Fibular head transfixion wire and its relationship to common peroneal nerve: cadaveric analysis

Abstract

Proximal tibio-fibular joint is routinely stabilised during leg lengthening, peri-articular fractures and deformity corrections of tibia. Potential injury to the common peroneal nerve at the level of the fibula head/neck junction during wire insertion is a recognised complication. Previous studies have mapped the course of the common peroneal nerve and its branches at the level of the fibular head, and guidelines are published regarding placement of proximal tibial wires. This study aims to relate the course of the common peroneal nerve to the placement of a lateral insertion fibula head transfixion wire. Standard 1.8-mm Ilizarov ‘olive’ wires were inserted in the fibula head of 10 un-embalmed cadaveric knees. Wires were inserted percutaneously to the fibula head using surface anatomy landmarks and palpation technique. The course of the common peroneal nerve was then dissected. Distances from wire entry point to the course of the common peroneal nerve were measured post-wire insertion. The mean distance of the common peroneal nerve from the anterior aspect of the broadest point of the fibular head was 24.5 mm (range 14.2–37.7 mm). Common peroneal nerve was seen to cross the neck of fibula at a mean distance of 34.8 mm from the tip of fibula (range 21.5–44.3 mm). Wire placement was found to be on average, 52 % of the maximal AP diameter of the fibula head and 64 % of the distance from tip of fibula to the point of nerve crossing fibula neck. When inserting a fibula head transfixion wire, care must be taken not to place wire entry point too distal or posterior on the fibula head. Observing a safe zone in the anterior half of the proximal 20 mm of the fibula head would avoid injury to the nerve. In cases where palpation of fibula is difficult due to patient habitus, we recommend consideration of the use of fluoroscopic guidance during wire transfixion of the proximal tibio-fibular articulation to avoid wire insertion too distally and subsequent potential nerve injury.

Safe corridor for fibular transfixation wire in relation to common peroneal nerve: A cadaveric analysis

“…[14][15][16] We have found that the distance from the tip of the styloid process of the fibula to the nerve as it winds around the neck was 32.3 mm (range 20-50 mm). This finding was similar quoted by the following authors as mentioned in Table 3.This finding concurs with Rupp et al 17 and Dearden et al 5 and same as Ryan et al 6 . In case small metaphyseal fragments, need of drop wires are essential.…”

“…The distance of the nerve behind the fibula at the widest AP diameter was 25 mm (range 16-35 mm) from the anterior aspect of the fibula which was similar to 24.5 mm as reported by Dearden et al 5 In nine of twenty specimens, the nerve was touching and lying in the posterior border of fibula at its maximum AP diameter. If wire is inserted in posterior aspect of fibula there is a risk of injury to CPN.…”

“…Average measurements of the distance from the tip of the fibula head to the wire and to the nerve as it crosses the fibula neck and the full length of fibula and percentage ratio of the distance of the wire from the tip of the fibula to the nerve and ratio of fibula where nerve crosses the neck. The mean diameter of the fibular head at it broadest diameter in the AP plane was found to be 20.6 mm (range 17-26 mm) which was similar to 22.34 mm similar to Dearden et al 5 The wires in our series were seen to be inserted, on average, 9.45 mm from the anterior aspect of the fibula at its broadest point which was bit lower than Dearden et al 5 From these measurements, a ratio was calculated and demonstrates that the wire was on average inserted in the center or 46% of total anterior-to posterior diameter at its widest point (range 35-55 %) when using a landmark palpation technique. So the center of fibula is just posterior when compared to palpatory center as discussed earlier.…”

“…[1][2][3][4] Proximal wires are placed from the lateral side usually by palpation techniques. 5 A thorough knowledge of the anatomy of the CPN and its branches is essential for fibular transfixation wire placement during ilizarov fixator application. In the leg, the CPN courses superficial to the lateral surface of the fibula and approximately 1-2 cm distal to the fibular head and passes into the fibular tunnel 6,7 .…”

Endoscopic Curettage of Bone Cyst of the Fibular Head

“… 3 For excision of an intramedullary lesion of the fibular head and neck, a safe zone is observed in the anterior half of the proximal 20 mm of the fibula head that would avoid injury to the peroneal nerve. 4 However, creation of this bone window may damage the insertions of the lateral collateral ligament, popliteofibular ligament, and biceps femoris tendon or cause avulsion fractures of the fibular head. The purpose of this Technical Note is to report the details of endoscopic curettage of a bone cyst of the fibular head.…”