eISSN: 1509-572x
ISSN: 1641-4640
Folia Neuropathologica
Current issue Archive Manuscripts accepted About the journal Editorial board Journal's reviewers Abstracting and indexing Subscription Contact Instructions for authors Ethical standards and procedures
SCImago Journal & Country Rank
vol. 43

Original article
The lower extremity nerve injuries – own experience in surgical treatment

Jerzy Gosk
Roman Rutowski
Jerzy Rabczyński

Folia Neuropathol 2005; 43 (3): 148-152
Online publish date: 2005/09/30
Article file
- The lower.pdf  [1.10 MB]
Get citation
JabRef, Mendeley
Papers, Reference Manager, RefWorks, Zotero
Communicating author:
Jerzy Gosk, Department of Trauma and Hand Surgery Medical University of Wrocław, ul. R. Traugutta 57/59, 50-417 Wrocław, Poland,
tel. +48 71 370 02 12, fax +48 71 344 25 29, e-mail: chiruraz@churaz.am.wroc.pl

The lower extremity nerves injuries are relatively rare and their frequency is assessed to about 20% of overall lesions to the peripheral nerve system [12]. The injuries of the common peroneal nerve are the most frequent and the lesions of the sciatic and tibial nerve are rather rare [6,9-11,16]. Lesions of the femoral and obturator nerve are unusual [2,7,8]. The mechanism of injury of the lower extremity nerves includes laceration, compression, traction and focal ischemia [23,27]. All degrees of severity of the injury from neurapraxia to axonotmesis to neurotmesis may be observed in medical practice [27]. The relatively frequent causes of the lower extremity nerve injuries are penetrating trauma, bone fractures, joint dislocations, injection injuries and operative iatrogenic lesions [3,4,8,9,13,18,21,22,24]. Nerve injuries in the lower limbs are said to have a worse prognosis than those in the upper limbs [23,25].
Material and methods
In the period of 1980-2004, 270 patients with the lower extremity nerve injuries were treated surgically (Department of Trauma and Hand Surgery Medical University of Wrocław). The clinical material consisted of 192 males and 78 females aged from 3 months to 74 years. In the collected material we observed injuries of the following nerves: common peroneal nerve – 125 cases, sciatic nerve – 93 cases, simultaneous common peroneal and tibial nerve – 21, tibial nerve – 17, femoral nerve – 10, medial plantar nerve – 1, superficial peroneal nerve on the foot – 2, deep peroneal nerve on the foot – 1. The reasons of the lower extremity nerve injuries included: wounds – 67 (51 cases with discontinuity), bone fractures – 46 (7 cases with discontinuity), injection injuries – 31, operative iatrogenic lesions – 42 (9 cases with discontinuity), contusions – 38 (5 cases with discontinuity), joint dislocations – 27 (2 cases with discontinuity), other causes – 19 (4 cases with discontinuity). The following surgical procedures were carried out during the treatment: external neurolysis – 164 (Fig. 1), internal neurolysis – 27 (Fig. 2), reconstruction with 2 – 8 sural nerve grafting from 1 to 20 cm – 63 (Fig. 3), direct neurorrhaphy – 12 (Fig. 4), neurotisation – 3, supplementary tenomioplasty (tendon transfer) – 23 (in 1 case without revision of the sciatic nerve) (Fig. 5). Seventeen (17) reoperations were performed: neurolysis of the distal anastomosis after previous reconstruction of the common peroneal nerve – 5, reconstruction after previous neurolysis of the common peroneal nerve – 2, reconstruction after early reconstruction – 3, repeated neurolysis of the sciatic (3), femoral (1) and common peroneal nerve (1) – 5, neurolysis of the common peroneal nerve after previous neurolysis of the sciatic nerve – 2. The control examinations and evaluation of the results of the surgical treatment include the group of 120 patients. The shortest time of after – surgical observation was 2 years. We evaluated the power of muscles based on the BMRC scale (M0-M5) [6,19] and the sensory recovery based on the modified Highet scale (S0-S4) [20]. The examination of the following muscles was performed: quadriceps and sartorius, semimembranosus and semitendinosus, biceps femoris, gastrocnemius and soleus, tibialis anterior and posterior, flexor digitorum longus, flexor hallucis longus, peroneus longus and brevis, extensor digitorum longus, extensor hallucis longus, intrinsics on the plantar aspect of the foot. The following methods of evaluation have been established [23]: very good result – M S3-4, good result – M3,4,5 S2, poor result – M2 S1, bad result – M0-1 S0.

The results of the surgical treatment are shown in table I. The obtained results were analysed in the aspect of the performed surgical procedure and the outcome of this analysis is shown in table II. The efficacy of the surgical intervention (very good and good results) in these groups was: neurolysis – 68.5% (61 from 89 cases), reconstruction –sural nerve grafting – 48. 1% (13 from 27 cases), reconstruction – direct suture – 50% (2 from 4 cases). Proportional participation of the particular surgical procedures in very good and good results were: neurolysis – 80.3%, reconstruction – sural nerve grafting – 17. 1%, reconstruction – direct suture – 2.6% and in poor and bad results were: neurolysis – 63.6%, reconstruction – sural nerve grafting – 31.8%, reconstruction – direct suture – 4.6%.

In our material most often we observed injuries of the common peroneal nerve (54%) and high lesions of the sciatic nerve (34.4%). It confirms the observations of the other authors about the extreme sensibility of the common peroneal nerve to trauma factors [6,16,18,23,25] (Fig. 6, 7). Post – traumatic lesions of the tibial (Fig. 8) and femoral nerve were rather rare. The injuries without discontinuity of the neural trunks were predominant (71.1%) and the mechanism of lesion was different and more than once composed (traction, compression, ischemia). The most frequent cause of neurotmesis was penetrating trauma (wounds) – 65.4%. After the surgical treatment the significant improvement (very good and good results) was found in 63.3% of cases – table I. The best results were obtained in lesions in – continuity treated by neurolysis, which efficacy was 68.5%. During analysis of the reasons of the failure in this group of patients, a strong correlation between ultimate therapeutic results and timing of the operation was found. Very good and good results were obtained when the delay was not more than 8 months. No improvement after the surgical treatment in continuity lesions may be also connected with intrafascicular fibrous tissue proliferation (grade C). This process may occupy a large part of the nerve [14]. The improvement in these cases can be obtained only after reconstruction with sural nerve grafting and the condition of the success is resection of a whole, non- conducts part of the nerve. This kind of decision is not simple and needs wide experience. The choice of the appropriate operative technique should be based on preoperative clinical examination and emg result as well as a microscopic assessment of the nerve structure and intraoperative tests (electrical stimulation) [12,15]. In our material in 2 cases the decision about resection of the common peroneal nerve has been taken due to no improvement after previous neurolysis. Reconstructions with 3 – 5 sural nerve grafting (8 and 14 cm) have been performed, but in these cases the delay was very long. After microsurgical recontructions very good and good results were observed in 48.1% (sural nerve grafting) and in 50% (direct neurorrhaphy). A significant improvement was obtained when a gap of the nerve trunk was not more than 8 cm and it was possible to put the sural nerve in good blood supply tissues. Cases, in which it is necessary to supplement very large gaps and the bed for the sural nerve is scarred and fibrous, have a worse prognosis [14,23,25]. This type of lesions is most often the result of extensive damage including not only the peripheral nerve system, but also the muscular, skeletal and vascular systems [1,17]. The results obtained in our own material are comparable with the results of the other authors [1,5,6,16,23,25,26]. Encouraging results of the surgical treatment of the lower extremity nerve injuries observed in our own and other authors’ materials fully motivate usefulness of this type of management. With the low risk of worse lower extremity function it is possible, in favorable conditions, to achieve a significant improvement of its efficiency. The patient is allowed to live with the activity like before trauma. The efficacy of the treatment is strictly dependent on an early surgical intervention, mechanism and degree of the nerve injury as well as appropriate method of the surgical therapy.

1. Adamczyk R, Motyka M, Cierpka L, Totuszyński J. Uszkodzenia dużych naczyń kończyn dolnych współistniejące ze złamaniami i zwichnięciami. Chir Narz Ruchu Ortop Pol 1989; 4–6: 312-317.
2. Barrick EF. Entrapment of the obturator nerve in association with a fracture of the pelvic ring. J Bone Joint Surg 1998; 2: 258-261.
3. Cornwall R, Radomisli TE. Nerve injury in traumatic dislocation of the hip. Clin Orthop Relat Res 2000; 377: 84-91.
4. De Hart MM, Riley LH Jr. Nerve injuries in total hip arthroplasty. J Am Acad Orthop Surg 1999; 7: 101-111.
5. Driuk NF, Galich SP, Chaikovskii IuB. Surgical treatment of sequelae of nerve trunk injuries of the lower limbs. Ortop Travmatol Protez 1989; 3: 27-29.
6. Fabre T, Piton C, Andre D, Lasseur E, Durandeau A. Peroneal nerve entrapment. J Bone Joint Surg Am 1998; 80: 47-53.
7. Fricker RM, Troeger H. Obturator nerve palsy due to fixation of an acetabular reinforcement ring with transacetabular screws. A case report. J Bone Joint Surg Am 1997; 79: 444-446.
8. Gruson KI, Moed BR. Injury of the femoral nerve associated with acetabular fracture. J Bone Joint Surg 2003; 3: 428-431.
9. Gusta A, Jakuszewski M, Kędzierski M. Powikłania neurologiczne po wszczepieniu endoprotezy stawu biodrowego. Chir Narz Ruchu Ortop Pol 2004; 69 (3): 185-187.
10. Katirji B, Wilbourn AJ. High sciatic lesion mimicking peroneal neuropathy at the fibular head. J Neurol Sci 1994; 121: 172-175.
11. Kline DG, Kim D, Midha R, Harsch C, Tiel R. Management and results of sciatic nerve injuries: a 24 year experience. J Neurosurg 1998; 89: 13-23.
12. Kuś H. Postępowanie w urazach nerwów obwodowych. Materiały naukowe XXVIII Zjazdu PTOiT. Szczecin 1990; pp. 16-27.
13. Leversedge FJ, Gelberman RH, Clohisy JC. Entrapment of the sciatic nerve by the femoral neck following closed reduction of a hip prosthesis. J Bone Joint Surg 2002; 84: 1210-1213.
14. Millesi H. Nerve grafting. Clin Plast Surg 1984; 11: 105-113.
15. Millesi H. Techniques for nerve grafting. Hand Clin 2000; 16: 73-91.
16. Mont MA, Dellon AL, Chen F, Hungerford MW, Krackow KA, Hungerford DS. The operative treatment of peroneal nerve palsy. J Bone Joint Surg Am 1996; 78: 863-869.
17. Nichols JS, Lillehei KO. Nerve injury associated with acute vascular trauma. Surg Clin North Am 1988; 68: 837-852.
18. Nogueira MP, Paley ZD, Bhave A, Herbert A, Nocente C, Herzenberg JE. Nerve lesions associated with limb lengthening. J Bone Joint Surg 2003; 85: 1502-1510.
19. Omer GE. Report of the Committee for evaluation of the clinical result in peripheral nerve injury. J Hand Surg 1983; 8: 754-758.
20. Päzold HJ, Henkert K. Operative Behandlung von Verletzungen peripherer Nerven. Zentralbl Chir 1990; 115: 677-684.
21. Reilly MC, Zinar DM, Matta JM. Neurologic injuries in pelvic ring fractures. Clin Orthop Relat Res 1996; 329: 28-36.
22. Schmalzried TP, Amstutz HC. Nerve injury and total hip arthroplasty. In: Gelberman RH (ed.). Operative nerve repair and reconstruction. JB Lippincott Company – Philadelphia 1991; Vol. 2, 89: 1245-1254.
23. Sedel L. The surgical management of nerve lesions in the lower limbs. Clinical evaluation, surgical technique and results. Int Orthop 1985; 9: 159-170.
24. Selander D. Peripheral nerve injury caused by injection needles. Br J Anaesth 1993; 71: 323-325.
25. Trumble TE, Vanderhooft E, Khan U. Sural nerve grafting for lower extremity nerve injuries. J Orthop Trauma 1995; 9: 158-163.
26. Vastamaki M. Decompression for peroneal nerve entrapment. Acta Orthop Scand 1986; 57: 551-554.
27. Wood MB. Peripheral nerve injuries to the lower extremity. In: Gelberman RH (ed.). Operative nerve repair and reconstruction. JB Lippincott Company – Philadelphia 1991; Vol. 1, 35: 489-504.
Copyright: © 2005 Mossakowski Medical Research Centre Polish Academy of Sciences and the Polish Association of Neuropathologists. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
Quick links
© 2021 Termedia Sp. z o.o. All rights reserved.
Developed by Bentus.