Anatomy of nerve_injuries_lower_limb

1. Anatomy of Nerve InjuriesAnatomy of Nerve Injuries
Lower LimbLower Limb
By- Dr. Armaan SinghBy- Dr. Armaan Singh

2. » Dermatomes
» Entrapment of Nerves
» Pierce Muscle
» Pierce Fascia
» Repetitive Movements

3. » Must know the course of nerve
» Dermatomes
» Entrapment of nerves
» Pierce muscle
» Pierce fascia
» Repetitive movements

4. Nerves supply
» Skin
» Muscles (group)
» Tendons
» Bones
» Joints
» Blood vessels

5. » External forces
» Fibro-osseous tunnels, tether
the nerve
» Oedema
» Callus formation as a result of a
fracture
» External compression due to
specific movements
» Mechanical compression
» Compartment syndromes
» The nerve is tender at the site
of compression

6. » Fibrous bands
» Accessory muscles
» Spurs
» Narrow notches
» Anatomical variations of the nerve
itself

8. » Affects branches of
lumbar or sacral
plexuses
» Pierces muscle
» Pierces fascia
» Increase in
compartment pressure
» Compressed by external
pressure

9. » Lower five intercostal nerves
» Subcostal nerve T12
» 10th
intercostal nerves at the
level of the umbilicus
» Iliohypogastric nerve L1
» Ilioinguinal nerve L1

10. » Subcostal nerve T12
» Iliohypogastric nerve L1
» Ilioinguinal nerve L1
» Femoral branch of the
genitofemoral nerve L1,2
» Lateral cutaneous nerve of
the thigh L2,3
» Femoral nerve L2,3,4
» Obturator nerve L2,3,4

11. Cutaneous Nerves

12. » Branch of lumbar plexus
» Lateral border of psoas
» Anterior to quadratus
lumborum
» Neurovascular plane
between internal oblique
and transversus
» Lateral cutaneous supplies
upper part of buttock

13. » Pierces internal oblique
above anterior superior
iliac spine
» Pierces aponeurosis of
external oblique an inch
above superficial ring
» Supplies skin over
lower part of rectus
sheath
» Can be trapped
piercing aponeurosis
Iliohypogastric Nerve

14. » Ilioinguinal nerve
» L1 branch of lumber plexus
» Lateral border of psoas
» Anterior to quadratus
lumborum
» Neurovascular plane between
internal oblique and
transversus
Ilioinguinal Nerve

15. » Pierces internal oblique
4 cm medial to
» Anterior superior iliac
spine
» Enters inguinal canal
» Leaves through
superficial ring
» Supplies the skin of the
medial part of the thigh
» Adjoining portion of the
scrotum and labia
Ilioinguinal Nerve

16. » May be trapped post
surgery, due to adhesions
» Poor tone in abdominal
muscles
» Pain increased by
increased tension in the
anterior abdominal wall
» Hyperextension of hip
» Tenderness 4 cm from
anterior superior iliac
spine
Ilioinguinal Nerve

17. » Pain increased
» Increased tension in the
anterior abdominal wall
» Hyperextension of hip
» Tenderness 4 cm medial to
anterior superior iliac spine
Ilioinguinal Nerve Entrapment

18. » Iliohypogastric in 5.6%
» Ilioinguinal 90.7%
» Union of branches of
ilioinguinal and genital branch
of the genitofemoral nerve 13%
» Genitofemoral passing through
superficial inguinal ring 35.2%
» Piercing inguinal ligament
5.6%
» Femoral branch 13%
Akita et al., 1999

19. » Lumbar plexus L1,2
» Anterior aspect of the
psoas
» Genital branch enters the
deep inguinal ring
» Femoral branch lies on the
lateral side of femoral
artery in the femoral
sheath

20. » Enters thigh on lateral aspect
of femoral artery in femoral
sheath
» Pierces anterior wall of the
sheath
» Supplies skin a hands breath
below the inguinal ligament

21. » Union with ilioinguinal
nerve on anterior aspect
of spermatic cord
» Supplies ventral aspect
of scrotum and adductor
region
» Cutaneous branch on
the dorsal-caudal aspect
» May also supply dorsal
scrotum
Akita et al., 1999
Genitofemoral Nerve

22. Genitofemoral Nerve

23. » Lumbar plexus in psoas
» Lateral aspect of psoas
» Pierces inguinal ligament
» Lies in fibrous tunnel
» Divides into two
» Pierces deep fascia

24. » A centimeter medial to
anterior superior iliac
spine
» Crosses the lateral
angle of femoral triangle
» Divides into two
» Pierces deep fascia
» Anterolateral aspect of
the thigh
» Anterior portion of
gluteal region
LCN
Lateral Cutaneous Nerve of Thigh

25. » Entrapment in the fascial
tunnel
» Injured in the thigh by
asymmetric bars in
gymnastics
» Causes meralgia
paraesthetica
» Post laparoscopic surgery
Lateral Cutaneous Nerve of Thigh

26. » Largest branch of the lumbar plexus
» Lateral aspect of psoas
» Passes under the inguinal ligament
» Outside femoral sheath
» 2 cm below
» Divides into terminal branches
» Muscular
» Articular
» Cutaneous

27. Muscular branches
»Rectus femoris
»Vastus medialis,
»Vastus lateralis
»Vastus intermedius
»Sartorius, pectineus
Cutaneous
»Medial cutaneous nerves of thigh
»Intermediate cutaneous nerves of thigh
»Saphenous
Articular branches to hip and knee joints
Femoral Nerve

28. » Dancers may stretch the
nerve by prolonged
hyperextension of the hip
» Compress the nerve
under the inguinal
ligament
» Nerve may also be
compressed due to a
haematoma following a
partial tear of the iliacus
O’Brien, 1997
Femoral Nerve

29. Femoral nerve
Saphenous
Femoral Nerve

30. » Lumbar plexus in psoas
» Medial aspect of psoas
» Side wall of pelvis under
peritoneum
» Leaves through obturator
foramen
» Divides into anterior and
posterior divisions
Obturator Nerve L2,3,4

31. » Supplies the parietal
peritoneum on side wall of
the pelvis
» Is related to the ovary
» Pathology in the ovary or
endometriosis may result
in referred pain to the hip,
knee or medial side of the
high
Obturator Nerve

32. » Anterior division of
the obturator
leaves pelvis
» Anterior to
obturator externus
» Descends in front
of adductor brevis
» Behind pectineus
and adductor
longus
Obturator nerve

33. » Adductor longus
» Adductor brevis
» Gracilis
» It gives an articular twig
to the hip joint
» Skin on the medial side
of the thigh
Anterior Division Obturator

34. Obturator Nerve

35. » It may be entrapped as it leaves the
pelvis
» Pierces and supplies the obturator
externus
» Causing spasm of the adductor
muscles
Posterior Division Obturator

36. » Supplies adductor portion of adductor
magnus, above hiatus
» Articular twig to knee joint and cruciate
ligaments
» Causing spasm of the adductor
muscles
» It may be entrapped as it leaves the
pelvis or between fascial planes
Posterior Division Obturator

37. Obturator nerve
Obturator Nerve
Fascial planes

38. » Pressure on obturator
nerve
» Pain on inner aspect
of thigh relieved by
flexion of hip
» Increased by
extension, adduction
and medial rotation

39. Obturator Nerve

43. » Compression of pudendal
nerve in cyclists due to saddle
» History of change of saddle
» Compressing dorsal nerve of
penis
Pudendal Nerve

45. » Is the largest nerve in
diameter in the body
» It passes out of the pelvis
below piriformis and
descends between the
greater trochanter of the
femur and the ischial
tuberosity
» Passes deep to gluteus
maximus
» More distally it lies on
adductor magnus

46. » Is crossed by the long
head of biceps femoris
» Divides in middle of thigh
» Tibial and common
peroneal nerves
» Common peroneal may
pierce piriformis if divides
in pelvis
» Supplies hamstrings
» Adductor magnus below
hiatus
Sciatic Nerve

47. » Occasionally it divides in the
pelvis
» Then the common peroneal
portion may pierce the piriformis
muscle to enter the thigh
» Recurrent injury to the
hamstring muscles produces
inflammation and possible
scarring which could interfere
with the normal mobility of the
sciatic nerve and produce
clinical signs of adverse neural
tension
Sciatic Nerve

48. » The larger terminal branch of the
sciatic nerve
» Crosses popliteal fossa
» Passes deep to soleus
» In posterior compartment between
flexor digitorum longus flexor
hallucis longus
» Passes deep to flexor retinaculum
» Gives off medial calcaneal nerve
which pierces retinaculum
» Divides into medial and lateral
plantar nerves
Tibial Nerve

49. » The tibial nerve supplies all the muscles of
the posterior compartment of calf
» In popliteal fossa gives off
» Superomedial, middle and inferomedial
genicular branches
» Nerve to medial and lateral heads of
gastronemii
» Plantaris
» Popliteus
» Soleus
» Sural nerve
Tibial Nerve

50. » Medial side of psoas
» Side wall of pelvis
» Obturator canal
» Divides anterior posterior
division

51. » Sural nerve is joined by
sural communicating
from commom peroneal
» Pierces deep fascia
» Supplies posterior and
lateral portion of calf
» Lateral border of foot
» Entrapment occurs most
frequently in runners with
a history of ankle sprain
Sural Nerve

52. Sural Nerve

53. » Deep fascia from medial malleolus to
medial margin of calcaneus
Anterior to posterior
» Tibialis posterior
» Flexor digitorum longus
» Posterior tibial artery
» Tibial nerve
» Both give off medial calcaneal artery and nerve
» Then both divide into medial and lateral plantar
branches
» Flexor hallucis longus

54. » Gives off the medial calcaneal nerve
under cover of the retinaculum
» It then pierces the flexor retinaculum
to supply the posterior and medial
aspect of the heel
Tibial Nerve

55. » Tibial divides into the medial and
lateral plantar nerves
» They enter two tunnels separated
by a fascial septum
» Stretching from the calcaneus to
the deep fascia of the abductor
hallucis

56. » Passes under the abductor
hallucis
» Then runs on the plantar
surface of the flexor digitorum
longus
» Dividing into its digital
branches
» Sensory to the plantar aspect
of the medial three and a half
toes
Medial Plantar Nerve

57. » Motor to the abductor hallucis
» Flexor hallucis brevis
» Flexor digitorum brevis
» First or unipennate lumbrical
Medial Plantar Nerve

58. » Crosses the sole of the foot deep to the
abductor hallucis, flexor digitorum
brevis and the abductor digiti minimi
» To the base of 5th
metatarsal
» Superficial to flexor hallucis longus,
flexor digitorum longus and flexor
accessorius
» Lateral plantar nerve supplies the
lateral one-and-a-half toes
» Supplies all the other intrinsic muscles
of the foot
Medial Plantar Nerve

59. » The tibial nerve may be
compressed in the
proximal portion of the
tunnel before it divides
» More distally, either the
medial or lateral plantar
nerves may be involved
» Hyper dorsiflexion,
external rotation and
eversion can produce
symptoms of tarsal tunnel
syndrome

60. » Pain worse if foot is
pronated
» Tender over flexor
retinaculum
» Pain in heel, if medial
calcaneal is involved
» Pain in sole of foot if
plantar nerves
involved

61. » Orthotics may help if
marked pronated foot
» Anti-inflammatories
» Splint at night

63. » Depressed
transverse arch in
runners and ballet
dancers with
mobile first ray
» Neuroma on
digital nerve to the
second cleft or
third cleft
morton neuroma.jpg
Morton’s Foot

64. » Pronated foot
» Depressed transverse
arch at heads of
metatarsals
» Pain worse with tight
shoes on
» Relieved by removing
shoes
Medial Plantar

65. » If sciatic nerve divides
inside the pelvis
» Common peroneal nerve
pierces the piriformis
» May be entrapped
» In popliteal fossa
» The common peroneal
nerve lies between the
tendon of biceps femoris
and the lateral head of
gastrocnemius

66. » In popliteal fossa gives off
» Lateral cutaneous of calf
» Sural communicating
» Superior lateral, inferior lateral
genicular nerves
» Leaves fossa at lateral angle
» Crosses neck of fibula deep to
peroneus longus
» Gives off recurrent genicular, deep
and superficial peroneal
» Vulnerable to injury as it winds around neck of
fibula
» Foot drop, plantar flexed, inverted
Common Peroneal

67. » Nerves can be
compressed in
compartments
» Anterior compartment
deep peroneal nerve
» Lateral compartment
superficial peroneal
» Posterior compartment
tibial nerve

68. » Branch of the common
peroneal at the neck of the
fibula
» Pierces the lateral inter-
muscular septum to enter the
anterior compartment
» Supplies all muscles in
anterior compartment tibialis
anterior, extensor hallucis
longus, extensor digitorum
longus, peroneus tertius and
extensor digitorum brevis

69. » Skin of cleft between first and second toes
» The nerve may be compressed due to
anterior compartment syndrome
» Muscle most at risk is tibialis anterior
» Entrapment occurs most frequently in
runners. It also occurs in soccer players,
dancers and skiers
» It occurs most often under the inferior
extensor retinaculum. Repetitive ankle
sprains, tight fitting shoes or trauma may
also cause entrapment
Deep Peroneal Nerve

70. » Runs in the lateral
compartment of the calf
» Between the peroneus
longus and brevis
supplying both these
muscles
» Pierces the deep fascia
10–12 cm above the
lateral malleolus supplies
most of the dorsum
Superficial Peroneal Nerve

71. » Divides 6 cm above the
lateral malleolus into
branches, which supply the
dorsum of the foot
» The first cleft is supplied by
the deep peroneal
» The lateral border is
supplied by the sural nerve
» Medial border to ball of big
toe saphenous
» Rest superficial peroneal

72. » Entrapment occurs where
the superficial peroneal
pierces the deep fascia
» Particularly if there is
herniation of the muscle
due to fascial defects
» Chronic ankle strains also
stretch the nerve

73. » Grade III ankle injuries have a
high incidence of traction injuries
to both the peroneal and
posterior tibial nerves
Taunton & Fricker, 1996