t was excised, the sciatic nerve lay isolated over a length of 25 cm. There was useful recovery over the course of 2 years (Table 1). We have seen a n u m b e r of iatrogenic cases. One patient presented in severe pain after a poorly p e r f o r m e d tibial osteotomy. There was a complete lesion of the tibial nerve with sympathetic paralysis in the foot. Repair of the false a n e u r y s m of the posterior tibial artery was followed b y rapid and complete pain relief. In another case a false expanding a n e u r y s m of the lateral genicular artery was caused b y an arthroscopic meniscectomy. The diagnosis was not m a d e until it was too late to p r e v e n t massive ischaemic fibrosis of all muscles in the leg.
Penetrating missile injuries Delorme in 1915 [8], then Inspector General of the Medical Services of the Armies of France, outlined a m e t h o d for the treatment of shell and bullet w o u n d s based on three principles: resection of scar until a healthy bed is obtained, excision of a d a m a g e d nerve until healthy faces are seen, and tension-free suture
b y adequate immobilisation and flexion of the adjacent joints or b y grafting. Tinel [9] s u p p o r t e d this adding ' w h e n the distance b e t w e e n the segments of the nerve trunk is too great to permit direct suture the only legitimate operation is nerve grafting...'. Stewart and K i n n i n m o n t h [10] treated 23 patients with shotgun w o u n d s to limbs over 4 years. This valuable paper used the Red Cross W o u n d Classification [11]. N o limbs were a m p u t a t e d for vascular injury alone, but three amputations in the lower limbs were indicated because of injury to the sciatic or tibial nerves. S e d d o n [12] described 240 cases of missile injury to the sciatic nerve and its divisions, commenting: patients w h o present with complete paralysis require exploration anyway, because there is no other means of knowing w h e t h e r the nerve has been completely severed. Discovering it to be in continuity is fortuitous. The debate then centres on finding the reason w h y resection and suture should not be p e r f o r m e d ... Kline and H u d s o n [13] describe over 150 cases of w o u n d s to the lUmbo-sacral plexus, the femoral and sciatic nerve and its divisions confirming the value of recording nerve action potentials (NAPs) demonstrating lesions in continuity because spontaneous recovery usually occurred. We have operated in 33 patients with penetrating missite injuries to t r u n k nerves in the lower limbs. The indications for operations included: fracture, bleeding, aneurysm, arterio-venous fistula, severe pain and a nerve defect. Thirty-eight nerves were repaired and an arterial injury complicated 10. Demonstrating NAPs from indirect injury from traction or h a e m a t o m a was certainly useful in the u p p e r limbs but we f o u n d them unreliable in the analysis of sciatic nerve lesions. It seems that the appearance and texture of the nerve is a better guide to resection as S e d d o n [12] found. I therefore think that a vigorous approach is justified in the treatment of nerve d a m a g e in penetrating missile injuries of the lower limbs. The nerve lesion m a y be the first sign of a false a n e u r y s m or arterio-venous fistula. In 25% of our cases the two distinct pain syndromes, causalgia and neurostenalgia, regularly respond to operative treatment. Results of repair are b y no means bad and are better than in traction lesions. © 1998 Blackweli ScienceLtd, Footand Ankle Surgery,4, 109-117
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Fractures or dislocations Watson-Jones [14] described nerve palsies caused by fractures or dislocations; this was amongst the earliest, the largest, and the best of such reports. His precise description of the mechanisms of injury to the nerves included an analysis of the common peroneal nerve lesion from fractures of the fibular neck. Both he and Platt [15] favoured early exploration of nerves injured by fractures; others have taken a more cautious view. Siegel and Gelberman [16] found that 85% of nerves injured in closed fractures recovered spontaneously; and in 65-70% of nerves injured in open fractures, 90% destined to recover had done so by 4 months. On the other hand, Seddon [12] found spontaneous recovery in less than 50% of his 57 cases of nerve palsies after lower limb fractures. About the sciatic nerve palsy associated with fracture of the femur he wrote 'it is wise always to explore the nerve'. We believe that the nerves damaged in skeletal injury in the lower limbs should be explored when: the fracture needs internal fixat~ion;there is a vascular injury; wound exploration is necessary; the fracture or dislocation is irreducible; the neurological lesion becomes more dense whilst under observation; and the injury to the nerve occurred during operation. Neurophysiological studies should be interpreted with caution. The distinction between a degenerative lesion (axonotmesis and neurotmesis) and the conduction block (neurapraxia) is often obvious from clinical examination. In conduction block (neurapraxia) some modalities of function are usually preserved: deep pressure sense conveyed by somatic afferents; vaso and sudo motor function through the post-ganglionic efferents of the sympathetic system. Another difficulty is that electrical phenomena characteristic of denervated muscle, such as insertional activity and fibrillation potentials, will not be seen for some days after the nerve lesion. Furthermore, axonotmesis in which the prognosis for recovery is good if the cause of the lesion is removed cannot be distinguished from neurotmesis save by the passage of time or exposure of the nerve. However, the informed surgeon co-operating with an advised neurophysiologist will always find useful evidence from such studies.
The lumbo-sacral plexus This is protected by the stability of the pelvic girdle, in distinction to the brachial plexus which has the © 1998BlackwellScienceLtd, Footand Ankle Surgery, 4, 109-117
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mobility of the forequarter on the trunk. This is one reason for the relatively scanty literature and rare report of repairs to the lumbo-sacral plexus. Such injuries occur only from massive violence of a lifethreatening nature. London [17] described cases emphasising the vulnerability of the nervi errigente. R~f [18] noted the high incidence of nerve injuries in displaced shear fractures of the pelvis. Huittinen and Slatis [19] found 31 cases of nerve injury in a series of 68 unstable pelvic fractures; L5 and $1 roots were most commonly damaged and six patients were incontinent. Huittenen [20] performed post mortem examinations in 42 pelvic fracture and found damage to the lumbo-sacral plexus in 20 subjects. Hemi-pelvic dislocation damaged the lumbo-sacral trunk and superior gluteal nerve and comminution of the lateral sacral mass was associated with compression of the sacral nerves, and intradural injuries were caused by comminution and displacement of the sacro-iliac joints. In Stoehr's [21] series of 53 cases no less than 40% occurred in the course of operations. Moossy et al. [22] made the important observation that the characteristic pain following avulsion of spinal nerves from the conus could be relieved by dorsal root entry zone (DREZ) coagulation. They are very few reports of successful repair in these injuries. Meyer [23] achieved function close to normal after he grafted the third and fourth lumbar nerves which had been severed by glass. Carlstedt repaired the lumbo-sacral plexus in three cases of closed traction injury to the pelvis (personal communication, 1996). In one the repair was intra-spinal (pre-ganglionic) of $1, $2 and $3 roots. Functional recovery occurred in all three patients. It seems that these results justify a more vigorous approach in the treatment of patients with severe neural deficit in severe pain notwithstanding the difficulties in diagnosis and the forbidding surgical technical problems.
The hip The sciatic nerve is particularly at risk in posterior column fractures. Epstein [24] found 68 nerve injuries in his series of 830 cases and the outcome was poor in 32%. Letournel and Judet [25] found a pre-operative incidence of 12% which rose to 17.5% in the posterior column group from their series of 469 patients. Badger [26] commented: 'sciatic nerve damage is an indication for early manipulation followed
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immediately by open reduction of the fracture and repair of the sciatic nerve if practicable'. It seems hard to add to this. Our experience is limited to 19 cases. In some, release of the nerve from entanglement about a bone fragment, entrapment within the joint, or compression by callus was followed by early relief of pain and improvement of function. The outlook for nerves violently stretched is much worse and only one of our four patients who underwent repair of ruptures of the trunk gained useful recovery.
The knee Damage to the common peroneal nerve at the knee, from fracture dislocations or severe varus injuries, is frequently complicated by arterial injury. The outcome is bad not only because of the extensive longitudinal damage to the nerve but also from ischaemic injury to muscles and to end organs. Sunderland [27] made interesting observations to explain the selective vulnerability of this division of the sciatic nerve: i.e. it is superficial; tethered to the main trunk above the neck of the fibula below; and has less connective tissue and a smaller proportion of autonomic fibres than the tibial division, so that the brunt of the injury is borne by the larger motor and sensory fibres. This is also true at the level of the hip and sciatic notch. The traction lesion has a particularly bad reputation but Sedel and Nizard [28] achieved useful results in 12 of 17 such cases repaired by graft, with gaps ranging from 7 to 20 cm. Posterior tibialis transfer improved function in five of these. They recommended adequate resection of the scarred nerve and found that the length of the graft was not critical. Wilkinson and Birch [29] recorded a series of 27 repairs of the common peroneal nerve excluding those associated with arterial injury (all of which did badly). Results were broadly similar to those achieved by Sedel and Nizard [28]. Wilkinson and Birch [29] emphasised the harmfulness of delay. Four cases of primary grafting at the time of emergency ligament reconstruction did well. I have seen a particularly significant result by Mr D. Roussow (London) who grafted a 15-cm defect in the common peroneal nerve at the same time as emergency repair of the lateral ligament complex. The patient had excellent function 22 months after the nerve graft.
Iatrogenic nerve injuries Accidental damage to nerves in the lower limbs is common and is distressing both to the patient and the clinician. The frequency with which the pain and loss of function exceeds that provoked by the disorder requiring active treatment is depressing. Nerves are injured by doctors in many ways: by drugs causing neuropathy; by anticoagulants causing intra- or extraneural haemorrhage; by intraneural injection of drugs; in neglected ischaemia; by pressure or traction in the anaesthetised patient; by ionising radiation; and by direct injury in the field of surgery. In the last 15 years we operated in 150 cases of such lesions of trunk nerves in the lower limbs and in 50 more cases of cutaneous nerves. One particularly risky operation is that undertaken for a 'cyst' or 'ganglion', often performed through a short incision. Examples include excision of the common peroneal nerve mistaken for the biceps femoris tendon; the sciatic nerve for a 'ganglion'; the tibial nerve for the plantaris tendon; and the common peroneal and sural nerve in varicose vein surgery. During hip arthroplasty the sciatic nerve is particularly at risk. Ratliff [30] reported a series of 50 patients with this complication. Schmalzreid and Amstutz [31] found an incidence of 0.7% in their series of over 3000 hip replacements: the incidence was highest in operations for arthritis after congenital dislocation of the hip (5.8%). We have seen over 100 such cases. Surgery was performed in 54 to establish the cause, relieve pain and restore function. It seems convenient to separate 'direct' injury, from cement, knife or scissor, or ligation (17 cases) from 'indirect' causes, i.e. extra- and intra-neural bleeding, ischaemia, and traction and compression (37 cases). Lengthening of the leg by 2 cm or more causes attenuation of longitudinal blood supply and partial epineurial rupture of the sciatic nerve. This makes the case for urgent revision of the arthroplasty where lengthening is associated with nerve lesion to remove strain on the nerve. It is significant that in those cases where colleagues urgently drained haematoma, either outside or within the nerve trunk, early relief of pain and recovery of function followed in every case. In one case the sciatic nerve was cut during exploration of a complex proximal fracture at the hip. The nerve was immediately sutured and 2 years later there was recovery of both motor power and © 1998 BlackwelIScienceLtd, Footand Ankle Surgery, 4, 109-117
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sensibility in both components of the nerve. It seems best to give a formal warning when recommending arthroplasty of the hip to patients where the risk is significant, as in revision arthroplasty or arthroplasty for congenital dislocation of the hip. The case for urgent re-exploration in cases of severe pain or a dense lesion is amply confirmed by the promising outcome in some cases where this was undertaken. Amongst the most serious consequences of accidental damage to nerves are those following lesions of the slender cutaneous nerves, e.g. to the long saphenous, sural and plantar nerves. We consider the pain following damage to such nerves as post-traumatic neuralgia, which is not sympathetically maintained and does not respond to sympatholytic treatment. It is insensitive to transcutaneous nerve stimulation. It is strange that deliberate section of, e.g. the sural nerve, is hardly ever attended by pain when that operation has been performed for the purpose of nerve grafting but accidental damage so often is. When such nerves are divided the only treatment with any prospect of success is the restoration of neural continuity by direct suture or by interposition of a freeze thawed muscle graft [32, 33]. However, Thomas et al. [34] showed that results for this technique are worse in the lower limbs than in the upper. Prevention is better than cure. Knowledge of the topographical disposition of nerves to the foot and ankle, and respect for them in placing and developing incisions, is the only way forward.
Results of nerve repair in the lower limb It is clear that the sciatic nerve has an undeservedly bad reputation: we have seen four impressive results from primary repair of stab wounds at the hip, three were performed by colleagues on the day of injury. Sunderland et al. [35] present a detailed study of one such case. Seddon [12] commented, in discussing a very large series of injuries to the sciatic nerve and its divisions, that there was a marked lack of correlation between neurological and functional recovery: one of our patients with total sciatic paralysis continued rock climbing. Another, with complete common peroneal paralysis pilots jet aircraft and is playing 18 holes of golf. These patients are not wildly exceptional. By contrast there was a few who, with only a slight © 1998 Blackwell Science Ltd, Foot and A n k l e Surgery, 4, 109-117
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Table 2 Results of repair in c o m m o n peroneal a n d tibial divisions: children a n d adults 1975-1995
Good Fair Poor
Common peroneal rzerve *
Tibial nerve ~-
25 17 28
11 23 18
• n - 7 0 ; ~-n =52.
neurological deficit, were themselves.
very
sorry
for
We follow Seddon [12] in classifying results according to the strength of muscle and recovery of sensation for each of the divisions of sciatic trunk. A good result means power at least 4/5, protective sensation with no more than mild hypersensitivity and no spontaneous pain; a fair result implies motor power of 3/5, protective sensation and hypersensitivity not so bad as to interfere with daily activities. Poor or bad results imply muscle recovery less than 3/5, with or without fixed deformity, trophic changes, and poor sensation with spontaneous pain or hypersensitivity interfering with function. The results from 122 repairs of the common peroneal and tibial divisions between the hip and the knee are shown in Table 2. Assuming acceptable conditions for both patient and surgeon the general conditions for exploration of nerves include: a dense or a painful partial lesion in open wounds from whatever cause, and it must be said that when a nerve stops working after a surgeon has been near it with knife or scissors, is such a case; the sciatic palsy associated with closed fractures of the shaft of the femur; when the nerve palsy is associated with an arterial injury; and when the nerve lesion develops or progresses in the possible presence of such an injury. The factors which limit recovery after repair of the nerve are fully described by Seddon [12]. These include the age of the patient, the level of the injury, and the violence of the injury. We should add that associated injury to a major artery is a bad feature even when the vessel is promptly repaired. The treating surgeon can modify only two conditions which determine outcome. The first of these includes the proper treatment of the associated injuries to skeleton, muscle and skin and in particular of the vessels. The next is to minimise the interval
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R. B I R C H
between injury and repair. We have already noted good outcome following primary suture of the sciatic nerve at the hip. Repair of that nerve after 12 months is scarcely worthwhile. Most of our late repairs of the common peroneal nerve failed to restore function. Every week counts. Carefully considered neurophysiological investigations are undoubtedly useful in following the course of nerve recovery, or the lack of it, in closed lesions and these should be matched with the clinical evidence. To take the example of the common peroneal palsy from closed fracture of the distal femur or proximal tibia in which there is no clinical evidence of recovery of sensation or of muscle power, one in which the Tinel sign remains static and does not progress distally. Electromyographic confirmation of complete paralysis of t h e relevant muscles by 6 weeks from injury, is a good indication for recommending exploration of the nerve; such findings at 3 months from the injury constitute an overwhelming indication for exploration. The decision becomes more difficult when neurophysiological evidence suggests that the lesion is incomplete or that there is even some regeneration. A surgeon's judgement may become clouded when faced with a nerve lesion after his or her operation. It is, too often, tempting to iake an optimistic view - of waiting and seeing, in expectation of recovery; an expectation which is dashed with depressing frequency. The factors that affect the outcome include age (children usually doing better); the violence of the injury (traction lesions doing much worse than stab wounds or those from penetrating missile injury or from open fractures); and delay between injury and repair, which is particularly significant for high injuries to the sciatic nerve and for the tibial division. Pain
characteristics
Dissatisfaction with the terms 'reflex sympathetic dystrophy' (RSD), with 'sympathetically maintained pain' (SMP) and 'sympathetically independent pain' (SIP) led to the adoption by the International Association for the Study of Pain (IASP) of the proposal of Stanton-Hicks et al. [36], who wrote that 'SMP' can be associated with a number of diseases and a positive response to a sympathetic block should neither be a factor in the nomenclature of the disease nor define the disease'. Thomas and Ochoa [37] severely cautioned against the too easily labelling of
pains as SMP or not; they pointed out that the 'syndrome' of RSD might be no more than a group of symptoms provoked by a wide range of causes, each demanding accurate diagnosis and treatment: While sympathetic events might well influence the abnormal sensory physiology in some of these patients, it is not scientifically rigorous to assume that the sympathetic nervous system has a pathogenic role in determining pain, or the weakness of the subjective response of a patient to a ritualistic medical intervention. Verdugo and Ochoa [38] suggested that pain relief in the absence of successful sympathetic block is in fact a placebo effect. Bonney [39] added that, unfortunately, relief after successful block might also be a placebo effect! These are serious criticisms and must be acknowledged in any classification of pain following injury to peripheral nerves. The classification that follows has the apparent merit of making some sense of pain states after injury, by relating clinical presentation to method of treatment (Birch et al. [40]). 1. Causalgia (IASP Complex regional pain syndrome Type 2). This most severe pain state is uncommon. In most of our cases the provoking lesion was a partial w o u n d to the sciatic nerve, usually from a penetrating missile injury and often with an associated vascular injury. The combination of allody=nia, hyperpathia, extending beyond the territory of the afflicted nerve combined with clinical evidence of vaso and sudo motor instability, and relief of pain by sympathetic block is diagnostic. 2. Reflex Sympathetic Dystrophy (IASP CRPS Type 1). Sympathetically maintained pain in the absence of damage to a trunk nerve. 3. Post-traumatic neuralgia, which can be divided between that following major injury to a major nerve trunk and that following injury to a nerve of cutaneous sensation. A sympathetic manipulation does not affect this and it remains amongst the most resistant of all pain states. 4. Pain due to persistent compression, distortion or ischaemia, which we term neurostenalgia. This group undoubtedly contains many examples of Seddon's 'irritative' lesions [12]. 5. Central pain. This can be divided between that following rupture of spinal nerves at the transitional © 1998 Blackwell Science Ltd, Foot and Ankle Surgery, 4, 109-117
NERVE INJURIES OF THE LOWER LIMBS
zone or peripheral to it leading to pure deafferentation, and that following avulsion of the roots of the limb plexus from the spinal cord itself, a lesion which is truly an injury of the central nervous system. 6. Pain maintained either deliberately or subconsciously by the patient in response to a challenge such as a wish to obtain compensation, or resentment against a public body such as an Insurance Company, or other provocation. Causalgia and neurostenalgia respond well to decisive surgical intervention, directed towards relief of the cause, repair of an associated arterial injury and, in causalgia itself, some form of sympathetic blockade which need not necessarily be a formal open sympathectomy. In neurostenalgia the nerve trunk is intact, the lesion is neurapraxia, prolonged conduction block or at worst axonotmesis and the nerve is in some way irritated, tethered, compressed or ischaemic. Treatment of the cause relieves the pain. A 43-year-old woman went through operation of ligation of the short saphenous vein. This was complicated by intense pain and foot drop. A striking feature was the intensity of the pain and its relation to the posture of the leg. She found comfort by lying immobile with the knee and ankle flexed, any attempt to stretch the leg brought on agonising pain. The nerve was re-explored at 7 days from the first operation, and we found the common peroneal nerve encirled by a suture which had reduced its diameter to about one-half of normal. The epineurial vessels in the distal trunk were empty. The suture was removed, the epineurium had not been breached, the suture had been passed around the nerve not through it. This patient was free of pain on awakening, and recovery of nerve lesion was complete at 12 months; it was axonotmesis. Central pain is very much more common, of course, after traction injuries of the brachial plexus but there is the occasional case of pain relief after successful repair of proximal injuries of the lumbo-sacral plexus or following DREZ lesion. Moossy et al. [22] does offer, at last, some hope for the treatment of this particularly severe pain state.
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deformity; transfer of musculo-tendinous units to restore balance across joints; similar transfer to restore loss of active movements; and, on occasion, arthrodesis. These interventions are palliative, often due to the failure of primary treatment, and no musculo-tendinous transfer matches the result of good nerve regeneration. The most common indications in the world remain poliomyelitis and leprosy. Our own experience of some 200 cases is drawn largely from lesions of the lower motor neurone. Pulvertaft's [41] classification of causes of paralysis is good. The precepts of reconstructive work were defined by, amongst others, Nicoladoni [42], Vulpius [43] and Codavilla [44] whose work was largely directed towards treatment of the lower limbs afflicted by poliomyelitis. The reviews of Sharrard [45] and Huckstep [46] are also excellent. The prerequisites for success include: clear definition of loss of function which can be remedied only by transfer; the prognosis for neural function being known; strong motivation on the part of the patient; and the absence of severe pain. Sensation in the body part is desirable. Two essential requirements include the absence of fixed deformity; and, in dynamic deformity, re-alignment or modification of the causal force so that the affected joints are rebalanced. This last is of utmost importance in a growing child. Fixed equinovarus is a common deformity of the ankle and foot, it is often the result of post-ischaemic fibrosis. A 34-year-old man presented with pain, degenerative lesion of the tibial nerve and severe equino varus deformity after fracture of the tibia. At operation the tibial nerve and artery were exposed and decompressed, the tendo-calcaneus and tendons of tibialis posterior, flexor hallucis longus and flexor digitorum profundus were widely lengthened bringing the foot into a plantigrade position. There was early relief of pain and functional plantar flexion of the heel and toes were regained by I year. Similarly useful results have been seen in 18 other patients and a notable feature was the relief of pain with recovery of some sensation in the sole of the foot.
Reconstruction
C o m m o n peroneal n e r v e palsy
Reconstructive surgery signifies operations other than nerve repair designed to restore function. It includes: the release or correction of a fixed
The first method of treatment, by arthrodesis, seems to have fallen into disfavour. Angus and Cowell [47] found a large number of unsatisfactory results after
© 1998 BlackwellScienceLtd, Foot and Ankle Surgery, 4, 109-117
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R. B I R C H
triple arthrodesis. N o t all of their patients h a d c o m m o n p e r o n e a l palsy. L a m b r i n u d i ' s m o r e elegant o p e r a t i o n [48] is technically v e r y difficult to d o a n d w h e n d o n e in the y o u n g w a s often f o l l o w e d b y d e g e n e r a t i v e c h a n g e s in the ankle. The idea of restoring active dorsiflexion c o m e s f r o m O b e r [49] w h o r e c o m m e n d e d f o r w a r d transfer of the tibialis p o s t e r i o r m u s c l e b y a superficial route. Watkins et al. [50] r e v i e w e d 25 cases f o l l o w i n g Putti's idea of t r a n s f e r r i n g the m u s c l e t h r o u g h the i n t e r o s s e o u s m e m b r a n e ; g o o d results w e r e seen in 17 cases. L i p s c o m b e a n d S a n c h e z [51] a n d T u r n e r a n d C o o p e r [52] w e r e g u a r d e d l y optimistic. L a r g e r series of m o d i f i e d transfers in the t r e a t m e n t of l e p r o s y c o m e f r o m S r i n a v a s s a n et al. [53], R i c h a r d s [54] a n d S o a r e z [55]. R i c h a r d s e m p h a s i s e d that the tendo-achilles m u s t be l e n g t h e n e d if p a s s i v e dorsiflexion is less t h a n 20 °. Soares [55] s h o w e d that p a s s a g e of the tibialis p o s t e r i o r t h r o u g h the i n t e r o s s e o u s m e m b r a n e is better t h a n w h e n the c i r c u m tibial r o u t e is used. We h a v e u s e d A d a m s ' [56] technique, p r e f e r r i n g t e n d o n to t e n d o n s u t u r e o v e r s u t u r e into bone. Active dorsiflexion w a s r e g a i n e d in one-half of the 51 cases: in s o m e others the tenodesis effect u s e f u l l y corrected deformity.
The growing foot
We h a v e seen v e r y severe p r o g r e s s i v e d e f o r m i t i e s in c h i l d r e n w i t h failure of r e c o v e r y t h r o u g h either the c o m m o n p e r o n e a l n e r v e or the tibial trunk. It is v e r y i m p o r t a n t to r e m e m b e r that n o a r t h r o d e s i s s h o u l d ever be p e r f o r m e d in the g r o w i n g limb unless the m u s c u l a r i m b a l a n c e p r o v o k i n g that d e f o r m i t y has b e e n corrected. The s u r g e o n s h o u l d be alert to the n e e d for a r e - b a l a n c i n g o p e r a t i o n to p r e v e n t fixed d e f o r m i t y of the skeleton. E a c h case m u s t be t a k e n o n its merits b u t p r o g r e s s i v e d e f o r m i t y will e n s u e if care is n o t t a k e n to m a i n t a i n a b a l a n c e b e t w e e n e v e r s i o n a n d inversion. C a l c a n e u s d e f o r m i t y is n o w u n c o m m o n b u t w e h a v e seen cases of it in children w i t h d a m a g e d tibial d i v i s i o n a n d h a v e f o u n d the o p e r a t i o n of posterior transfer of tibialis anterior ( H e r n d o n et al. [57]) to be valuable. We t h i n k it is i m p o r t a n t first to b a l a n c e the forces of i n v e r s i o n a n d e v e r s i o n b e f o r e directing attention to the p o s i t i o n of the heel.
Conclusion In this r e v i e w I h a v e a t t e m p t e d to e m p h a s i s e the c o n t i n u i n g clinical significance of injuries to nerves in the l o w e r limbs a n d the c o n s e q u e n c e s of those injuries. It is s a l u t o r y to recollect the great c o n t r i b u t i o n s m a d e b y those w h o w e n t before 'Verachtet m i r die Meister nicht!'
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