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Anatomic Study of the Superficial Peroneal Nerve Using Sonography

¹ Laboratoire d'Anatomie, Faculté de Médecine, Lille, France; and Service de Radiologie et d'Imagerie Musculosquelettique, Hôpital Roger Salengro, Rue Emile Laine, Lille 59037, France.

Received October 2, 2008; accepted after revision December 30, 2008.

 
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Address correspondence to C. Canella (clacanella{at}yahoo.com.br).

Abstract

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OBJECTIVE. The purpose of our study was to show that sonography allows precise assessment of the location and course of the superficial peroneal nerve and of its relationship with other structures.

MATERIALS AND METHODS. This study, initially undertaken in cadavers, was followed by sonographic studies of 30 healthy adult volunteers (60 legs) by two radiologists in consensus. The location and course of the superficial peroneal nerve and its relationship with the adjacent anatomic structures were analyzed.

RESULTS. The entire course of the superficial peroneal nerve could be identified using sonography. The level at which the superficial peroneal nerve emerges between the peroneus longus and extensor digitorum longus muscles and the level at which it pierces the crural fascia and becomes subcutaneous were found to be highly variable. The superficial peroneal nerve was found to be located in the anterior compartment in 26.7% of the legs and to divide before piercing the crural fascia in 6.7% of the legs.

CONCLUSION. The superficial peroneal nerve can be clearly depicted by sonography. Knowledge of the nerve's precise location, which may show individual variations, may have useful clinical applications.

Keywords: anatomy • common peroneal nerve • crural fascia • sonography • superficial peroneal nerve • ultrasound

Introduction

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The superficial peroneal nerve, also called superficial fibular or musculocutaneous nerve, is a branch of the common peroneal nerve. The superficial peroneal nerve supplies the sensitive innervation of the skin of the dorsal surface of the toes except the lateral side of the little toe and the adjacent sides of the big and index toes. This nerve, which may present several anatomic variations, can be injured during trauma or surgery, especially in the ankle region [1, 2]. It may also be compressed where it pierces the crural fascia and becomes subcutaneous (entrapment syndrome) [3-7].

During the past few years, sonography has been reported to be a useful imaging method for the assessment of many disorders affecting the nerves of the appendicular skeleton [7, 8]. However, to our knowledge, no detailed description of the superficial peroneal nerve on sonography has been reported to date. Precise mapping of the course of this nerve may have useful clinical implications, such as confirming lesions of the superficial peroneal nerve, avoiding injury to it during surgery, and aiding the injection of anesthetics when a regional ankle block anesthesia is considered [9-11].

The purpose of our study was to show that sonography allows precise assessment of the location and course of the superficial peroneal nerve in the leg and of its relationships with other structures.

Materials and Methods

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Anatomic Cadaveric Study
The study was initially undertaken on cadavers to gain a better understanding of the anatomic course of the superficial peroneal nerve. Four leg specimens (two right and two left) were harvested from four embalmed cadavers (three men and one woman; mean age at death, 71 years) for dissection. Another leg specimen (right leg of woman; age at death, 78 years) was sectioned into contiguous 3-mm axial slices. The location and course of the superficial peroneal nerve and its relationships with the adjacent anatomic structures were analyzed simultaneously and in consensus by two musculoskeletal radiologists with 4 and 8 years of experience in musculoskeletal sonography, respectively. All the specimens were photographed using a digital camera. The axial sections were then used for histologic examination.

Sonographic Study in Cadavers
Four other cadaveric leg specimens were used to confirm the accuracy of the sonographic depiction of the superficial peroneal nerve. Three leg specimens (two right and one left) were collected from three embalmed cadavers (two men and one woman; mean age at death, 77 years). The same two musculoskeletal radiologists performed sonography in the axial plane to depict the superficial peroneal nerve in consensus. They injected blue stain (Bleu Patente V, Guerbet) under sonographic guidance in contact with the suspected superficial peroneal nerve at two places: where it emerges superficially between the peroneus longus and extensor digitorum longus muscles, separated by the anterior crural intermuscular septum, in the proximal portion of the leg, and more distally, where it pierces the crural fascia and becomes subcutaneous. Two legs were then dissected, and the third was sectioned into contiguous 3-mm axial slices.

View larger version (24K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —Schematic drawings of normal course of superficial peroneal nerve. Drawings of normal course of superficial peroneal nerve in leg after dissection show peroneus longus muscle (PL) exposed (A) and displaced (B). Superficial peroneal nerve (yellow) is localized deep to PL in lateral compartment of leg. It passes forward and downward and emerges (curved arrow, A) between PL and extensor digitorum longus muscle (EDL). Superficial peroneal nerve courses superficially in lateral compartment between peroneus brevis (asterisk, B) and EDL (single straight black arrow, B) muscles. Then, superficial peroneal nerve pierces crural fascia (curved arrow, B) and divides into two branches: medial dorsal cutaneous nerve (open arrow, B) and intermediate dorsal cutaneous nerve (double arrows, B).

View larger version (27K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —Schematic drawings of normal course of superficial peroneal nerve. Drawings of normal course of superficial peroneal nerve in leg after dissection show peroneus longus muscle (PL) exposed (A) and displaced (B). Superficial peroneal nerve (yellow) is localized deep to PL in lateral compartment of leg. It passes forward and downward and emerges (curved arrow, A) between PL and extensor digitorum longus muscle (EDL). Superficial peroneal nerve courses superficially in lateral compartment between peroneus brevis (asterisk, B) and EDL (single straight black arrow, B) muscles. Then, superficial peroneal nerve pierces crural fascia (curved arrow, B) and divides into two branches: medial dorsal cutaneous nerve (open arrow, B) and intermediate dorsal cutaneous nerve (double arrows, B).

In the lateral or anterior muscular compartment of the leg, the location of the superficial peroneal nerve was observed by assessing the anterior crural intermuscular septum as hyperechoic tissue attached to the anterior border of the fibula and located between the peroneus longus and extensor digitorum longus muscles. The structures surrounding the nerve, the location of the nerve's division, and the number of branches were also analyzed in real time while scanning. Three measurements were performed at the two levels used for injection in the cadaveric study. First, the diameter of the superficial peroneal nerve (largest and orthogonal axes); second, the distance separating the superficial peroneal nerve from the anterior tibial crest medially, which is the only palpable bone in the anterior part of the leg; and third, the distance separating the superficial peroneal nerve from the tip of the lateral malleolus distally, which is the most lateral outstanding bone in the ankle. For this purpose, a mark indicating the location of the nerve was made on the skin and the measurements were performed using a tape measure. An average value was also determined for the measurements at each level.

Statistical analysis with the Student's t test and Pearson's correlation method was performed to standardize the sample. A p value of < 0.05 was considered to indicate a statistically significant difference.

Results

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Anatomic Study
The anterior and lateral compartments of the leg, which are covered by the crural fascia, are separated by the anterior crural intermuscular septum. The anatomic study of five leg specimens showed the superficial peroneal nerve as a branch of the common fibular nerve located deep to the proximal portion of the peroneus longus muscle in the lateral compartment of the leg. The superficial peroneal nerve then passes forward and downward between the peroneus longus muscle and the anterior crural intermuscular septum (Figs. 1A, 1B, 2A, 2B, 2C, and 2D). It then courses superficially in the lateral compartment between the peroneus brevis muscle and the anterior crural intermuscular septum, in front of the deep surface of the crural fascia.

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —Anatomic study. Photographs of dissected specimen (A) and gross axial anatomic slice (B) show superficial peroneal nerve (solid white arrows) emerging between peroneus brevis muscle (PB) and anterior crural intermuscular septum (open arrows, B), which separates this muscle from extensor digitorum longus (EDL) muscle. Note that superficial peroneal nerve is in contact with deep surface of crural fascia (curved arrow, B), artery (A, black arrow) for peroneus muscles, and small vein (V, B). V = vein, PL= peroneus longus muscle.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —Anatomic study. Photographs of dissected specimen (A) and gross axial anatomic slice (B) show superficial peroneal nerve (solid white arrows) emerging between peroneus brevis muscle (PB) and anterior crural intermuscular septum (open arrows, B), which separates this muscle from extensor digitorum longus (EDL) muscle. Note that superficial peroneal nerve is in contact with deep surface of crural fascia (curved arrow, B), artery (A, black arrow) for peroneus muscles, and small vein (V, B). V = vein, PL= peroneus longus muscle.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —Anatomic study. Photograph of distal gross anatomic slice of dissected specimen shows superficial peroneal nerve (straight arrow) above crural fascia (curved arrow). EDL = extensor digitorum longus muscle.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —Anatomic study. Photograph of axial histologic slice obtained at same level as B shows superficial peroneal nerve (SPN) above peroneus brevis muscle (PB) in lateral compartment of leg. Curved arrow = crural fascia, straight arrows = anterior crural intermuscular septum, A = artery for peroneus muscles, V = vein.

View larger version (76K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —Appearance of anatomic variation of superficial peroneal nerve. Photograph of anatomic dissection of cadaveric specimen shows two nerve branches (arrows) of superficial peroneal nerve, which has divided before piercing crural fascia (asterisk).

View larger version (72K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —Appearance of anatomic variation of superficial peroneal nerve. In 59-year-old healthy female volunteer, sonograms obtained in axial plane show superficial peroneal nerve (arrows, B) and its division (arrows, C) before it pierces crural fascia (arrowheads). Insets show position of leg for scanning.

View larger version (71K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —Appearance of anatomic variation of superficial peroneal nerve. In 59-year-old healthy female volunteer, sonograms obtained in axial plane show superficial peroneal nerve (arrows, B) and its division (arrows, C) before it pierces crural fascia (arrowheads). Insets show position of leg for scanning.

Sonographic Study in Cadavers
In each specimen, axial sonographic images showed an ovoid structure with a fasciculated appearance along the theoretic course of the superficial peroneal nerve. The needle could be positioned in contact with the nerve under sonographic guidance in each case. Dissections and axial sections confirmed the blue coloration of the superficial peroneal nerve in each case. The puncture made by the needle could also be identified as a small pointed aperture. Unfortunately, some spreading of the blue into the adjacent soft tissues was also noted in each case.

Sonographic Study in Volunteers
The entire course of the superficial peroneal nerve could be identified with sonography in each leg. The proximal part of the superficial peroneal nerve was close to the adjacent peroneus longus and extensor digitorum longus muscles; this sometimes made depiction of the nerve difficult, but the superficial peroneal nerve could be detected in all legs. The superficial peroneal nerve became very easy to analyze once it emerged superficially close to the deep surface of the crural fascia, thereby revealing its forward and downward course. It was located in the lateral compartment between the peroneus longus muscle and the anterior crural intermuscular septum in 44 legs (73.3%), whereas in 16 legs (26.7%) it was found in the anterior compartment between the anterior crural intermuscular septum and the extensor digitorum muscle. When present, this anterior nerve location was generally bilateral (87.5% of cases).

The place where the nerve pierced the crural fascia was also very easily detected (Figs. 4A, 4B, 4C, and 4D). The mean distance between the superficial peroneal nerve's emergence from the crural fascia and the lateral malleolus was 92.2 mm (Table 1). In 58.3% (n = 35) of the legs, the superficial peroneal nerve pierced the crural fascia distally. In each leg, we observed a small lump of hyperechoic tissue at the level where the superficial peroneal nerve pierced the crural fascia. We also noticed a vein close to the superficial peroneal nerve along its entire course, located at either its superficial or its deep surface (Figs. 4A, 4B, 4C, and 4D). An artery to the peroneus muscles was detected beside the nerve in seven of the 60 legs (11.7%), also along its entire course (Fig. 5).

View larger version (75K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —Sonograms obtained in axial plane of superficial peroneal nerve. Insets show position of leg for scanning. Superficial peroneal nerve (arrows) in healthy 60-year-old male volunteer is shown after emerging between peroneus longus (PL) and extensor digitorum longus (EDL) muscles (A) and more distally just before (B) and after (C) it pierces crural fascia (arrowheads, B and C).

View larger version (76K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —Sonograms obtained in axial plane of superficial peroneal nerve. Insets show position of leg for scanning. Superficial peroneal nerve (arrows) in healthy 60-year-old male volunteer is shown after emerging between peroneus longus (PL) and extensor digitorum longus (EDL) muscles (A) and more distally just before (B) and after (C) it pierces crural fascia (arrowheads, B and C).

View larger version (78K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —Sonograms obtained in axial plane of superficial peroneal nerve. Insets show position of leg for scanning. Superficial peroneal nerve (arrows) in healthy 60-year-old male volunteer is shown after emerging between peroneus longus (PL) and extensor digitorum longus (EDL) muscles (A) and more distally just before (B) and after (C) it pierces crural fascia (arrowheads, B and C).

View larger version (69K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4D —Sonograms obtained in axial plane of superficial peroneal nerve. Insets show position of leg for scanning. Note also vein (solid arrow) superficially located to superficial peroneal nerve (cursors) and hyperechoic tissue surrounding nerve (open arrow) in healthy 29-year-old female volunteer. Arrowheads point to crural fascia. EDL = extensor digitorum longus muscle.

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —Sonogram of healthy 35-year-old male volunteer obtained in axial plane shows artery for peroneus muscles (red) beside superficial peroneal nerve (arrows). Note that nerve is in anterior compartment of leg above extensor digitorum longus muscle (EDL) and medially to anterior intermuscular septum (dotted line).

The superficial peroneal nerve divided before piercing the crural fascia in only four legs (6.7%); this variation was unilateral (Figs. 3A, 3B, and 3C). In all other legs, the superficial peroneal nerve divided after piercing the crural fascia; the mean distance between its division and the spot at which it pierced the crural fascia was 2.1 cm. No more than two branches were identified in all the volunteers.

The thickness of the superficial peroneal nerve and the distances separating the superficial peroneal nerve from the anterior tibial crest and the tip of the lateral malleolus, respectively, are given in Table 1. There were no statistically significant differences between the values according to the sex and age of the volunteers. No statistically significant difference was observed between right and left legs.

Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
Because the superficial peroneal nerve may be injured in different parts of the leg, the aim of our study was to determine whether it can be seen on sonography. Knowledge of the nerve's exact location, which may evidence individual variations, may have useful clinical applications including optimization of surgical approaches used for the treatment of superficial peroneal nerve lesions and minimization of iatrogenic superficial peroneal nerve injuries, aid in the accurate injection of anesthetics when a regional ankle block is considered [9-11], or correct placement of electrodes for the study of sensory nerve conduction in the superficial peroneal nerve [12].

The results of our study confirm that the course of the superficial peroneal nerve can be clearly depicted by sonography despite the thinness of the nerve, thanks to high-resolution sonography and real-time imaging. The superficial peroneal nerve was especially well depicted along its superficial course against the deep surface of the crural fascia and then in the subcutaneous tissue. The presence of fat around the nerve, as reported in the anatomy literature [13, 14], also contributed to its easy detection. Power Doppler imaging allowed detection of a vein associated with the superficial peroneal nerve, but this vein was not helpful for detecting the nerve since the superficial peroneal nerve was detected easily using B, mode imaging. In our study, the superficial peroneal nerve was found to measure slightly larger at the level where it pierces the crural fascia than proximally. We believe that the increased thickness of the superficial peroneal nerve observed distally may be explained by the fact that measurements were performed just before the nerve divided.

In the current literature, there are no values describing the level of emergence of the superficial peroneal nerve between the peroneus longus and extensor digitorum longus muscles, separated by the anterior crural intermuscular septum. This knowledge appears valuable because the nerve shows a superficial position distal to this level. Indeed, surgical biopsies of the superficial peroneal nerve can easily be performed along this superficial course in patients with peripheral neuropathy from an unknown cause, and sonography may prove useful in planning surgery. It may also help to avoid damage to the superficial peroneal nerve in the course of varicectomy surgery.

Most superficial peroneal nerve compressions occur where the nerve pierces the crural fascia. However, the distance between that spot and the tip of the lateral malleolus has been reported in anatomic studies, with mean values ranging from 8 to 13 cm (extreme values, 3-18 cm) [3, 13, 15-17]. Our results are in agreement with these measurements (mean, 9.2 cm), and our range (6-16 cm) confirms the high variability of the level at which the superficial peroneal nerve pierces the fascia. These results highlight the potential usefulness of sonography in showing precisely where this occurs because neuromas frequently develop at this site [4-7]. It is also interesting to note that the superficial peroneal nerve was observed to pierce the crural fascia distally, which has been reported to predispose to traction injury [3, 4], in more than half of our volunteers.

We were unable to find any values of the distance between the level at which the nerve pierces the crural fascia and the anterior tibial crest in the available literature. Our results show that the location of the nerve also varies in the axial plane. Moreover, in 16 of the 60 legs (26.7%), the nerve was located in the anterior compartment of the leg throughout its course. The anterior location of the superficial peroneal nerve has been reported in the literature with a variable frequency (35-47%) [12, 13, 18]. Knowledge of this anatomic variation is important when a fasciotomy is considered for the treatment of entrapment syndrome [18]. Other anatomic variations concerning the origin, course, and level of division of the superficial peroneal nerve and the number of branches have been reported in the literature, but most of the reported variations are exceptional [12, 13, 15, 19, 20]. The only variation that we observed was division of the superficial peroneal nerve before it pierces the crural fascia (25% of cadaveric specimens, 6.7% of volunteers' legs). Knowledge of this anatomic variation might be useful when surgery is performed or a selective anesthetic block of the lateral part of the leg must be undertaken.

The presence of an artery to the peroneus muscles has been described in several anatomic studies [13, 14, 19-23], but to our knowledge, the frequency of this variation has not been reported. In our study, this artery was identified in 40% of the cadaveric legs and in 11.7% of the volunteers' legs. Its detection was facilitated by the presence of fat around it and by the use of power Doppler imaging in volunteers. This structure was visualized next to the superficial peroneal nerve. Although analysis of this artery was not among the aims of our study, recognition of its presence might have useful clinical implications because the muscles surrounding the superficial peroneal nerve can be used as vascularized grafts by some orthopedic and plastic surgeons [12].

We acknowledge several limitations in our study. First, we did not perform any intra- and interobserver analyses of the sonographic assessment of the superficial peroneal nerve. Second, we did not correlate our measurements to measurements of the length and diameter of the legs, but this correlation has not been performed in anatomic and surgical studies.

In conclusion, the results of our study showed that the superficial peroneal nerve can be clearly depicted by sonography in healthy adult subjects. However, these potential applications of sonography must now be confirmed in clinical studies.

Acknowledgments
 
We thank Franck Stevendart for the illustrations, Maurice Demeulaere for the anatomic preparation, and Hervé Cotten for his assistance and analyses in the histologic study.

References

Top Abstract Introduction Materials and Methods Results Discussion References

 

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This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Canella, C. Articles by Cotten, A. Search for Related Content PubMed PubMed Citation Articles by Canella, C. Articles by Cotten, A. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?