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7/28/2019 Anatomy of Nerve Injuries Lower Limb BMJ
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MOB TCD
Anatomy of Nerve InjuriesLower Limb
Professor Emeritus Moira OBrien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
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Anatomy of Nerve Injuries
Dermatomes Entrapment of Nerves
Pierce Muscle
Pierce Fascia
Repetitive Movements
MOB TCD
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Must know the course of nerve Dermatomes
Entrapment of nerves
Pierce muscle
Pierce fascia
Repetitive movements
Anatomy of Nerve InjuriesMOB TCD
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Dermatomes and Myotomes
Nerves supply Skin
Muscles (group)
Tendons
Bones
Joints
Blood vessels
MOB TCD
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Extrinsic Factors
External forces Fibro-osseous tunnels, tether
the nerve
Oedema
Callus formation as a result of afracture
External compression due tospecific movements
Mechanical compression Compartment syndromes
The nerve is tender at the siteof compression
MOB TCD
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Fibrous bands
Accessory muscles
Spurs
Narrow notches
Anatomical variations of the nerve itself
Extrinsic FactorsMOB TCD
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Lumbosacral PlexusMOB TCD
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Entrapment Syndromes
in Lower Limb
Affects branches of lumbaror sacral plexuses
Pierces muscle
Pierces fascia
Increase in compartmentpressure
Compressed by external
pressure
MOB TCD
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Skin of Anterior Abdominal Wall
Lower five intercostal nerves Subcostal nerve T12
10th intercostal nerves at the
level of the umbilicus
Iliohypogastric nerve L1 Ilioinguinal nerve L1
MOB TCD
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Cutaneous Nerves of Thigh
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
MOB TCD
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Cutaneous NervesMOB TCD
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Iliohypogastric Nerve L1
Branch of lumbar plexus Lateral border of psoas
Anterior to quadratus
lumborum
Neurovascular plane betweeninternal oblique and
transversus
Lateral cutaneous supplies
upper part of buttock
MOB TCD
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Pierces internal obliqueabove anterior superior
iliac spine
Pierces aponeurosis of
external oblique an inchabove superficial ring
Supplies skin over lower
part of rectus sheath
Can be trapped piercingaponeurosis
Iliohypogastric NerveMOB TCD
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Pierces internal oblique4 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 NerveMOB TCD
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May be trapped postsurgery, due to adhesions
Poor tone in abdominal
muscles
Pain increased byincreased tension in the
anterior abdominal wall
Hyperextension of hip
Tenderness 4 cm fromanterior superior iliac spine
Ilioinguinal NerveMOB TCD
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Pain increased Increased tension in the anterior
abdominal wall
Hyperextension of hip
Tenderness 4 cm medial to anteriorsuperior iliac spine
Ilioinguinal Nerve EntrapmentMOB TCD
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Cutaneous Nerves
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
MOB TCD
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Genitofemoral Nerve
Lumbar plexus L1,2
Anterior aspect of the psoas
Genital branch enters the deep
inguinal ring
Femoral branch lies on thelateral side of femoral artery in
the femoral sheath
MOB TCD
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Femoral Branch Genitofemoral
Enters thigh on lateral aspectof femoral artery in femoral
sheath
Pierces anterior wall of the
sheath
Supplies skin a hands breath
below the inguinal ligament
MOB TCD
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Union with ilioinguinal nerveon anterior aspect of
spermatic cord
Supplies ventral aspect of
scrotum and adductor region
Cutaneous branch on the
dorsal-caudal aspect
May also supply dorsal
scrotumAkita et al., 1999
Genitofemoral NerveMOB TCD
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Genitofemoral NerveMOB TCD
C
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Lateral Cutaneous Nerve
of Thigh L2,3
Lumbar plexus in psoas Lateral aspect of psoas
Pierces inguinal ligament
Lies in fibrous tunnel
Divides into two
Pierces deep fascia
MOB TCD
MOB TCD
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A centimeter medial toanterior 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 ThighMOB TCD
MOB TCD
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Entrapment in the fascial tunnel Injured in the thigh by
asymmetric bars in gymnastics
Causes meralgia paraesthetica
Post laparoscopic surgery
Lateral Cutaneous Nerve of ThighMOB TCD
MOB TCD
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Femoral Nerve L2,3,4
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
MOB TCD
MOB TCD
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Muscular branches Rectus femoris
Vastus medialis,
Vastus lateralis
Vastus intermedius Sartorius, pectineus
Cutaneous
Medial cutaneous nerves of thigh
Intermediate cutaneous nerves of thigh Saphenous
Articularbranches to hip and knee joints
Femoral NerveMOB TCD
MOB TCD
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Dancers may stretch thenerve 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 iliacusOBrien, 1997
Femoral NerveMOB TCD
MOB TCD
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Femoral nerve
Saphenous
Femoral NerveMOB TCD
MOB TCD
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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 L2,3,4MOB TCD
MOB TCD
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Supplies the parietalperitoneum on side wall of the
pelvis
Is related to the ovary
Pathology in the ovary orendometriosis may result in
referred pain to the hip, knee or
medial side of the high
Obturator NerveMOB TCD
MOB TCD
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Anterior Division Obturator
Anterior division ofthe obturator
leaves pelvis
Anterior to
obturator externus
Descends in front
of adductor brevis
Behind pectineus
and adductor
longus
Obturator nerve
O C
MOB TCD
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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
MOB TCD
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Obturator Nerve
MOB TCD
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It may be entrapped as it leaves the pelvis
Pierces and supplies the obturator externus
Causing spasm of the adductor muscles
Posterior Division Obturator
MOB TCD
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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
MOB TCD
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Obturator nerve
Obturator Nerve
Fascial planes
MOB TCD
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Howship Rhomberg Sign
Pressure on obturator
nerve
Pain on inner aspect of
thigh relieved by flexion of
hip
Increased by extension,
adduction and medial
rotation
MOB TCD
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Obturator Nerve
MOB TCD
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Psoas Muscle
MOB TCD
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Sacral Plexus
MOB TCD
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Pudendal Nerve
MOB TCD
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Compression of pudendal nerve in
cyclists due to saddle
History of change of saddle
Compressing dorsal nerve of penis
Pudendal Nerve
Sciatic NerveMOB TCD
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Sciatic Nerve
Posterior Cutaneous Nerve Thigh
MOB TCD
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Sciatic Nerve L4,5, S1,2,3
Is the largest nerve indiameter 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
MOB TCD
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Is crossed by the long headof 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
MOB TCD
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Occasionally it divides in thepelvis
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 thesciatic nerve and produce
clinical signs of adverse neural
tension
Sciatic Nerve
MOB TCD
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The larger terminal branch of thesciatic nerve
Crosses popliteal fossa
Passes deep to soleus
In posterior compartment betweenflexor digitorum longus flexor
hallucis longus
Passes deep to flexor retinaculum
Gives off medial calcaneal nervewhich pierces retinaculum
Divides into medial and lateral
plantar nerves
Tibial Nerve
MOB TCD
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The tibial nerve supplies all the muscles of theposterior 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
MOB TCD
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Obturator Nerve L2,3,4
Medial side of psoas Side wall of pelvis
Obturator canal
Divides anterior posterior
division
SMOB TCD
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Sural nerve is joined by suralcommunicating from
commom peroneal
Pierces deep fascia
Supplies posterior and lateralportion of calf
Lateral border of foot
Entrapment occurs most
frequently in runners with ahistory of ankle sprain
Sural Nerve
S l NMOB TCD
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Sural Nerve
MOB TCD
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Flexor Retinaculum
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 plantarbranches
Flexor hallucis longus
Tibi l NMOB TCD
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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
M di l d L l Pl NMOB TCD
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Medial and Lateral Plantar Nerves
Tibial divides into the medial and lateralplantar nerves
They enter two tunnels separated by a
fascial septum
Stretching from the calcaneus to the deepfascia of the abductor hallucis
M di l Pl t NMOB TCD
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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 themedial three and a half toes
Medial Plantar Nerve
M di l Pl t NMOB TCD
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Motor to the abductor hallucis
Flexor hallucis brevis
Flexor digitorum brevis
First or unipennate lumbrical
Medial Plantar Nerve
M di l Pl t NMOB TCD
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Crosses the sole of the foot deep to theabductor hallucis, flexor digitorum brevis
and the abductor digiti minimi
To the base of 5th metatarsal
Superficial to flexor hallucis longus, flexordigitorum longus and flexor accessorius
Lateral plantar nerve supplies the lateralone-and-a-half toes
Supplies all the other intrinsic muscles ofthe foot
Medial Plantar Nerve
T l T l S dMOB TCD
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Tarsal Tunnel Syndrome
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 beinvolved
Hyper dorsiflexion, external
rotation and eversion can
produce symptoms of tarsaltunnel syndrome
T l T l S dMOB TCD
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Pain worse if foot ispronated
Tender over flexor
retinaculum
Pain in heel, if medialcalcaneal is involved
Pain in sole of foot if
plantar nerves involved
Tarsal Tunnel Syndrome
T l T l S dMOB TCD
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Orthotics may help if markedpronated foot
Anti-inflammatories
Splint at night
Tarsal Tunnel Syndrome
T l T l S dMOB TCD
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Tarsal Tunnel Syndrome
M t M t t l i
MOB TCD
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Mortons Metatarsalgia
Depressedtransverse arch in
runners and ballet
dancers with mobile
first ray
Neuroma on digital
nerve to the second
cleft or third cleft
morton neuroma.jpg
Mortons Foot
M di l Pl tMOB TCD
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Pronated foot
Depressed transversearch at heads ofmetatarsals
Pain worse with tight
shoes on Relieved by removing
shoes
Medial Plantar
Common Peroneal NerveMOB TCD
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L4,5, S1,2,3
If sciatic nerve divides insidethe 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 lateralhead of gastrocnemius
Common PeronealMOB TCD
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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, deepand superficial peroneal
Vulnerable to injury as it winds around neck of fibula
Foot drop, plantar flexed, inverted
Common Peroneal
Compartments in CalfMOB TCD
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Compartments in Calf
Nerves can becompressed in
compartments
Anterior compartment
deep peroneal nerve
Lateral compartment
superficial peroneal
Posterior compartment
tibial nerve
Deep Peroneal NerveMOB TCD
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Deep Peroneal Nerve
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 inanterior compartment tibialis
anterior, extensor hallucis
longus, extensor digitorum
longus, peroneus tertius andextensor digitorum brevis
Deep Peroneal NerveMOB TCD
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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 causeentrapment
Deep Peroneal Nerve
Superficial Peroneal NerveMOB TCD
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Runs in the lateralcompartment of the calf
Between the peroneus longus
and brevis supplying both
these muscles Pierces the deep fascia
1012 cm above the lateral
malleolus supplies most of
the dorsum
Superficial Peroneal Nerve
Nerve Supply of DorsumMOB TCD
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Nerve Supply of Dorsum
Divides 6 cm above the lateralmalleolus 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
Superficial Peroneal NerveMOB TCD
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Superficial Peroneal Nerve
Entrapment occurs where the
superficial peroneal piercesthe deep fascia
Particularly if there is
herniation of the muscle due
to fascial defects Chronic ankle strains also
stretch the nerve
Ankle InjuriesMOB TCD
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Ankle Injuries
Grade III ankle injuries have a high
incidence of traction injuries to both theperoneal and posterior tibial nerves
Taunton & Fricker, 1996
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BMJ Publishing Group Limited (BMJ Group) 2012. All rights reserved.
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