AOTRAUMA.ORG Центр Илизарова  

Общие вопросы/General questions Ортопедия и травматология Help Информационные технологии в медицине
 вверх
 отправить
 поиск
 админ
 главная


Отсутствие активного разгибания I пальца стопы
Ортопедия и травматология Отправлено Alexander Chelnokov 13 Февраль 2003, 01:48
У некоторых пациентов встречается после травмы или операции не свисание стопы как при неврите малоберцового нерва, а только отсутствие активного разгибания I пальца. То есть не работает длинный разгибатель (extensor hallucis longus). Это было у больных с переломами голени в аппаратах, сейчас у одного пациента с переломом вертлужной впадины и одного с двойным переломом голени, у обоих еще до остеосинтеза. Что вызывает это состояние? Заранее спасибо.


<  |  >

 

  • Сообщения о Ортопедия и травматология
  • Также Alexander Chelnokov
  • Связаться с автором
  • Ответить

    Re: Отсутствие активного разгибания I пальца стопы
    Alexander Artemiev 13 Февраль 2003, 01:50
    Мне довелось однажды задеть спицей малоберцовый нерв при эстетической коррекции голени... Два месяца, которые прошли до начала восстановления - самые грустные в моей жизни...Перечитал,
    пересоветовался, пережил...
    Итак:
    1.Независимо от уровня повреждения периферических нервов - начиная от сдавления грыжей на поясничном уровне - в первую очередь страдает порция малоберцового нерва.
    2. Из этой порции нерв,иннервирующий м.extensor hallucis longus - самый страдающий - эта мышца и у меня восстановилась в последнюю очередь.
    3. Во всех учебниках анатомии дифференциация этих нервов заканчивается на уровне разделения общего малоберцового нерва на глубокую и поверхностную ветвь.
    И я до определенного времени был уверен, что мелкие ветви входят в мышцу как бы в проксимальной части брюшка. Онако мне доводилось
    повреждать именно нерв, иннервирующий эту мышцу почти в средней трети голени,или, скажем, на границе верхней и средней трети... Видимо,
    нерв входит в мышцу где-то в середине брюшка...
    4. Я эти случаи как-то во всех случаях связывал со спицами - может быть,не совсем внимательно смотрел до операции...
    С уважением Александр Артемьев

    [ Ответить ]

    • Re: Отсутствие активного разгибания I пальца стопы
      Отправитель: Alexander Chelnokov 13 Февраль 2003, 02:06
      a> Мне довелось однажды задеть спицей малоберцовый нерв при эстетической
      a> коррекции голени... Два месяца, которые прошли до начала

      Повезло, что нетяжелое повреждение было.

      a> мышцу как бы в проксимальной части брюшка. Онако мне доводилось
      a> повреждать именно нерв, иннервирующий эту мышцу почти в средней трети

      Да, именно такое встречалось. Непонятна избирательность у пациента с переломом вертлужной впадины.

      Вот что успел в Medline накопать:

      ===============================================
      Knee Surg Sports Traumatol Arthrosc 1999;7(1):15-9 Related Articles, Links

      Nerve and vessel injuries during high tibial osteotomy combined with
      distal fibular osteotomy: a clinically relevant anatomic study.

      Georgoulis AD, Makris CA, Papageorgiou CD, Moebius UG, Xenakis T,
      Soucacos PN.

      Department of Orthopaedic Surgery, University of Ioannina Medical
      School, Greece.

      Based on our clinical experience and an anatomical study, we examined the conditions under which injury to the popliteal artery, tibial nerve or peroneal nerve and its branches may occur during high tibial osteotomy. In 250 high tibial osteotomies performed in our department, we observed the following intraoperative complications. (1) The popliteal artery was severed in 1 patient and repaired by the same surgical team using a microsurgical technique. (2) A tibial nerve paresis also occurred in 1 patient. (3) In 3 patients, temporary palsy of the anterior tibialis muscle was documented. (4) In 4 other patients, palsy of the extensor hallucis longus occurred. To
      investigate the causes of these complications in the popliteal artery, tibial nerve and branches of the peroneal nerve, we dissected the neurovascular structures surrounding the area of the osteotomy in 10 cadaveric knees and performed a high tibial osteotomy in another 13 cadaveric knees. We concluded the following. (1) The popliteal artery and tibial nerve are protected, at the level of the osteotomy, behind the popliteus and tibialis posterior muscles. Damage can occur only by placing the Hohman retractor behind the muscles. The insertion of the muscles is very close to the periosteum and can be separated only with a scalpel. (2) The tibialis anterior muscle is innervated by a group
      of branches arising from the deep branch of the peroneal nerve. In two-thirds of the dissected knees, we found a main branch close to the periosteum, which can be damaged by dividing the muscle improperly or due to improper placement and pressure of the Hohman retractor. This
      may explain the partially reversible muscle palsy. (3) The extensor hallucis longus is also innervated by 2-3 thin branches, arising from
      the deep branch of the peroneal nerve, but in 25% of the specimens, only one large branch was found. This branch is placed under tension
      by manipulating the distal tibia forward. Thus, it may be damaged by the Hohman retractor during distal screw fixation, tensioned by hyperextension or directly injured during midshaft fibular osteotomy.


      DP - 1979 Feb
      TI - [The isolated loss of extension of the great toe following osteotomy of
      the fibula (author's transl)]
      PG - 31-8
      AB - A peroneal nerve palsy can be observed following operative procedures or
      traumatic lesions of the lower leg. Primary damage of the nerve must be
      differentiated from the tibialis-anterior syndrome and the
      pseudo-paralysis. Following corrective osteotomies of the tibia with
      dissection of the fibula in the upper or medial third isolated lesions of
      the extensor hallucis longus muscle can be seen. Electromyographic and
      anatomical studies reveal that they may be caused by an isolated damage of
      the motor nerve fibres connecting the deep branch of the peroneal nerve
      with the extensor hallucis longus muscle lying very close to the fibula.
      Suggestions how to avoid this damage are made in the paper.
      FAU - Sturz, H
      AU - Sturz H
      FAU - Rosemeyer, B
      AU - Rosemeyer B
      LA - ger
      PT - Journal Article
      TT - Die isolierte Grosszehenheberschwache nach Fibulaosteotomie.
      CY - GERMANY, WEST
      TA - Z Orthop Ihre Grenzgeb
      JID - 1256465
      SB - IM
      MH - Electromyography
      MH - English Abstract
      MH - Female
      MH - Hallux/*innervation
      MH - Human
      MH - Male
      MH - Osteotomy/*adverse effects
      MH - Paralysis/*etiology/physiopathology
      MH - *Peroneal Nerve/anatomy & histology/injuries
      MH - Tibia/*surgery
      EDAT- 1979/02/01
      MHDA- 1979/02/01 00:01
      PST - ppublish
      SO - Z Orthop Ihre Grenzgeb 1979 Feb;117(1):31-8.

      DP - 1992 Mar
      TI - The dropped big toe.
      PG - 222-5
      AB - Surgical procedures for exposure of the upper third of the fibula have
      been known to cause weakness of the long extensor of the big toe
      post-operatively. The authors present three representative cases of
      surgically induced dropped big toe. From cadaveric dissection, an anatomic
      basis was found for this phenomenon. The tibialis anterior and extensor
      digitorum longus muscles have their origin at the proximal end of the leg
      and receive their first motor innervation from a branch that arises from
      the common peroneal or deep peroneal nerve at about the level of the neck
      of the fibula. However, the extensor hallucis longus muscle originates in
      the middle one-third of the leg and the nerves innervating this muscle run
      a long course in close proximity to the fibula for up to ten centimeters
      from a level below the neck of the fibula before entering the muscle.
      Surgical intervention in the proximal one-third of the fibula just distal
      to the origin of the first motor branch to the tibialis anterior and
      extensor digitorum longus muscles carries a risk of injury to the nerves
      innervating the extensor hallucis longus.
      AD - Department of Orthopaedic Surgery, National University of Singapore.
      FAU - Satku, K
      AU - Satku K
      FAU - Wee, J T
      AU - Wee JT
      FAU - Kumar, V P
      AU - Kumar VP
      FAU - Ong, B
      AU - Ong B
      FAU - Pho, R W
      AU - Pho RW
      LA - eng
      PT - Journal Article
      CY - SINGAPORE
      TA - Ann Acad Med Singapore
      JID - 7503289
      SB - IM
      MH - Adolescent
      MH - Case Report
      MH - Female
      MH - Foot Deformities, Acquired/*etiology/pathology/radiography
      MH - *Hallux
      MH - Human
      MH - Intraoperative Complications/*etiology/pathology/radiography
      MH - Middle Age
      MH - Peroneal Nerve/*injuries
      EDAT- 1992/03/01
      MHDA- 1992/03/01 00:01
      PST - ppublish
      SO - Ann Acad Med Singapore 1992 Mar;21(2):222-5.


      DP - 1999 May
      TI - Dropped hallux after the intramedullary nailing of tibial fractures.
      PG - 481-4
      AB - We made a prospective study of 208 patients with tibial fractures treated
      by reamed intramedullary nailing. Of these, 11 (5.3%) developed
      dysfunction of the peroneal nerve with no evidence of a compartment
      syndrome. The patients with this complication were significantly younger
      (mean age 25.6 years) and most had closed fractures of the forced-varus
      type with relatively minor soft-tissue damage. The fibula was intact in
      three, fractured in the distal or middle third in seven, with only one
      fracture in the proximal third. Eight of the 11 patients showed a 'dropped
      hallux' syndrome, with weakness of extensor hallucis longus and numbness
      in the first web space, but no clinical involvement of extensor digitorum
      longus or tibialis anterior. This was confirmed by nerve-conduction
      studies in three of the eight patients. There was good recovery of muscle
      function within three to four months in all cases, but after one year
      three patients still had some residual tightness of extensor hallucis
      longus, and two some numbness in the first web space. No patient required
      further treatment.
      AD - Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, UK.
      FAU - Robinson, C M
      AU - Robinson CM
      FAU - O'Donnell, J
      AU - O'Donnell J
      FAU - Will, E
      AU - Will E
      FAU - Keating, J F
      AU - Keating JF
      LA - eng
      PT - Journal Article
      CY - ENGLAND
      TA - J Bone Joint Surg Br
      JID - 0375355
      SB - AIM
      SB - IM
      MH - Adolescent
      MH - Adult
      MH - Aged
      MH - Female
      MH - Follow-Up Studies
      MH - *Fracture Fixation, Intramedullary
      MH - Hallux/*innervation
      MH - Human
      MH - Hypesthesia/etiology
      MH - Male
      MH - Middle Age
      MH - Muscle Denervation
      MH - Muscle, Skeletal/innervation
      MH - Peroneal Nerve/*injuries
      MH - Postoperative Complications/*etiology
      MH - Tibial Fractures/*surgery
      EDAT- 2000/06/29 11:00
      MHDA- 2000/07/15 11:00
      PST - ppublish
      SO - J Bone Joint Surg Br 1999 May;81(3):481-4

      DP - 1991
      TI - Complications of reamed intramedullary nailing of the tibia.
      PG - 184-9
      AB - A retrospective review of 60 acute fractures of the tibia treated with
      reamed intramedullary nailing was undertaken to document the spectrum of
      complications associated with this procedure. Forty-five tibial fractures
      were followed to radiographic union; follow-up averaged 25 months (range,
      10-63 months). Complications were categorized into intraoperative, early
      postoperative, and late postoperative groups. Intraoperative complications
      occurred in 6 of the 60 (10%) fractures and included propagation of the
      tibial fracture into the insertion site of the nail in four cases. In each
      of two other fractures, at least one of the proximal interlocking screws
      was documented to have poor bony purchase. These complications did not
      affect final fracture alignment or clinical result. Early complications
      included soft-tissue complications, complications of fixation, and
      neurologic complications. Four patients developed hematomas at the nail
      insertion site. Eight fractures were stabilized in greater than 5 degrees
      of varus or valgus. Neurologic deficits directly related to the procedure
      were documented in 18 patients (30%). The majority were minor sensory
      neuropraxias of the peroneal nerve. Sixteen (89%) of these nerve palsies
      were transient, resolving within 3-6 months. Two patients had persistent
      nerve deficits at 1-year follow-up. In the late complications group, 10 of
      the 45 (22%) tibial fractures followed to union developed patellar
      tendinitis. Nonunion developed in two fractures, both of which required
      additional surgical procedures to obtain fracture union. Two deep
      infections occurred, both of which resolved after local wound care,
      fracture union, and nail removal. Overall, 26 of the 45 tibial fractures
      available for follow-up (58%) developed some complication attributable to
      the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)
      AD - Department of Orthopaedics, Hospital for Joint Diseases, New York, New
      York.
      FAU - Koval, K J
      AU - Koval KJ
      FAU - Clapper, M F
      AU - Clapper MF
      FAU - Brumback, R J
      AU - Brumback RJ
      FAU - Ellison, P S Jr
      AU - Ellison PS Jr
      FAU - Poka, A
      AU - Poka A
      FAU - Bathon, G H
      AU - Bathon GH
      FAU - Burgess, A R
      AU - Burgess AR
      LA - eng
      PT - Journal Article
      CY - UNITED STATES
      TA - J Orthop Trauma
      JID - 8807705
      SB - IM
      MH - Adolescent
      MH - Adult
      MH - Bone Nails
      MH - Female
      MH - Follow-Up Studies
      MH - Fracture Fixation, Intramedullary/*adverse effects
      MH - Hematoma/etiology
      MH - Human
      MH - Infection/etiology
      MH - Intraoperative Complications
      MH - Male
      MH - Middle Age
      MH - Peripheral Nervous System Diseases/etiology
      MH - Peroneal Nerve
      MH - Postoperative Complications
      MH - Retrospective Studies
      MH - Tibial Fractures/*surgery
      EDAT- 1991/01/11 19:15
      MHDA- 2001/03/28 10:01
      PST - ppublish
      SO - J Orthop Trauma 1991;5(2):184-9


      DP - 2002 May
      TI - Extensor hallucis longus innervation: an anatomic study.
      PG - 245-51
      AB - Thirty legs from skeletally mature embalmed cadavers were dissected to
      define the most common pattern and the variants of innervation of the
      extensor hallucis longus muscle and its clinical significance.
      Twenty-seven muscles had only one innervating branch (90%). Only three
      muscles had two innervating branches (10%). Twenty-one of the branches
      entered the muscles from the fibular side (63.6%), six entered the muscles
      from the tibial side (18.2%), and six entered the muscles from the
      anterior edge (18.2%). The branches innervating the extensor hallucis
      longus from the fibular side had a closer relation with the fibular
      periosteum than those entering the muscle from the tibial side or the
      anterior edge. The mean length of these branches between their points of
      origin and entry in the extensor hallucis longus was 5.0 +/- 1.5 cm. The
      high risk zone for the iatrogenic injury to the muscular branch of the
      extensor hallucis longus was located between 5.9 +/- 1.7 and 10.9 +/- 1.7
      cm inferior to the most distal palpable point of the fibular head. The
      current study confirmed that the extensor hallucis longus was supplied
      mostly by one nerve that usually entered the muscle from the fibular side
      and had a close relation to the fibular periosteum in the dangerous zone.
      AD - Department of Orthopaedic Surgery, Medical College of Ohio, Toledo, OH
      43614-5807, USA.
      FAU - Elgafy, Hossein
      AU - Elgafy H
      FAU - Ebraheim, Nabil A
      AU - Ebraheim NA
      FAU - Shaheen, Philip E
      AU - Shaheen PE
      FAU - Yeasting, Richard A
      AU - Yeasting RA
      LA - eng
      PT - Journal Article
      CY - United States
      TA - Clin Orthop
      JID - 0075674
      SB - AIM
      SB - IM
      MH - Cadaver
      MH - Dissection
      MH - Female
      MH - Human
      MH - Leg/*innervation
      MH - Male
      MH - Muscle, Skeletal/*innervation
      EDAT- 2002/04/20 10:00
      MHDA- 2002/06/12 10:01
      PST - ppublish
      SO - Clin Orthop 2002 May;(398):245-51
      ========================================================================





      --
      Best regards,
      Alexander N. Chelnokov

      [ Ответить ]
    Re: Отсутствие активного разгибания I пальца стопы
    DG Alllan 13 Февраль 2003, 01:51
    The nerve to the EHL is a proximal branch off the peroneal. It can run along the fibula in its proximal third. It is danger especially during osteotomies of the fibula, therefore the fibula problably should not be cut in its
    proximal third.

    DG Alllan
    Springfield Illinois, USA
    [ Ответить ]

    Re: Отсутствие активного разгибания I пальца стопы
    Chris Oliver 13 Февраль 2003, 01:53
    J Bone Joint Surg Br 1999 May;81(3):481-4

    Dropped hallux after the intramedullary nailing of tibial fractures.

    Robinson CM, O'Donnell J, Will E, Keating JF.

    Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, UK.

    We made a prospective study of 208 patients with tibial fractures treated by reamed intramedullary nailing. Of these, 11 (5.3%) developed dysfunction of the peroneal nerve with no evidence of a compartment syndrome. The patients with this complication were significantly younger (mean age 25.6 years) and most had closed fractures of the forced-varus type with relatively minor soft-tissue damage. The fibula was intact in three, fractured in the distal or middle third in seven, with only one fracture in the proximal third. Eight of the 11
    patients showed a 'dropped hallux' syndrome, with weakness of extensor hallucis longus and numbness in the first web space, but no clinical involvement of extensor digitorum longus or tibialis anterior. This was confirmed by nerve-
    conduction studies in three of the eight patients. There was good recovery of muscle function within three to four months in all cases, but after one year three patients still had some residual tightness of extensor hallucis longus, and two some numbness in the first web space. No patient required further treatment.
    [ Ответить ]

    Re: Отсутствие активного разгибания I пальца стопы
    David Goetz 14 Февраль 2003, 09:10
    It is possible to damage the motor branch to the EHL with the drill bit for the proximal locking screw of the tibial rod. We have had one such case confirmed: loss of isolated motor loss to the EHL without other weakness or numbness. A brief contracture of the EHL was seen intraoperative at the time of the drill "plunge" into the anterior compartment.

    David R. Goetz MD
    Medical Director, Orthopaedic Trauma
    [ Ответить ]

    Re: Отсутствие активного разгибания I пальца стопы
    Michael Tucker 14 Февраль 2003, 09:12
    The circumstance of 'dropped hallux' does occur occasionally after tibial IM nailing. I have experienced this 2-3 times in my career without obvious explanation. This subject was covered reasonably well in the following article


    JBJS (British) 81(3):481-484 Dropped Hallux After Intramedullary Nailing of Tibial Fractures


    Should be available online. Hope this helps.

    Mike Tucker


    Michael C. Tucker, MD
    Director, Orthopaedic Trauma Service
    Assistant Professor of Orthopaedic Surgery
    Department of Orthopaedic Surgery
    Medical College of Georgia
    1120 15th St.
    Augusta, GA 30912
    [ Ответить ]


    ( Ответить )

    Powered by Zope  Squishdot Powered MedLink
    Посетитель: 0825524
      "По форме правильно, а по существу - издевательство" В.И.Ленин
    ©2001-2019Orthoforum Coordinator.
    [ Главная | Отправить сообщение | Поиск | Админ ]