Title: Ultrasound-Guided Common Peroneal Nerve Block and Scar
Infiltration for Chronic Postoperative Neuropathic Pain: A Case Report
Jaskaran Singh1 Varun Singla2 Babita Ghai2 Nitika Goel2
Fortis hospital,Amritsar1 ;PGIMER,Chandigarh2
Chronic postoperative pain, especially with neuropathic features, poses a
significant challenge in orthopedic surgery patients.1This case highlights the
management of a 38-year-old female presenting with persistent neuropathic
pain along the superficial peroneal nerve distribution two years after
intramedullary nailing of the tibia and ORIF of the fibula for distal tibia and
fibula fractures.
The case was reviewed under the policy of
Postgraduate Institute of Medical Education
and Research (PGIMER), Chandigarh,
which exempts IRB review for reports
devoid of identifiable patient information.
No identifiable patient information is
included in this report. Written informed
consent for treatment and case reporting was
obtained from the patient. The patient
presented with electric shock-like pain while
flexing and touching left leg, paresthesia,
and scar hypersensitivity despite previous
proximal interlocking screw removal in April
2022 and physiotherapy. Management
included ultrasound-guided interventions: a
common peroneal nerve block with 0.5%
bupivacaine (10 mL) and
methylprednisolone (60 mg), as well as scar
infiltration over left knee with 0.5%
bupivacaine (4 mL) and 20 mg of methyl
prednisolone.2-4
Methodology
The patient had a history of a fractured left distal tibia and
fibula due to a fall. Intramedullary nailing of the tibia and
open reduction and internal fixation (ORIF) of the fibula
were performed in September 2021. The patient presented to
the orthopedic outpatient department (OPD) in April 2022
with continuous pain with NRS score of 8 in the fractured
leg . After the removal of the proximal interlocking screw in
April 2022, the patient was referred to the physical and
rehabilitation OPD in September 2022 for isometric
quadriceps strengthening exercises. In August 2023, the
patient was referred to the pain clinic for complex regional
pain syndrome (CRPS) and scar tenderness.5
On examination, pain and paresthesia were noted in the
superficial peroneal nerve distribution, along with scar
tenderness at the knee. The interventions provided
substantial pain relief. The patient reported a 99% resolution
of neuropathic pain immediately post-procedure, with
significant improvements in mobility, including enhanced
knee flexion and reduced heaviness while walking with NRS
score of 3. Minimal residual pain at the nailing site was
managed conservatively with oral analgesics (T.
Amitriptyline 5 mg at bedtime for 5 days, followed by 10
mg at bedtime, and Tablet with combination of 100 mg of
aceclofenac, 325 mg of paracetamol, and 15mg of
serratiopeptidase for 3 days) and physiotherapy.
Follow-up at three months confirmed sustained pain relief
and functional improvement.
Results
This case underscores the efficacy of ultrasound-guided nerve blocks
and scar infiltration in addressing chronic postoperative neuropathic
pain. Targeted interventions not only alleviate pain but also improve
functional outcomes and quality of life. The role of multimodal
strategies, integrating pharmacologic, interventional, and rehabilitative
therapies, remains critical in optimizing recovery. Clinicians managing
similar presentations should consider ultrasound-guided techniques as
part of a comprehensive pain management plan.
Conclusion
Post Surgery After proximal screw removal
Chronic postoperative pain with neuropathic characteristics remains
a complex issue in orthopedic surgery. Neuropathic pain can arise
due to nerve injury, fibrosis, or persistent inflammation, significantly
impacting the patient’s quality of life. Ultrasound-guided peripheral
nerve blocks and scar infiltration have been explored as effective
interventional strategies to alleviate chronic postoperative pain. This
case report discusses a patient with chronic neuropathic pain
following tibia and fibula fracture surgery, emphasizing the role of
targeted pain management techniques.

References
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