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
NERVES OF LOWER LIMB
Arise from lumbar and sacral plexus
Main nerves of lumbar plexus are
1. emoral nerve
!. "bturator nerve
#. $ateral cutaneous nerve of thigh
Main nerves of sacral plexus are
1. %uperior gluteal nerve
!. &nferior gluteal nerve
#. 'udendal nerve
(. %ciatic nerve which terminates in popliteal fossa into
a. )ibial nerve
b. *ommon peroneal nerve
FEMORAL NERVE L2,3,4
+ranch of lumbar plexus
,erve of anterior compartment of thigh
Arise in abdomen, -nters thigh behind inguinal ligament lateral to femoral artery, ! inch
below inguinal ligament divides into anterior and posterior divisions
Anterior i!i"ion
M#"$#%&r branches sartorius, 'ectineus
C#t&neo#"
Medial cutaneous nerve of thigh
&ntermediate cutaneous nerve of thigh
'o"terior i!i"ion
C#t&neo#" ..%aphenous nerve...s/in of Anteromedial surface of leg, medial border of
foot upto ball of great toe
M#"$#%&r ( 0uadriceps femoris
Arti$#%&r to hip and /nee joint
FEMORAL NERVE INJUR)
*omplete division is rare
&njured by stab or gunshot wound
M#"$%e" *&r&%+,e
1uadriceps femoris
Motor %o""
$oss of /nee extension
Sen"or+ %o""
"n anterior and medial aspect of thigh
Medial side of lower leg
Medial border of foot upto ball of great toe
OBTURATOR NERVE
OBTURATOR NERVE INJUR)
C&#"e"
'enetrating wounds
Anterior dislocation of hip joint
"bturator hernia
M#"$%e" *&r&%+,e
All the adductor muscles except for hamstring part of adductor magnus
Motor %o""
adduction of thigh
Sen"or+ %o""
Medial side of thigh
LATERAL CUTANEOUS NERVE OF THIGH L2,3
+ranch of lumbar plexus
-nter thigh behind lateral end of inguinal ligament
Divides into anterior and posterior branches
Di"tri-#tion
$ateral aspect of thigh and /nee
$ower lateral 0uadrant of gluteal region
INJUR) OF LATERAL CUTANEOUS NERVE OF THIGH L2,3
C&#"e"
*ompression or inflammation
're"ent&tion
%harp pain in the course of distribution
OBTURATOR NERVE
Adductor
magnus
adductor part
adductor brevis
Knee joint
Popliteal
artery
Posterior division
ip joint
pectineus
Adductor longus
Adductor brevis
gracilis
!ubsartorial ple"us
#emoral artery
$%
$&
$'
Anterior division
Adductor
region o(
t)ig)
pelvis
abdomen
SU'ERIOR GLUTEAL NERVE
+ranch of sacral plexus
-nters gluteal region from pelvis through greater sciatic
foramen above piriformis
2uns between gluteus medius and minimus
M#"$%e" inner!&te
3luteus medius
3luteus minimus
)ensor fascia lata
INJUR) TO SU'ERIOR GLUTEAL NERVE
M#"$%e" *&r&%+,e
3luteus medius
3luteus minimus
Motor %o""
$oss of abduction of hip
Uni%&ter&% in.#r+ shows lipping gait and *o"iti!e
trene%en-er/," "i/n i.e. Drooping of pelvis on one side when
ipsilateral foot is lifted off the ground
Bi%&ter&% in.#r+ shows 0&%in/ /&it
INFERIOR GLUTEAL NERVE
In1erior /%#te&% ner!e
+ranch of sacral plexus
-nter gluteal region from pelvis through greater sciatic
foramen below piriformis
2uns between gluteus maximus and medius
Muscle innervated
3luteus maximus
INJUR) TO INFERIOR GLUTEAL NERVE
M#"$%e *&r&%+,e
3luteus maximus muscle
Motor %o""
&mpairment of hip extension and lateral rotation
Difficulty in raising the body from sitting or stooping
position

SCIATIC NERVE INJUR)
*ommonly injured in following conditions
I2V2Di"$ 'ro%&*"e
Di"%o$&tion o1 3i* .oint
'iri1or4i" "+nro4e
Intr&4#"$#%&r in.e$tion
'enetr&tin/ 0o#n &n 1r&$t#re o1 *e%!i"
Most lesions are incomplete
456 cases involve common peroneal due to superficial position
$'
$*
!+
!%
!&
,$UTEA$ RE,-ON
BA.K O# T-,
$O/ER
$E,
#OOT
!A.RA$ P$E0U!
.O11ON PERONEA$
NERVE
!.-AT-. NERVE
B-.EP! #E1OR-! !ORT EA2
KNEE 3O-NT
!K-N O# $ATERA$
$E,
$ATERA$
.UTANEOU! O#
$E,
!UPER#-.-A$
PERONEA$
2EEP
PERONEA$
PERONEU!
$ON,U! AN2
BREV-!
!K-N
O#
$E,
!K-N O# .$E#T
BET/EEN #-R!T %
TOE!
1U!.$E! O#
#RONT O# $E,
ANK$E 3O-NT
E0TEN!OR
2-2-TORU1
BREV-!
!K-N O# $ATERA$
!-2E O# #OOT
AN2 $-TT$E TOE
!K-N O# 2OR!U1
!.-AT-. AN2 .O11ON PERONEA$ NERVE
!.-AT-. NERVE AN2 T-B-A$ NERVE
$*
$* !+
!%
!&
PE$V-!
,$UTEA$
RE,-ON
BA.K O# T-,
$O/ER $E,
!O$E O# #OOT
)ip joint
To all )amstrings muscle
Knee joint
1uscles o( bac4 o( leg
!ural nerve
1edial plantar
nerve
Abductor )allucis
#le"or )allucis and
digitorum brevis
-st lumbrical
!4in and
joints o(
sole
All ot)er
muscles
o( sole
!4in o(
sole
$ateral plantar nerve
!.-AT-.
NERVE
T-B-A$ NERVE
SCIATIC NERVE INJUR) IN INTERVERTEBRAL DISC 'ROLA'SE
SCIATIC NERVE INJUR) IN MIS'LACED INTRA GLUTEAL
INJECTION
&ntramuscular injections are usually given in gluteus maximus
%ciatic nerve passes midway between greater trochanter and ischial
tuberosity
To &!oi in.#r+ to "$i&ti$ nerve, in.e$tion should be given in
#**er o#ter 5#&r&nt
SCIATIC NERVE AND 'IRIFORMIS S)NDROME
*ertain leg positions pull the piriformis up against the sciatic nerve
causing buttoc/ pain 7 radiating leg pain
SCIATIC NERVE INJUR) IN DISLOCATION OF HI' JOINT
%ciatic nerve travels in gluteal region on the posterior surface of
hip joint
'rone to injury in posterior dislocation of hip joint
SCIATIC NERVE INJUR)
M#"$%e"
hamstring muscles and all the muscles below /nee8
Motor %o""
%evere impairment in /nee flexion
$oss of all movements at foot
De1or4it+
foot drop due to weight of foot.
SCIATIC NERVE INJUR)
Sen"or+ %o""
All sensation below /nee below the /nee except the medial aspect of leg and foot
upto ball of big toe.
$oss of sensation of sole ma/es the patient vulnerable to trophic ulcers
SCIATICA
'ain along the sensory distribution of sciatic nerve
'osterior aspect of thigh
'osterior and lateral sides of leg
$ateral part of foot
C&#"e"
'rolapse of intervertebral disc
&ntrapelvic tumor
&nflammation of sciatic nerve
INJUR) TO COMMON 'ERONEAL NERVE
C&#"e
racture of fibular nec/, entrapment by leg casts or splints
M#"$%e" *&r&%+,e
Anterior and lateral muscles of leg
De1or4it+
-0uinovarus.. foot is plantar flexed and inverted due to actions of
unopposed plantar flexors and invertors.
INJUR) TO COMMON 'ERONEAL NERVE
Sen"or+ %o""
Anterior and lateral side of leg
Dorsum of foot and digits
Medial side of big toe
$ateral border of foot and lateral side of little toe along with medial border upto
the ball of great toe is unaffected
INJUR) TO TIBIAL NERVE
C&#"e
2arely injured in fractures of upper end of tibia or penetrating
wound
M#"$%e *&r&%+,e
All muscles of bac/ of leg and sole
De1or4it+
*alcaneovulgus Dorsiflexion and -version of foot
INJUR) TO TIBIAL NERVE
Sen"or+ %o""
9hole of the sole of foot
May result into trophic ulcers