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Case Report Plastic and Aesthetic Research

Isolated tibial nerve injury: a rare presentation

Rahul Krishnarao Patil , Prashant Verkey , Harshal Patil , Deepesh Manoharan 1
2
1
1
1 Jubilee Institute for the Surgery of Hand Aesthetic and Microvascular Surgery, Jubilee Mission Hospital, Thrissur 680005, Kerala, India.
2 Department of General Surgery, Jubilee Mission Hospital, Thrissur 680005, Kerala, India.
Address for correspondence: Dr. Rahul Krishnarao Patil, Sparsh Hospital, Infantry Road, Opp. Commissioners Office, Bengaluru 560001,
Karnataka, India. E-mail: doctrahul@yahoo.co.in

ABSTRACT
Tibial nerve injury is rare and is always associated with other injuries due to its close association
with the other structures. We present a rare case of isolated injury to the tibial nerve where the nerve
was avulsed from the middle third of the leg, but all other structures were intact. The nerve was
reconstructed with sural nerve grafts. The patient recovered sensation of the sole twelve months
following the reconstruction and was able to maintain a normal gait and is living normal life. The
results of nerve repairs in lower limbs in general have been poor. The treatment options for such an
interesting case are discussed along with the management and outcome of the presented patient.
Key words:
Nerve injuries in the lower limb, nerve reconstruction in lower extremity, tibial nerve injury

INTRODUCTION conditions. The common end result of the tibial nerve
injury or neuropathy around the ankle is loss of sensations
The tibial nerve lies between the superficial and the deep of the plantar foot, vasomotor changes due to lack of
muscles of the posterior compartment of the leg. It is auto‑regulation, subsequently leading to callosities and
well‑protected from direct trauma due to this thick cover recurrent ulcerations and paralysis of the intrinsic muscles
of muscles. In the lowermost part of the leg and ankle, the of foot leading to toe deformities.
nerve is relatively superficial but is guarded anteriorly by We report a very unusual presentation of isolated posterior
the posterior surface of the medial malleolus, superficially tibial nerve injury following a road traffic accident. Our
by the flexor retinaculum and posteriorly by the Achilles’s search failed to reveal any similar case reported in the
tendon. This protected location makes isolated injury to English literature.
the tibial nerve is very uncommon. Even in cases of open
fractures and associated vascular injuries of the lower CASE REPORT
[1]
extremity complete transaction of the tibial nerve is rare.
Injuries to the sciatic and common peroneal nerves are
more common due to their vulnerable position. [2,3] Most A written consent was obtained from the patient and her
of the available literature on peripheral nerve injuries in attendants. A 15‑year‑old girl sustained injury to her left leg
the lower extremity has documented the results and the following road traffic accident. Though the exact mechanism
treatment options for peroneal and sciatic nerve injuries. of injury could not be elicited, she remembered falling
down from her two‑wheeler after it collided with a car. She
Other common causes of lower limb neuropathy are sustained a small puncture wound over the lower posterior
diabetic neuropathy and compression neuropathies. leg and was referred to our hospital after the first aid at
[5]
[4]
Tibial nerve involvement is more common in these chronic a local hospital. On examination, she had a penetrating
wound over the Achilles tendon with some soft tissue mass
Access this article online avulsed through the tear in the Achilles tendon [Figure 1].
Quick Response Code: The avulsed soft tissue was tender on touch. She had a lack
Website: of sensation over the plantar foot, and the foot was warm.
www.parjournal.net
The skin texture and turgor were found to be normal. With
a provisional diagnosis of tibial nerve injury, the wound was
DOI: explored. The soft tissue avulsed and protruding through
10.4103/2347-9264.153207 the tendon was the tibial nerve [Figure 2a]. While the
posterior tibial vessels and the flexor tendons were intact.

Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015 85