Lower limb peripheral nerve injury

Lower Limb Peripheral Nerve
Injury

 Root value: Ventral division of L2-L4.
 Muscle supply:
 Adductor Longus
 Adductor brevis
 Gracilis
 Pectineus
 Adductor Magnus
 Adductor Brevis

 Causes:
 Dislocation of hip joint
 Pelvic fracture
 Hernia through obturator foramen
 Prolonged labor
 Compression of the nerve against the wall of pelvis by mass of tumor or foetus

 Signs and Symptoms:
 Sensory Deficits :
o Sensory alteration over medial aspect of
thigh and knee
 Loss of sensation
 Parasthesia
 Pain
o Pain increases with stretch of nerve
(extension, abduction and lateral rotation)

 Motor Deficits:
o Wasting on the medial side of thigh
o During ambulation thigh is abnormally abducted and externally
rotated results in circumductory and wide based gait
o Anterior division :
 Adductor longus
 Adductor brevis
 Gracilis
 Pectinius

o Posterior division :
 Adductor magnus
 Adductor brevis
 Deformity:
o Hip flexion and abduction due to overactivity of tensor fascia lata

 Root value: Dorsal division of ventral
rami of L2-L4
 Muscle supply:
 Anterior Branch:
 Pectineus
 Sartorius
 Posterior Branch:
 Rectus Femoris
 Vastus Lateralis
 Vastus Medialis
 Vastus Intermedius

 Causes:
 Psoas abscess
 Pelvic aneurysm / neoplasm
 Fracture of pelvis or femur
 Hip dislocation
 Inguinal hernia
 Complication of spinal anesthesia
 Prolapse intervertebral disc
 Lumbar spondylosis or stenosis
 Neuropathy secondary to diabetes mallitus
 Hysterectomy
 Penetrating wounds over lower abdomen

 Sign and symptoms:
 Sensory Deficit :
 Anterior division : Anterior and medial aspect of thigh
 Saphenous nerve : Medial aspect of leg and foot
 Loss of sensation, Numbness, tingling, dull ache
 Pain in the inguinal region That is relieved by hip flexion and external rotation
 Autonomous zone :
 Small area superior and medial to patella

 Coldness
 Dryness
 Motor Deficit :
 Anterior division: sartorius and pectineus
 Posterior division: rectus femoris, vastus Lateralis, Vastus medialis and vastus
intermedius
 Difficulty in going up and down the stairs. Esp down the stairs
 Difficulty in walking and knee buckling depending upon severity of injury
 Reflex: Quadriceps jerk lost

 Gait:
 Quadriceps gait
 Hand on knee gait
 Trunk leans in forward flexion to extend knee at the beginning of the stance phase to lock
the knee when there is quadriceps muscle weakness
 Use Hands to push knee into extension
 Deformity:
 Genu recurvatum:
 Because quadriceps is paralyzed the patient will try to lock the knee into hyperextension
to get the COG well in Front of knee joint to keep it stable

Lateral Femoral Cutaneous Nerve

 Root value: dorsal divisions of the L2-L3
o It then passes under the inguinal ligament then into the thigh then divides into two
branches :
 Anterior branch: Anterior and lateral parts of the thigh to knee.
 Posterior branch: Lateral and posterior surfaces of the thigh from the level of the
greater trochanter to the middle of the thigh.

 Entrapment of lateral femoral cutaneous nerve of thigh beneath inguinal ligament
 Pure Sensory Syndrome
 Causes :
 Tight corset/ tight clothing
 Seat Belt
 Obesity
 Pregnancy

 Pain, Burning and paresthesia on lateral aspect of thigh
 Worsen on prolonged standing, squatting and walking
 Hyper sensitivity to heat
 Tenderness over ASIS
 No muscle weakness
 Differentiation from L3 radiculopathy and Femoral Neuropathy is very important

 Root value: spinal nerves L4 to S3 from sacral plexus
 Muscular branch :
 Biceps femoris
 Semi tendinous
 Semi membranous
 Adductor magnus
 Articular Branch :
 Hip joint
 2 branches:
Tibial nerve Common peroneal nerve

 Causes:
 Penetrating wound around pelvis
 Hip arthroplasty
 Trauma
 Fracture of pelvis and femur
 Hip Joint dislocation
 IM injection in gluteal region
 Infection
 Sitting on hard surface
 Compression by Neoplasm, lymphoma or
foetal head
 Popliteal cyst

 Sensory Deficit:
 Complete loss of sensation below knee except saphenous nerve distribution
 Motor deficit:
o Weakness/ paralysis of following muscles:
 Biceps femoris
 Semimembranous
 Semi Tendinous
 Hamstring part of adductor magnus

o Muscles of tibial nerve – Posterior compartment of leg
o Muscles of common peroneal nerve – Lateral and anterior compartment of leg and foot
o All the muscles below the knee are paralyzed, and the weight of the foot causes it to
assume the plantar-flexed position, or Foot Drop.
o Clawing of toes with trophic ulceration Due to lack of sensation over foot
 Gait:
 Steppage gait : (High stepping) gait abnormality characterised by foot drop due to loss
of dorsiflexion
 The foot hangs with the toes pointing down, causing the toes to scrape the ground
while walking, requires to lift the leg higher than normal when walking.

 Root value: L4-S3 of sacral plexus
 Muscle supply:
 Gastrocnemius
 Soleus
 Popliteus
 Plantaris
 Tibialis Posterior
 Flexor hallucis longus
 Flexor Digitorum Longus
 Cutaneous Branch:
 Medial Plantar nerve
 Lateral Plantar nerve
 Medial Calcaneal Branches

 Causes:
 Deep penetrating injury to knee or upper
leg
 Dislocation of knee
 Tarsal tunnel syndrome
 Compression under flexor retinaculum
 Tibial nerve can be affected along with
sciatic nerve palsy
 Tibial nerve alone is affected at or below
popliteal fossa
 Signs and symptoms:
 Sensory deficit:
 Sole of foot
 Medial aspect of heel

 Motor deficit:
Following muscles will be paralyzed :
 Gastrocnemius
 Soleus
 Plantaris
 Popliteus
 Tibialis posterior
 FHL
 FDL
 Intrinsic foot muscles
 Ankle jerk lost
 Plantar reflex : non elicitable

 Deformity:
 Talipes calcaneo valgus
 Dorsiflexion
 Eversion
 Abduction

 Tarsal tunnel syndrome:
o Tibial Nerve is entrapped in tarsal tunnel
o Formed by thick ligament flexor
retinaculum covering tarsal bones
o Following structures travel through
the tarsal tunnel:
 Tibial Nerve
 Tibialis posterior tendon
 Flexor hallucis longus tendon
 Flexor digitorum longus tendon
o In the tunnel, the nerve splits into:
 Medial plantar nerve
 Lateral plantar nerve

 Sensory deficits :
o Paresthesia and numbness that extend to
toes and sole
o Heel sensation will be spared as the
calcaneal branch arise proximal to tarsal
tunnel
o Pain :
 Perimalleolar pain,
 Increased with Weight bearing
 Pain increases at night
 Motor Deficits :
 Involves weakness of the muscles that
passes through tarsal tunnel
 Weakness of intrinsic foot muscles
 Ankle jerk - Normal

 Root value: L4-S2
 Branches:
o Lateral Popliteal Nerve
o Common fibular Nerve
 Superficial peroneal nerve
 Deep peroneal nerve
o Sensory Branches:
 Lateral sural cutaneous nerve
 Deep peroneal nerve

 Causes:
 Compression of the nerve by tight plaster or splint
 Fracture of neck of fibula/ head of fibula Hansens disease
 Trauma to knee- damage to fibular collateral ligament
 Entrapped by fibrous arch as it winds around the neck of fibula
 Prolonged immobilization during which leg rest in external rotation
 Habitual crossing of legs

 Sensory deficit:
o Sensory deficit is seen over the cutaneous
distribution of following nerve
 Lateral sural cutaneous nerve
o Deep peroneal nerve palsy
 Web space between great toe and
second toe
o Superficial peroneal nerve palsy
 Anterior and lateral aspect of leg
 Dorsum of foot and toe except the web
space area between great toe and second
toe

 Motor deficit:
o Superficial peroneal nerve palsy
 Tibialis Anterior
 EHL
 EDL
 EDB
o Deep peroneal nerve palsy
 Peroneus Longus
 Peroneus Brevis

 Deformity:
 Equino Varus Deformity
 Due to over activity of posterior compartment of muscles and invertors
 Plantarflexed and Inverted
 Foot Drop Deformity

 Gait:
 Steppage gait(High stepping Gait)
 Slapping gait (each step makes a slapping noise)

Lower limb peripheral nerve injury

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Lower limb peripheral nerve injury