Anatomy, Bony Pelvis and Lower Limb, Superficial Peroneal (Fibular) Nerve


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Alexandrea Garrett


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Zachary Geiger


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Hajira Basit
Phillip Hynes


Updated:
6/12/2019 12:51:13 AM

Introduction

The superficial peroneal nerve is also known as the superior fibular nerve. The superficial peroneal nerve originates from the common peroneal nerve alongside the deep peroneal nerve. The superficial peroneal nerve is the smaller of the two nerves.[1] The common peroneal nerve is comprised of fibers from spinal nerves L4 through S1 which itself originates from the bifurcation of the sciatic nerve which is composed of nerve fibers from spinal nerves L4 through S3. The sciatic nerve terminates and bifurcates at the apex of the popliteal fossa and becomes the common peroneal nerve and the tibial nerve as it wraps around the fibular neck.[2][3] After bifurcation from the common peroneal, the superficial peroneal nerve courses within the peroneus longus muscle.[1] This nerve thus provides motor innervation to the peroneus longus muscle. Additionally, the nerve also innervates the peroneus brevis muscle.[1] The nerve exits through the peroneal muscles on the anterolateral aspect of the lower half of the lower leg approximately 12 cm above the ankle joint at a defect in the crural fascia also known as the deep fascia of the leg.[1] The remainder of the nerve has sensory function provided by two branches inferiorly which are known as the medial dorsal cutaneous nerve (the larger of the two branches) and the intermediate dorsal cutaneous nerve. These nerves provide sensory innervation to the anterolateral aspect of the leg, the dorsum of the foot, and the dorsal aspect of the toes with the exception of the first web space.[1] The first web space is innervated by the dorsal peroneal nerve.[4]

Structure and Function

The superficial peroneal nerve has both motor and sensory components. The motor component of the nerve innervates the lateral compartment of the lower leg which includes the peroneus longus and peroneus brevis muscles. Motor activation of these muscles by the superficial peroneal nerve is primarily responsible for eversion and mild plantar flexion of the foot.[5] The peroneus longus muscle is also involved in maintaining support for the arch of the foot.[6][5]

The medial dorsal cutaneous nerve and intermediate dorsal cutaneous nerves are the terminal branches of the superficial peroneal nerve. These nerves handle the sensory component of the superficial peroneal nerve to the dorsum of the foot although it does not provide sensory innervation to the first webspace. Instead, the dorsal peroneal nerve provides sensory innervation to this area.[1][4]

Blood Supply and Lymphatics

The lateral compartment of the lower leg in which the superficial peroneal nerve lies receives its vascular supply predominantly from the fibular artery and the posterior tibial artery.[1] However, the superficial peroneal nerve itself receives blood supply from the anterior tibial artery as well as it courses towards the dorsum of the foot.[7][8][9] Because the nerve often runs alongside small perforating cutaneous arteries from the anterior tibial artery, including the superficial peroneal nerve accessory artery, skin flaps or segments of skin including this nerve, known as superficial peroneal neurocutaneous island flaps, have been used for skin grafting purposes and foot reconstruction.[7][8][9] However, the superficial peroneal nerve accessory artery has been shown to be absent in some patients.[8]

Muscles

The superficial peroneal nerve supplies motor innervation to the following muscles:

  • Peroneus longus muscle
  • Peroneus brevis muscle

Physiologic Variants

Anatomic variations of deep (crural) fascia piercings have been widely identified for the superficial peroneal nerve.[10][11][12] It appears that the superficial peroneal nerve pierces the crural fascia as a single nerve then bifurcates into the medial dorsal cutaneous nerve and intermediate dorsal cutaneous nerve as described above approximately 82.7% of the time known as the Type 1 variant.[10] However, approximately 15.6% of the time, it appears that the superficial peroneal nerve bifurcates early, therefore piercing the fascial layer as the medial dorsal cutaneous nerve and intermediate dorsal cutaneous nerve separately. This anomaly is known as the Type 2 variant.[10] Moreover, 1.8% of the time, there is documentation of a Type 3 variant in which the superficial peroneal nerve pierces the fascial layer as a single entity and continues as the normal course for the medial dorsal cutaneous nerve without evidence for an intermediate dorsal cutaneous nerve.[10]

In addition to variation in fascial layer piercings, the superficial peroneal nerve has also been shown to be located in various compartments of the leg rather than the normal lateral leg compartment. According to one study in India, 28.3% of cadaveric specimens were found to have the superficial peroneal nerve located in the anterior compartment.[11]

Surgical Considerations

The superficial peroneal nerve is the only nerve that can be visualized in the human body without dissection by simply plantar flexing, inverting the ankle, and examining the dorsum of the foot.[13][14][15]Despite its straightforward visualization, damage to the superficial peroneal nerve is the most commonly reported complication when performing ankle arthroscopy likely resulting from the fact that anterior ankle arthroscopy is typically performed in the neutral or slightly dorsiflexed position rather than the plantarflexed and inverted position.[14] Complication rates as high as approximately 17% have been reported, with more than 25% of those complications related to superficial peroneal nerve damage.[13] The recommendation is to visualize the nerve first and mark its course on the skin preoperatively to avoid damage.[14][16]

It is important to consider the anatomic variations of the superficial peroneal nerve and its branches as the branch most commonly at risk for iatrogenic injury is the intermediate dorsal cutaneous nerve when it courses near the distal fibula and both the medial and intermediate dorsal cutaneous nerves at the level of the ankle.[12]

Clinical Significance

When the superficial peroneal nerve is injured, one will lose the ability to evert the foot based upon the motor mechanics of the nerve.[1] The dorsum of the foot will exhibit loss of sensation (excepting the first webspace between the great toe and second toe where the deep fibular nerve provides sensory innervation).[1][4] The nerve damage pattern can accompany damage directly to the common peroneal nerve which frequently occurs due to a blow to the lateral side of the knee or a fracture to the fibular head.[1][3] The superficial peroneal nerve can also become trapped, and this can result in pain and paresthesias over the lower leg as well as the dorsum of the foot. Entrapment of the nerve can be secondary to an ankle sprain or twisting injury to the ankle which causes the nerve to stretch in the lower leg or foot.[17] Additionally, the nerve can also become entrapped by the fascia in a patient with either acute or chronic compartment syndrome resulting in reduced blow flow and oxygen delivery to the nerve. Surgical decompression is required to provide relief from pain and other symptoms especially in the acute setting.[18]


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Anatomy, Bony Pelvis and Lower Limb, Superficial Peroneal (Fibular) Nerve - Questions

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An 18-year old male has suffered an injury to his left ankle after falling off of his bike on the pavement. It appears that he has suffered a fracture to his distal fibula. On physical exam, it appears that the patient has lost the ability to evert his left ankle. An injury to the superficial peroneal nerve is suspected. The superficial peroneal nerve supplies which of the following muscles?



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An 89-year old woman experiences a traumatic fall. In the Emergency Department, radiographs indicate that she has suffered a fracture to her right fibular head. She is experiencing pain at the fracture site in addition to paresthesias in her lower leg. The skin over the anterolateral leg and ankle is innervated by which of the following nerves?



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A 13-year-old female is playing softball. After sliding into second-base, she abruptly twists her right ankle and experiences significant pain and paresthesias. In addition to an ankle fracture, the physician suspects that she has also injured the nerve on the anterior aspect of her foot that is the only nerve that can be directly visualized in the human body. To what area of the body does this nerve provide sensation?



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A 17-year-old male is playing football and is tackled at the side of this leg. He falls down and complains of pain in the lower leg. He is taken to the local emergency department where an x-ray reveals a fracture of the proximal fibula. It is suspected that he may have injury to the superficial peroneal nerve. What would the physical exam show?



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A 50-year-old male is about to undergo an anterior ankle arthroscopy. Preoperatively, the surgeon would like to mark off the superficial peroneal nerve to avoid damage to the nerve during surgery. How should he manipulate the foot to properly visualize the nerve?



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Anatomy, Bony Pelvis and Lower Limb, Superficial Peroneal (Fibular) Nerve - References

References

De Maeseneer M,Madani H,Lenchik L,Kalume Brigido M,Shahabpour M,Marcelis S,de Mey J,Scafoglieri A, Normal Anatomy and Compression Areas of Nerves of the Foot and Ankle: US and MR Imaging with Anatomic Correlation. Radiographics : a review publication of the Radiological Society of North America, Inc. 2015 Sep-Oct     [PubMed]
Juneja P,Hubbard JB, Anatomy, Bony Pelvis and Lower Limb, Tibialis Anterior Muscles null. 2018 Jan     [PubMed]
Giuffre BA,Jeanmonod R, Anatomy, Sciatic Nerve null. 2018 Jan     [PubMed]
Garrett A,Geiger Z, Anatomy, Bony Pelvis and Lower Limb, Calf Deep Peroneal (Fibular) Nerve null. 2018 Jan     [PubMed]
D’Abarno A,Bhimji SS, Anatomy, Bony Pelvis and Lower Limb, Leg Lateral Compartment null. 2018 Jan     [PubMed]
Thevenon A,Serafi R,Fontaine C,Grauwin MY,Buisset N,Tiffreau V, An unusual cause of foot clonus: spasticity of fibularis longus muscle. Annals of physical and rehabilitation medicine. 2013 Sep     [PubMed]
Wang CY,Chai YM,Wen G,Han P,Cheng L, Superficial peroneal neurocutaneous flap based on an anterior tibial artery perforator for forefoot reconstruction. Annals of plastic surgery. 2015 Jun     [PubMed]
Kim JS,Son DG,Choi TH,Kim NG,Lee KS,Han KH,Kim JH,Lee SI,Kang D, An anatomic study of the superficial peroneal nerve accessory artery and its perforators, and clinical application of superficial peroneal nerve accessory artery perforator flaps. Annals of plastic surgery. 2008 Jun     [PubMed]
Recalde Rocha JF,Gilbert A,Masquelet A,Yousif NJ,Sanger JR,Matloub HS, The anterior tibial artery flap: anatomic study and clinical application. Plastic and reconstructive surgery. 1987 Mar     [PubMed]
Tomaszewski KA,Graves MJ,Vikse J,Pękala PA,Sanna B,Henry BM,Tubbs RS,Walocha JA, Superficial fibular nerve variations of fascial piercing: A meta-analysis and clinical consideration. Clinical anatomy (New York, N.Y.). 2017 Jan     [PubMed]
Prakash,Bhardwaj AK,Singh DK,Rajini T,Jayanthi V,Singh G, Anatomic variations of superficial peroneal nerve: clinical implications of a cadaver study. Italian journal of anatomy and embryology = Archivio italiano di anatomia ed embriologia. 2010     [PubMed]
Blair JM,Botte MJ, Surgical anatomy of the superficial peroneal nerve in the ankle and foot. Clinical orthopaedics and related research. 1994 Aug     [PubMed]
de Leeuw PA,Golanó P,Blankevoort L,Sierevelt IN,van Dijk CN, Identification of the superficial peroneal nerve: Anatomical study with surgical implications. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2016 Apr     [PubMed]
de Leeuw PA,Golanó P,Sierevelt IN,van Dijk CN, The course of the superficial peroneal nerve in relation to the ankle position: anatomical study with ankle arthroscopic implications. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2010 May     [PubMed]
Stephens MM,Kelly PM, Fourth toe flexion sign: a new clinical sign for identification of the superficial peroneal nerve. Foot     [PubMed]
Ferkel RD,Small HN,Gittins JE, Complications in foot and ankle arthroscopy. Clinical orthopaedics and related research. 2001 Oct     [PubMed]
Myers RJ,Murdock EE,Farooqi M,Van Ness G,Crawford DC, A Unique Case of Common Peroneal Nerve Entrapment. Orthopedics. 2015 Jul 1     [PubMed]
Styf JR,Körner LM, Chronic anterior-compartment syndrome of the leg. Results of treatment by fasciotomy. The Journal of bone and joint surgery. American volume. 1986 Dec     [PubMed]

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