Palpation to Identify the Medial Branch of the Medial Dorsal Cutaneous Nerve

NewsBot · Jul 8, 2020

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Accuracy of Palpation to Identify the Medial Branch of the Medial Dorsal Cutaneous Nerve in Medial Column Surgery: Correlation of Preoperative Nerve Marking with Intraoperative Findings During Lapidus Fusion
Troy J. Boffeli, et al
JFAS:July 07, 2020

The medial branch of the medial dorsal cutaneous nerve is frequently encountered in medial column surgery. Postoperative sensory nerve symptoms can lead to dissatisfaction and suboptimal outcome. The purpose of this case series is to correlate intraoperative nerve location on direct viewing with preoperative nerve localization to assess the accuracy of a specific nerve palpation technique. 100 consecutive patients undergoing elective Lapidus fusion were prospectively evaluated. Preoperative nerve localization and intraoperative comparison was performed along with assessment of nerve position in relation to the cuneiform and first tarsometatarsal joint. Preoperative nerve identification correlated with intraoperative findings in 99/100 consecutive cases. In 1/100 cases, the palpated nerve was proximal to the zone of dissection and was not visualized. The medial branch of the medial dorsal cutaneous nerve crossed the dorsal Lapidus incision at the medial cuneiform or first metatarsal base level in 95/100 cases; at the mid metatarsal level in 2/100 cases; and proximal to the medial cuneiform in 3/100 cases.
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NewsBot · Jul 8, 2020

Related Thread:
Palpation Skills in Foot and Ankle Anatomic Structures

NewsBot · Jan 31, 2022

An Anatomic Study of the Lateral Dorsal Cutaneous Nerve Using 3-Tesla MRI: A Comparison to Cadaveric Data With Surgical Applications
Claudio B. Ghetti, BA, Brendon C. Mitchell, MD, Vrajesh J. Shah, BS, ...
January 24, 2022

Background:
The lateral dorsal cutaneous nerve (LDCN) and the anastomotic branch of the sural nerve (AB) are cutaneous sensory nerves at risk of iatrogenic injury during lateral foot surgery. This study is the first to use a large cohort of high-resolution magnetic resonance images (MRIs) of the ankle to better describe the course of these nerves in vivo in order to aid surgeons intraoperatively. Our study intends to build on the “high and inside” approach to the proximal 5MT by accounting for variations in course of the LDCN and AB.

Methods:
One hundred twenty-five 3-tesla (T) MRI studies of the ankle were analyzed. Three reviewers measured the distance from the LDCN and AB to landmarks including the most proximal aspect of the fifth metatarsal tuberosity (5MT) and the peroneus brevis tendon (PBT).

Results:
Mean vertical distance from the LDCN to the 5MT was 0.8 ± 0.2 cm. Presence of an AB was visualized in 59 of 125 studies (47.2%) and was found 2.2 ± 0.5 cm dorsal to the 5MT. The AB was found to become superior to PBT at a horizontal distance 1.9 ± 0.5 cm proximal to the 5MT. The LDCN was found superior to the PBT at its insertion onto the 5MT in approximately 10% (n = 12) of our studies. During these instances, the LDCN was located an average of 0.3 cm dorsal to the PBT.

Conclusion:
Our proposed “safe zone” for the approach to the proximal 5MT remains superior to the LDCN and inferior to the AB and avoids crossing directly over either nerve in >95% of analyzed MRI studies. This incision begins 1.5 cm dorsal to the most proximal aspect of the 5MT and extends no more than 1 cm posteriorly. Careful dissection and identification of the LDCN and possible AB is necessary prior to further extension of incision.
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