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Anatomy of Nerve Injuries Lower 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

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Anatomy of Nerve Injuries

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

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Dermatomes and Myotomes

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

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Extrinsic Factors
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

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Extrinsic Factors
Fibrous bands
Accessory muscles Spurs Narrow notches Anatomical variations of the nerve itself

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Lumbosacral Plexus

Entrapment Syndromes in Lower Limb

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

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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

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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

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Cutaneous Nerves

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Iliohypogastric Nerve L1
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

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Iliohypogastric Nerve
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

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

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Ilioinguinal Nerve
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

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Ilioinguinal Nerve
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

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Ilioinguinal Nerve Entrapment

Pain increased Increased tension in the anterior abdominal wall Hyperextension of hip Tenderness 4 cm medial to anterior superior iliac spine

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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

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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 the lateral side of femoral artery in the femoral sheath

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Femoral Branch Genitofemoral

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

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Genitofemoral Nerve
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

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Genitofemoral Nerve

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

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Lateral Cutaneous Nerve of Thigh

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

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Lateral Cutaneous Nerve of Thigh

Entrapment in the fascial tunnel Injured in the thigh by asymmetric bars in gymnastics Causes meralgia paraesthetica Post laparoscopic surgery

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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

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Femoral Nerve
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

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Femoral Nerve
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
OBrien, 1997

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Femoral Nerve

Femoral nerve

Saphenous

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Obturator Nerve L2,3,4

Lumbar plexus in psoas Medial aspect of psoas Side wall of pelvis under peritoneum Leaves through obturator foramen Divides into anterior and posterior divisions

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Obturator Nerve
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

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Anterior Division Obturator

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

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Anterior Division Obturator

Adductor longus Adductor brevis Gracilis It gives an articular twig to the hip joint Skin on the medial side of the thigh

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Obturator Nerve

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Posterior Division Obturator

It may be entrapped as it leaves the pelvis Pierces and supplies the obturator externus Causing spasm of the adductor muscles

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Posterior Division Obturator

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

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Obturator Nerve

Obturator nerve

Fascial planes

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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

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Obturator Nerve

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Psoas Muscle

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Sacral Plexus

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Pudendal Nerve

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

Sciatic Nerve Posterior Cutaneous Nerve Thigh

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Sciatic Nerve L4,5, S1,2,3

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

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Sciatic Nerve
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

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Sciatic Nerve
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

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Tibial Nerve
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

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Tibial Nerve
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

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Obturator Nerve L2,3,4

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

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Sural Nerve
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

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Sural Nerve

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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 plantar branches Flexor hallucis longus

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Tibial Nerve
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

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Medial and Lateral Plantar Nerves

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

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Medial Plantar Nerve

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

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Medial Plantar Nerve

Motor to the abductor hallucis Flexor hallucis brevis Flexor digitorum brevis First or unipennate lumbrical

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Medial Plantar Nerve

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

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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 be involved Hyper dorsiflexion, external rotation and eversion can produce symptoms of tarsal tunnel syndrome

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Tarsal Tunnel Syndrome

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

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Tarsal Tunnel Syndrome

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

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Tarsal Tunnel Syndrome

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Mortons Metatarsalgia
Depressed transverse arch in runners and ballet dancers with mobile first ray Neuroma on digital nerve to the second cleft or third cleft
Mortons Foot

morton neuroma.jpg

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

Common Peroneal Nerve L4,5, S1,2,3

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

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Common Peroneal
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

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Compartments in Calf
Nerves can be compressed in compartments Anterior compartment deep peroneal nerve Lateral compartment superficial peroneal Posterior compartment tibial nerve

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Deep Peroneal Nerve

Branch of the common peroneal at the neck of the fibula Pierces the lateral intermuscular 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

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Deep Peroneal Nerve

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

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Superficial Peroneal Nerve

Runs in the lateral compartment 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

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Nerve Supply of Dorsum

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

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Superficial Peroneal Nerve

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

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

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