The clock face guide to peroneal intraneural ganglia: critical “times” and sites for accurate diagnosis

The aim of this study is to exploit the normal nature of peroneal nerve anatomy to identify constant magnetic resonance imaging (MRI) patterns in peroneal intraneural ganglia.

This study is designed as a retrospective clinical study.

MR images of 25 patients with peroneal intraneural ganglia were analyzed and were compared to those of 25 patients with extraneural ganglia and 25 individuals with normal knees. All specimens were interpreted as left-sided. Using conventional axial images, the position of the common peroneal nerve and either intraneural or extraneural cyst was determined relative to the proximal fibula and the superior tibiofibular joint using a symbolic clock face. In all patients, the common peroneal nerve could be seen between the 4 and 5 o’clock position at the mid-portion of the fibular head. In patients with intraneural ganglia, a single axial image could reproducibly and reliably demonstrate both cyst within the common peroneal nerve at the mid-portion of the fibular head (signet ring sign) between 4 and 5 o’clock and within the articular branch at the superior tibiofibular joint connection (tail sign) between 11 and 12 o’clock; in addition, cyst within the transverse limb of the articular branch (transverse limb sign) was seen at the mid-portion of the fibular neck between the 12 and 2 o’clock positions on serial images. Extraneural ganglia typically arose from more superior joint connections with the epicenter of the cyst varying around the entire clock face without a consistent pattern. There was no significant difference between the visual and template assessment of clock face position for all three groups (intraneural, extraneural, and controls). We believe that the normal anatomic and pathologic relationships of the common peroneal nerve in the vicinity of the fibular neck/head region can be established readily and reliably on single axial images. This technique can provide radiologists and surgeons with rapid and reproducible information for diagnosis and treatment planning.

By using conventional bony anatomy as reference points (namely fibular neck and mid-portion of fibular head), standard axial images can be used to interpret key features of peroneal intraneural ganglia and to establish their accurate diagnosis (rather than extraneural ganglia) and pathogenesis from an articular origin (rather than from de novo formation), a fact that has important therapeutic implications. Because of the relative rarity of peroneal intraneural cysts and physicians’ (radiologists and surgeons) inexperience with them and the complexity of their findings, they are frequently misdiagnosed and joint communications are not appreciated preoperatively or intraoperatively. As a result, outcomes are suboptimal and recurrences are common.