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Tarsal tunnel syndrome following intra-medullary fixation of a fractured tibia – a case report
Case Report
Tarsal tunnel syndrome following intra-medullary fixation of a fractured tibia ± a case report J. G. Kennedy, J. A. Harty, A. A. Syed, P. G. O' Grady and M. M. Stephens Tarsal tunnel syndrome resulting from intramedullary nailing of the tibia has not been previously reported. We present a case where the calcaneal traction pin employed to obtain fracture reduction caused inadvertent hemorrhage into the tarsal tunnel. Subsequent hemorrhagic consolidation within the tunnel caused a clinical posterior tibial nerve compression. Judicious placement of the calcaneal traction pin using easily identifiable bony landmarks can avoid this complication ß 2002 Published by Elsevier Science Ltd.
Introduction
J.G. Kennedy MMSc, MCh, FRCSI, FRCS(Orth), J. A. Harty AFRCSI, A. A. Syed FRCSI, P. G. O'Grady FRCSI, M. M. Stephens FRCSI, Department of Orthopedic Surgery, Cappagh Orthopedic Hospital and Mater Misericordiae Hospital, Dublin, Ireland J. G. Kennedy Department of Orthopaedic Surgery, Suite A 675, Memorial Sloan Kettering Hospital, 1275 York Avenue, New York, NY 10021, USA. Fax: 212 717 3573
Tarsal tunnel syndrome is an entrapment neuropathy of the posterior tibial nerve as it passes beneath the ¯exor retinaculum, posterior to the medial malleolus of the ankle (Keck 1962, Lam 1967). The causes of this neuropathy have been many and varied with compromise of the cross sectional area of the tunnel resulting from both intrinsic and extrinsic factors (Keck 1962, Lam 1962, Lam 1967, Chater 1970, Linscheid et al. 1970, Kenzora et al. 1980, Matricalli 1980, Menon et al. 1980, Baylan et al. 1981, Sammarco & Stephens 1989). We present the case of a tarsal tunnel syndrome resulting from hemorrhagic ®brosis within the tarsal canal. A small accumulation of blood from the insertion of a calcaneal traction pin tracked beneath the ¯exor retinaculum to accumulate within the tarsal tunnel. The resultant delayed neurapraxia was thus caused by a mechanism heretofore not presented in the orthopaedic literature as a possible etiological factor in tarsal tunnel syndrome.
Case report A 25-year-old male was involved in a motor vehicle accident in which he was thrown from a motorcycle and sustained a closed tibial
ß 2002 Published by Elsevier Science Ltd. doi: 10.1054/foot.2001.0720, available online at http://www.idealibrary.com on
diaphyseal shaft fracture. No neurovascular compromise was evident and he was brought to the operating room for intramedullary rod ®xation of the fracture. A Steinmann pin was placed through the body of the os calcis and traction reduction was performed to reduce the fracture. This was achieved with a combination of longitudinal traction and valgus force to maintain alignment. Following both proximal and distal interlocking of the intramedullary rod the traction was released, the pin removed and the patient returned to the recovery room in a comfortable and stable condition. The patient was discharged from the hospital 48 h later with a minimal amount of pain in the medial plantar surface of the foot. The patient returned to the out patient department 10 days later with sharp burning nocturnal pain in the plantar aspect of his foot. Examination con®rmed a plantar hyperaesthesia in association with an inability to abduct or adduct the great toe. Localized tenderness over the medial malleolus in conjunction with a positive Tinnel's tap over the posterior tibial nerve prompted an investigative electromyogram. This supported the diagnosis of tarsal tunnel syndrome with large polyphasic motor units in the abductor hallucis. Despite a course of anti-in¯ammatory medication and a continuous epidural infusion the
The Foot (2002) 12, 109±111 109
Tarsal tunnel syndrome following intra-medullary ®xation of a fractured tibia
patient's symptoms did not improve and a surgical release was performed. The ¯exor retinaculum was released in its entirety. An area of in¯ammation and ®brosis around the posterior tibial nerve was identi®ed and released (Fig. 1). Evidence of local nerve compression was evident upon dissection of the haemo®brosis. The abductor hallucis muscle was also released to identify the medial and lateral plantar branches as they entered the muscle. These were free of any compression. Following surgery the patient obtained immediate relief and has remained symptom free to date.
The etiology of tarsal tunnel syndrome is related to the posterior tibial nerve being con®ned to a ®bro-osseous tunnel. Both intrinsic and extrinsic factors have been implicated including varicosities, neurilemmomas, hypertrophic ¯exor retinaculae, exostoses and fractures of the distal tibia and calcaneus (Lam 1962, Chater 1970, Linscheid et al. 1970, Distifano et al. 1972, Janecki & Dovberg 1977, Kenzora et al. 1980, Matricalli 1980, Menon et al. 1980, Baylan et al. 1981, Taguchi et al. 1987, Sammarco & Stephens 1989). The mechanism of neuropathic injury we present has hitherto not been included in the literature to our knowledge. We propose that a calcaneal traction pin inserted in a position closer to the sustentaculum tali than to the posterior tubercle of the os calcis causes bleeding to track into the adjacent tarsal tunnel. As the fractured tibia was manipulated,
distraction and valgus angulation of the os calcis combined to cause compression of the tunnel. The tight ¯exor retinaculum found at time of surgery con®rms that this patient may have had a predisposition to compress the posterior tibial nerve. Both distraction and angulation caused by traction may have compromised an already tight ®bro-osseous tunnel. Upon release of the traction this compromise would be expected to reverse. This mechanism has been reported in the literature where the compression of the tibial nerve was reversed when traction and valgus angulation were removed (Takakura et al. 1991, Cimino 1993): This did not occur in the case we report and it is therefore clear that the hemorrhage into the tunnel from a juxtaposed traction pin and the consequent ®brosis should be implicated in the pathogenesis of this prolonged tarsaltunnel neurapraxia. The ideal position for a Steinmann traction pin to be placed clearly should not compromise surrounding neurovascular structures. The position of the pin we report on was not directly related to either the posterior tibial nerve or vessels. Local bleeding from bone caused tracking of blood into the ®bro-osseous tunnel. The risk of this complication might be lessened by placing the pin 1 cm posterior and 2 cm plantar to the posterior talar-articulating facet in the os calcis (Fig. 2). This position does not compromise the ¯exor retinaculum on the medial side or the calcaneo®bular ligament on the lateral side (Sammarco & Stephens 1989), and can be palpated as an easily identi®able bony landmark.
Fig. 1 Area of chronic inflammation with haemociderin deposition (curved arrows) and fibrosis (small arrows) H and E25.
Fig. 2 Anatomy of the tarsal tunnel with flexor retinaculum dissected along dotted line to demonstrate posterior tibial nerve and artery. The position of the traction pin is shown, demonstrating proximity to the tarsal tunnel. Placement of the pin in a more posterior and plantar position as recommended would avoid this potential complication.
Discussion
110 The Foot (2002) 12, 109±111
ß 2002 Published by Elsevier Science Ltd.
Tarsal tunnel syndrome following intra-medullary ®xation of a fractured tibia
We believe that this unusual complication of tibial nailing can be avoided with judicious placement of the calcaneal traction pin and with careful manipulation of the fracture fragments avoiding excessive stresses on distal structures. References Baylan S P, Paik S W, Barnert A L, Ko Y H, Yu J, Persellin R H 1981 Prevalence of the tarsal tunnel syndrome in rheumatoid arthritis. Rheum Rehab 29: 148±150 Chater E H 1970 Tarsal tunnel syndrome in rheumatoid arthritis. Br Med J 3: 406 Cimino W R 1993 Tarsal tunnel syndrome: Anatomic and clinical considerations. Tech Orthop 8: 35±39 Distifano V, Sack J T, Whittaker R, Nixon J E 1972 Tarsal tunnel syndrome. Clin Orthop 88: 76±79 Janecki C J, Dovberg J L 1977 Tarsal tunnel syndrome caused by neurilemoma of the medial plantar nerve; A case report. J Bone Joint Surg 59-A: 127±128 Keck C 1962 Tarsal tunnel syndrome. J Bone Joint Surg 44-A: 180
ß 2002 Published by Elsevier Science Ltd.
Kenzora J E, Lenet M D, Sherman M 1980 Synovial cyst of an ankle joint as a cause of tarsal tunnel syndrome. Foot Ankle 3: 181±183 Lam S J S 1962 A tarsal tunnel syndrome. Lancet 2: 1354 Lam S J S 1967 Tarsal tunnel syndrome. J Bone Joint Surg 49-B: 87±92 Linscheid R L, Burton R C, Fredericks E J 1970 Tarsal tunnel syndrome. South Med J 63: 1313±1323 Matricalli B 1980 Tarsal tunnel syndrome caused by ganglion compression. J Neurosurg Sci 24: 183±185 Menon J, Dorfman H D, Renbaum J, Frendlier S 1980 Tarsal tunnel syndrome secondary to neurilemoma of the medial plantar nerve. J Bone Joint Surg 62-A: 301±303 Sammarco G J, Stephens M M 1989 Tarsal tunnel syndrome caused by flexor digitorum accessorius longus. J Bone Joint Surg 72-A: 453±454 Taguchi Y, Nosaka K, Yasuda K, Teramoto K, Mano M, Yammaoto S 1987 The Tarsal tunnel syndrome: A report of 2 unusual cases. Clin Orthop 217: 247±252 Takakura Y, Kitada C, Sugimoto K, Tanaka Y, Tamai S 1991 Tarsal tunnel syndrome, causes and results of operative treatment. J Bone Joint Surg 73-B: 125±128
The Foot
(2002) 12, 109±111
111
Tarsal tunnel syndrome following intra-medullary fixation of a fractured tibia ± a case report J. G. Kennedy, J. A. Harty, A. A. Syed, P. G. O' Grady and M. M. Stephens Tarsal tunnel syndrome resulting from intramedullary nailing of the tibia has not been previously reported. We present a case where the calcaneal traction pin employed to obtain fracture reduction caused inadvertent hemorrhage into the tarsal tunnel. Subsequent hemorrhagic consolidation within the tunnel caused a clinical posterior tibial nerve compression. Judicious placement of the calcaneal traction pin using easily identifiable bony landmarks can avoid this complication ß 2002 Published by Elsevier Science Ltd.
Introduction
J.G. Kennedy MMSc, MCh, FRCSI, FRCS(Orth), J. A. Harty AFRCSI, A. A. Syed FRCSI, P. G. O'Grady FRCSI, M. M. Stephens FRCSI, Department of Orthopedic Surgery, Cappagh Orthopedic Hospital and Mater Misericordiae Hospital, Dublin, Ireland J. G. Kennedy Department of Orthopaedic Surgery, Suite A 675, Memorial Sloan Kettering Hospital, 1275 York Avenue, New York, NY 10021, USA. Fax: 212 717 3573
Tarsal tunnel syndrome is an entrapment neuropathy of the posterior tibial nerve as it passes beneath the ¯exor retinaculum, posterior to the medial malleolus of the ankle (Keck 1962, Lam 1967). The causes of this neuropathy have been many and varied with compromise of the cross sectional area of the tunnel resulting from both intrinsic and extrinsic factors (Keck 1962, Lam 1962, Lam 1967, Chater 1970, Linscheid et al. 1970, Kenzora et al. 1980, Matricalli 1980, Menon et al. 1980, Baylan et al. 1981, Sammarco & Stephens 1989). We present the case of a tarsal tunnel syndrome resulting from hemorrhagic ®brosis within the tarsal canal. A small accumulation of blood from the insertion of a calcaneal traction pin tracked beneath the ¯exor retinaculum to accumulate within the tarsal tunnel. The resultant delayed neurapraxia was thus caused by a mechanism heretofore not presented in the orthopaedic literature as a possible etiological factor in tarsal tunnel syndrome.
Case report A 25-year-old male was involved in a motor vehicle accident in which he was thrown from a motorcycle and sustained a closed tibial
ß 2002 Published by Elsevier Science Ltd. doi: 10.1054/foot.2001.0720, available online at http://www.idealibrary.com on
diaphyseal shaft fracture. No neurovascular compromise was evident and he was brought to the operating room for intramedullary rod ®xation of the fracture. A Steinmann pin was placed through the body of the os calcis and traction reduction was performed to reduce the fracture. This was achieved with a combination of longitudinal traction and valgus force to maintain alignment. Following both proximal and distal interlocking of the intramedullary rod the traction was released, the pin removed and the patient returned to the recovery room in a comfortable and stable condition. The patient was discharged from the hospital 48 h later with a minimal amount of pain in the medial plantar surface of the foot. The patient returned to the out patient department 10 days later with sharp burning nocturnal pain in the plantar aspect of his foot. Examination con®rmed a plantar hyperaesthesia in association with an inability to abduct or adduct the great toe. Localized tenderness over the medial malleolus in conjunction with a positive Tinnel's tap over the posterior tibial nerve prompted an investigative electromyogram. This supported the diagnosis of tarsal tunnel syndrome with large polyphasic motor units in the abductor hallucis. Despite a course of anti-in¯ammatory medication and a continuous epidural infusion the
The Foot (2002) 12, 109±111 109
Tarsal tunnel syndrome following intra-medullary ®xation of a fractured tibia
patient's symptoms did not improve and a surgical release was performed. The ¯exor retinaculum was released in its entirety. An area of in¯ammation and ®brosis around the posterior tibial nerve was identi®ed and released (Fig. 1). Evidence of local nerve compression was evident upon dissection of the haemo®brosis. The abductor hallucis muscle was also released to identify the medial and lateral plantar branches as they entered the muscle. These were free of any compression. Following surgery the patient obtained immediate relief and has remained symptom free to date.
The etiology of tarsal tunnel syndrome is related to the posterior tibial nerve being con®ned to a ®bro-osseous tunnel. Both intrinsic and extrinsic factors have been implicated including varicosities, neurilemmomas, hypertrophic ¯exor retinaculae, exostoses and fractures of the distal tibia and calcaneus (Lam 1962, Chater 1970, Linscheid et al. 1970, Distifano et al. 1972, Janecki & Dovberg 1977, Kenzora et al. 1980, Matricalli 1980, Menon et al. 1980, Baylan et al. 1981, Taguchi et al. 1987, Sammarco & Stephens 1989). The mechanism of neuropathic injury we present has hitherto not been included in the literature to our knowledge. We propose that a calcaneal traction pin inserted in a position closer to the sustentaculum tali than to the posterior tubercle of the os calcis causes bleeding to track into the adjacent tarsal tunnel. As the fractured tibia was manipulated,
distraction and valgus angulation of the os calcis combined to cause compression of the tunnel. The tight ¯exor retinaculum found at time of surgery con®rms that this patient may have had a predisposition to compress the posterior tibial nerve. Both distraction and angulation caused by traction may have compromised an already tight ®bro-osseous tunnel. Upon release of the traction this compromise would be expected to reverse. This mechanism has been reported in the literature where the compression of the tibial nerve was reversed when traction and valgus angulation were removed (Takakura et al. 1991, Cimino 1993): This did not occur in the case we report and it is therefore clear that the hemorrhage into the tunnel from a juxtaposed traction pin and the consequent ®brosis should be implicated in the pathogenesis of this prolonged tarsaltunnel neurapraxia. The ideal position for a Steinmann traction pin to be placed clearly should not compromise surrounding neurovascular structures. The position of the pin we report on was not directly related to either the posterior tibial nerve or vessels. Local bleeding from bone caused tracking of blood into the ®bro-osseous tunnel. The risk of this complication might be lessened by placing the pin 1 cm posterior and 2 cm plantar to the posterior talar-articulating facet in the os calcis (Fig. 2). This position does not compromise the ¯exor retinaculum on the medial side or the calcaneo®bular ligament on the lateral side (Sammarco & Stephens 1989), and can be palpated as an easily identi®able bony landmark.
Fig. 1 Area of chronic inflammation with haemociderin deposition (curved arrows) and fibrosis (small arrows) H and E25.
Fig. 2 Anatomy of the tarsal tunnel with flexor retinaculum dissected along dotted line to demonstrate posterior tibial nerve and artery. The position of the traction pin is shown, demonstrating proximity to the tarsal tunnel. Placement of the pin in a more posterior and plantar position as recommended would avoid this potential complication.
Discussion
110 The Foot (2002) 12, 109±111
ß 2002 Published by Elsevier Science Ltd.
Tarsal tunnel syndrome following intra-medullary ®xation of a fractured tibia
We believe that this unusual complication of tibial nailing can be avoided with judicious placement of the calcaneal traction pin and with careful manipulation of the fracture fragments avoiding excessive stresses on distal structures. References Baylan S P, Paik S W, Barnert A L, Ko Y H, Yu J, Persellin R H 1981 Prevalence of the tarsal tunnel syndrome in rheumatoid arthritis. Rheum Rehab 29: 148±150 Chater E H 1970 Tarsal tunnel syndrome in rheumatoid arthritis. Br Med J 3: 406 Cimino W R 1993 Tarsal tunnel syndrome: Anatomic and clinical considerations. Tech Orthop 8: 35±39 Distifano V, Sack J T, Whittaker R, Nixon J E 1972 Tarsal tunnel syndrome. Clin Orthop 88: 76±79 Janecki C J, Dovberg J L 1977 Tarsal tunnel syndrome caused by neurilemoma of the medial plantar nerve; A case report. J Bone Joint Surg 59-A: 127±128 Keck C 1962 Tarsal tunnel syndrome. J Bone Joint Surg 44-A: 180
ß 2002 Published by Elsevier Science Ltd.
Kenzora J E, Lenet M D, Sherman M 1980 Synovial cyst of an ankle joint as a cause of tarsal tunnel syndrome. Foot Ankle 3: 181±183 Lam S J S 1962 A tarsal tunnel syndrome. Lancet 2: 1354 Lam S J S 1967 Tarsal tunnel syndrome. J Bone Joint Surg 49-B: 87±92 Linscheid R L, Burton R C, Fredericks E J 1970 Tarsal tunnel syndrome. South Med J 63: 1313±1323 Matricalli B 1980 Tarsal tunnel syndrome caused by ganglion compression. J Neurosurg Sci 24: 183±185 Menon J, Dorfman H D, Renbaum J, Frendlier S 1980 Tarsal tunnel syndrome secondary to neurilemoma of the medial plantar nerve. J Bone Joint Surg 62-A: 301±303 Sammarco G J, Stephens M M 1989 Tarsal tunnel syndrome caused by flexor digitorum accessorius longus. J Bone Joint Surg 72-A: 453±454 Taguchi Y, Nosaka K, Yasuda K, Teramoto K, Mano M, Yammaoto S 1987 The Tarsal tunnel syndrome: A report of 2 unusual cases. Clin Orthop 217: 247±252 Takakura Y, Kitada C, Sugimoto K, Tanaka Y, Tamai S 1991 Tarsal tunnel syndrome, causes and results of operative treatment. J Bone Joint Surg 73-B: 125±128
The Foot
(2002) 12, 109±111
111