ࡱ> RTQq` 0bjbjqPqP 7<:: |||""""$#L.p#p#p#p#p#(((^.`.`.`.`.`.`.$/h1.|$)(($)$).p#p#/.t+t+t+$) p#|p#^.t+$)^.t+t++|-p#d# zǓt"@)X-B..0.-2)2--"2|-((t+( (S(((..d+(((.$)$)$)$)d"" NERVES OF LOWER LIMB AND THEIR INJURIES LEARNING OBJECTIVES At the end of lecture students should be able to Know the names of nerves and their main branches innervating lower limb Know the nerves closely related to a bone or other structure of lower limb Know the main nerves commonly vulnerable to injury Know the main area and loss of function if particular nerve is injured Define and under stand terms neuritis, anesthesia, par aesthesia, paralysis, neuralgia, sciatica LECTURE OUTLINE NERVES OF LOWER LIMB Arise from lumbar and sacral plexus Main nerves of lumbar plexus are 1. Femoral nerve 2. Obturator nerve 3. Lateral cutaneous nerve of thigh Main nerves of sacral plexus are 1. Superior gluteal nerve 2. Inferior gluteal nerve 3. Pudendal nerve 4. Sciatic nerve which terminates in popliteal fossa into a. Tibial nerve b. Common peroneal nerve FEMORAL NERVE L2,3,4 Branch of lumbar plexus Nerve of anterior compartment of thigh Arise in abdomen, Enters thigh behind inguinal ligament lateral to femoral artery, 2 inch below inguinal ligament divides into anterior and posterior divisions Anterior division Muscular branches sartorius, Pectineus Cutaneous Medial cutaneous nerve of thigh Intermediate cutaneous nerve of thigh Posterior division Cutaneous --Saphenous nerve---skin of Anteromedial surface of leg, medial border of foot upto ball of great toe Muscular quadriceps femoris Articular to hip and knee joint FEMORAL NERVE INJURY Complete division is rare Injured by stab or gunshot wound Muscles paralyzed Quadriceps femoris Motor loss Loss of knee extension Sensory loss On anterior and medial aspect of thigh Medial side of lower leg Medial border of foot upto ball of great toe OBTURATOR NERVE OBTURATOR NERVE INJURY Causes Penetrating wounds Anterior dislocation of hip joint Obturator hernia Muscles paralyzed All the adductor muscles except for hamstring part of adductor magnus Motor loss adduction of thigh Sensory loss Medial side of thigh LATERAL CUTANEOUS NERVE OF THIGH L2,3 Branch of lumbar plexus Enter thigh behind lateral end of inguinal ligament Divides into anterior and posterior branches Distribution Lateral aspect of thigh and knee Lower lateral quadrant of gluteal region INJURY OF LATERAL CUTANEOUS NERVE OF THIGH L2,3 Causes Compression or inflammation Presentation Sharp pain in the course of distribution SUPERIOR GLUTEAL NERVE Branch of sacral plexus Enters gluteal region from pelvis through greater sciatic foramen above piriformis Runs between gluteus medius and minimus Muscles innervated Gluteus medius Gluteus minimus Tensor fascia lata INJURY TO SUPERIOR GLUTEAL NERVE Muscles paralyzed Gluteus medius Gluteus minimus Motor loss Loss of abduction of hip Unilateral injury shows lipping gait and positive trendelenberg,s sign i.e. Drooping of pelvis on one side when ipsilateral foot is lifted off the ground Bilateral injury shows waddling gait INFERIOR GLUTEAL NERVE Inferior gluteal nerve Branch of sacral plexus Enter gluteal region from pelvis through greater sciatic foramen below piriformis Runs between gluteus maximus and medius Muscle innervated Gluteus maximus INJURY TO INFERIOR GLUTEAL NERVE Muscle paralyzed Gluteus maximus muscle Motor loss Impairment of hip extension and lateral rotation Difficulty in raising the body from sitting or stooping position SCIATIC NERVE INJURY Commonly injured in following conditions I.V.Disc Prolapse Dislocation of hip joint Piriformis syndrome Intramuscular injection Penetrating wound and fracture of pelvis Most lesions are incomplete 90% cases involve common peroneal due to superficial position SCIATIC NERVE INJURY IN INTERVERTEBRAL DISC PROLAPSE SCIATIC NERVE INJURY IN MISPLACED INTRA GLUTEAL INJECTION Intramuscular injections are usually given in gluteus maximus Sciatic nerve passes midway between greater trochanter and ischial tuberosity To avoid injury to sciatic nerve, injection should be given in upper outer quadrant SCIATIC NERVE AND PIRIFORMIS SYNDROME Certain leg positions pull the piriformis up against the sciatic nerve causing buttock pain & radiating leg pain SCIATIC NERVE INJURY IN DISLOCATION OF HIP JOINT Sciatic nerve travels in gluteal region on the posterior surface of hip joint Prone to injury in posterior dislocation of hip joint SCIATIC NERVE INJURY Muscles hamstring muscles and all the muscles below knee; Motor loss Severe impairment in knee flexion Loss of all movements at foot Deformity foot drop due to weight of foot. SCIATIC NERVE INJURY Sensory loss All sensation below knee below the knee except the medial aspect of leg and foot upto ball of big toe. Loss of sensation of sole makes the patient vulnerable to trophic ulcers SCIATICA Pain along the sensory distribution of sciatic nerve Posterior aspect of thigh Posterior and lateral sides of leg Lateral part of foot Causes Prolapse of intervertebral disc Intrapelvic tumor Inflammation of sciatic nerve INJURY TO COMMON PERONEAL NERVE Cause Fracture of fibular neck, entrapment by leg casts or splints Muscles paralyzed Anterior and lateral muscles of leg Deformity Equinovarus-- foot is plantar flexed and inverted due to actions of unopposed plantar flexors and invertors. 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