Tibial fractures are the most common long bone fractures and frequently associated with fibular fractures—in part, due to forces being transmitted across the interosseous membrane to the fibula.1 Fractures are generally managed by closed reduction or open reduction internal fixation (ORIF), 2 which is usually followed by a period of immobilization. The most common impairments associated with this type of injury include impaired muscle strength and limitations in joint range of motion (ROM).3 Impairments in strength can be addressed with therapeutic exercises, while joint mobilizations and ROM activities are used to restore joint mobility. However, this type of fractures can be aggravated by disruption of the soft tissues such as nerve and muscle injuries, all of which may slow the progress of recovery.3, 4, 5 Peripheral nerve injury, particularly the common fibular nerve is predisposed to injury caused by fractures of the tibia or fibula, especially at the proximal fibular region, where the common fibular nerve winds around to cross the fibular neck.5 If the nerve is damage, the potential for recovery is possible as long as the nerve cell body remains viable; new axons can sprout from the proximal end of damaged axons. However, successful functional regeneration requires that the proximal and distal ends of the connective tissue tube are aligned.6 Peripheral nerve regeneration occurs at a rate of 1mm/d, so patients with peripheral nerve injury may demonstrate functional limitations that persist for long periods of time.7 In the case of muscle injury, they are more common with tibial shaft fracture, particularly in muscles that originate near or pass by a fracture site. As the tissues heal, adhesions may form and depending on the severity could interfere with the muscle gliding, shortening, and force transmission, particularly in patients with severe weakness due to disuse or nerve damage. 8 The purpose of this case report is to describe and discuss the plan of care of a patient with common fibular nerve injury complicated by multiple lower leg fractures.
Patient Description/History and Systems Review
The patient in this case report is a 58 year-old healthy, active female, who was involved in a ski accident. Written informed consent was obtained from this patient, and all identifying information has been removed per HIPAA compliance. The patient was admitted to the ER after being the victim of a hit and run collision with another skier. X-rays revealed a left tibial plateau fracture along with spiral fractures of the left tibia and fibula. There was no vascular injury; however, the deep fibular nerve was damaged with the fibular fracture. Patient underwent temporary external fixation on the day of hospital admission, followed by ORIF six days later. Postoperatively, the patient’s leg was immobilized with a brace for 2 weeks, followed by a foot drop splint for 3 additional weeks. The patient was evaluated 5 weeks postoperatively, with chief complains of left leg pain, edema, impaired sensation over the anterior leg and dorsum of foot, and lack of active range of motion (AROM) of the ankle and toes in all directions. The patient understands the severity of her injury and knows that the nerve damage will significantly slow the rate of recovery. She is very motivated and willing to endure anything in order to resolve her symptoms. Her main goal is to be able to go back to her active lifestyle, in particular, back to skiing.
Clinical Impression #1
The patient’s impairments, for the most part, can be justified by the damage of the common fibular nerve. Injury to this nerve characteristically produces sensory and motor deficits. It provides cutaneous innervation to the lateral aspect of the leg below the knee via the lateral cutaneous nerve of the calf. Then, as it travels across the head...