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NERVE OF THE LOWER LIMB
GROUP MEMBERS
Sharifah Firdawina Bt Syid Ayob Syarifah Liyana Amira Bt Syed Abdullah Siti Mastura Bt Mirom Siti Nurliana Bt Zulkefli Siti Sarah Bt Abd Rahman Syadza Norain Bt Ahmad Zainuddin Syahedatul Shakinah Bt Jailany Syahirah Bt Ghazali Taqiah Bt Borhan Wan Ahmad Fathiizuddin Bin Wan Jamaluddin
OBJECTIVES
Identify and recognize the nerve of the lower limb
Study the course and the branch of each nerve
Recognize the nerve injuries and what is the effect to the lower limb
FEMORAL NERVE
By : Siti Mastura Binti Mirom09-1-225
FEMORAL NERVE
The largest branch of lumbar plexus One of the femoral triangle component But not one of the femoral sheath
components
OriginDorsal division of ventral rami of 2nd, 3rd, and
4th lumbar nerve.
LUMBAR PLEXUS
FEMORAL NERVE
FEMORAL TRIANGLE
COURSE
Descend through the psoas major
Pass behind the inguinal ligament
Enters thigh, and split into anterior and posterior division
ANTERIOR DIVISION
Muscular branch
Sartorius muscle
POSTERIOR DIVISION
Muscular branches
Pectineus muscle
Quadriceps muscle
CUTANEOUS SUPPLY BY FEMORAL NERVE
NERVE INJURY
Causes: Direct trauma Prolonged pressure on nerve Breaking bone of pelvis Lithotomy positionSymptoms: Sensation changes in the thigh, knee, or leg Weakness of knee or leg Difficulty in going up and downstair
OBTURATOR NERVE
By :Syahirah Ghazali09-1-230
INTRODUCTION
• 1. The largest nerve in the anterior lumbar plexus.
• 2. The lumbar plexus is a nerve network or grouping of nerves of the low back area.
• 3. Serves as a pathway for electrochemical signals connecting the brain to the back, abdomen, groin and knees.
• 4. Also considered as a part of the peripheral nervous system.
ORIGIN: L. 2, 3, 4
COURSE: 1) It emerges at the medial border of psoas major
2) Then, it descends on the side wall of the pelvis till it reaches the obturator
canal.3) In the obturator canal, it divides
into anterior and posterior division.
ANTERIOR DIVISION
Passes on the ‘anterior surface of adductor brevis’ (deep to pectineus & adductor longus)
Distribution: Motor supply: Adductor longus
Adductor brevis Adductor magnus
Cutaneous supply: Skin of medial side of thighArticular branch: To the hip joint
POSTERIOR DIVISION
Passes through obturator externus. Then, it descends vertically downwards on the ‘posterior surface of adductor brevis’ (anterior to adductor magnus)
Distribution: Motor supply: Obturator externus, adductor
magnusArticular branch: To the knee joint
INJURY
• Rare because the nerve lies deep into the pelvis.• Can occur during pelvic or abdominal surgery.• Numbness and pain radiating to inner thigh.• Loss of sensation of medial part of the thigh• Paralysis of adductor longus, brevis and magnus.• Adduction thigh weakness can occur cause posture
instability.• Electrical tests can help to confirm the diagnosis.
CONT.
Treatment:- Physical therapy- General exercise program- Massage therapy- Ultrasound- Electrical stimulationSevere:Injection of steroid(obturator nerve block)
SUPERIOR GLUTEAL NERVE
By :Syadza Norain Bt Ahmad Zainuddin09-01-228
The superior gluteal nerve is a nerve of gluteal region.
It originates in the pelvis and supplies the gluteus medius, the gluteus minimus, and the tensor fasciae lata muscles.
Superior gluteal nerve is responsible mainly for the abduction of the muscles that are supplied by it.
Origin L4,L5,S1 (branch of sacral plexus)
Courses and Distributions
Gluteus medius
Passes through the greater sciatic notch above the upper border of piriformis muscle, accompanied by the superior gluteal vessels.
Inferior branch Superior
branch
Passes between gluteus medius and gluteus minimus where it divides into
Muscular branch: gluteus medius
Muscular branch : gluteus minimus & tensor
fasciae lata
Articular branch :Hip joint
Gluteus medius
Gluteus minimusSuperior gluteal nerve
Nerve Injury
Paralysis of the gluteus medius
and gluteus minimus.
Weak abduction in the affected
hip joint.
Leads to dropping of the pelvis on the unsupported side “trendelenburg
sign”
In case of bilateral paralysis, it leads
to “waddling” gait.
TRENDELENBURG SIGN
When a person is asked to stand on one leg, the pelvis on the unsupported side descends or drops.
This indicate that the gluteus medius and gluteus minimius on the supported side is weak or non-functional.
This clinical observation is a positive Trendelenburg sign.
Causes : - Disruption of the nerve supply to the
abductors of the thigh (gluteus medius, gluteus minimus, and tensor fasciae latae) by an injury or disease (i.e. poliomyelitis), or when conditions such as congenital dislocation of the hip joint exist.
- Trendelenburg sign -
Trendelenburg sign
INFERIOR GLUTEAL NERVE
By :Syahedatul Shakinah binti Jailany09-1-229
ORIGIN
Dorsal divisions of the 5th lumbar
1st and 2nd sacral nerves
COURSE
Leaves the pelvis through the greater sciatic foramen
Below the piriformis Superficial to the sciatic nerve
BRANCHES
Enter the deep surface of the gluteus maximus principal extensor of the thigh also gives off small branches to supply the deep
gluteal muscles
FUNCTION
Hip extension Supplies gluteus maximus
Perform exercise with both affected and unaffected leg. When standing on stabilizing leg, keep knee slightly bent. Avoid twisting movements on stabilizing leg. Ensure body remains upright - no rocking forward and backwards. Isolate movement to hip, squeeze buttocks when extending leg backwards.
INJURY
Difficulty in jumping climbing stairs rising from a seated position
Subject to injury by compressionand ischemia in sedentary individuals
BLUNT INJURY ADHESION
Blunt trauma to the buttocks can cause not only injury to sciatic, but also to the superior and gluteal nerve as well.
Piriformis muscle might compress the inferior gluteal nerve :- With fibrous band in muscle With pressure against sarcopinous ligament
This can occur from minor pressure such as sitting on your wallet to great pressure like direct blow to buttock area (fall injury trauma).
This triggered point often perpetuate muscle tightness, leading directly to nerve compression.
SCIATIC NERVE
By :Siti Nurliana Binti Zulkefli09-1-226
SCIATIC NERVEOrigin : L4,L5-S1, S2, S3
Course From pelvis to gluteal region by passing
through the greater sciatic foramen below piriformis muscle.
Descends in middle line of the thigh.
Termination
At middle of the thigh, divide into two terminal branches,which are:
Medial popliteal (tibial) nerve : anterior division of L4,L5-S1, S2, S3
Lateral popliteal (common peroneal) nerve : dorsal division of L4,L5-S1, S2
RELATION:
Superficial relations Deep relations
a) In gluteal region Gluteus maximus Posterior cutaneous nerve of
the thighb) In back of the thigh Semimembranousus Semitendinosus Long head of biceps femoris
Descends from above downwards:Ischium Tendon of obturator internus and two gemilli musclesQuadratus femorisAdductor magnus
Branches:
A) Muscular branches :
1. Medial popliteal (tibial) nerve: Semimembranousus. Semitendinosus. Long head of biceps femoris. Ischial part of adductor magnus.
2. Lateral popliteal (common peroneal) nerve:
Short head of biceps femoris.
B) Articular branches : Hip joint.
C) Terminal branches : Medial popliteal (tibial) nerve :
anterior division of L4,L5-S1, S2, S3.
Lateral popliteal (common peroneal) nerve : dorsal division of L4,L5-S1, S2.
Surface anatomy: A point at the junction
between the upper and middle thirds of a line between the posterior superior iliac spine and the ischial tuberosity.
A point midway between the greater trochanter and the ischial tuberosity.
A point at the middle of the popliteal fossa.
Applied anatomy: Gluteal intermuscular injection Site : In the upper lateral quadrant of gluteal region or superior to a
line extending from the PSIS to the superior border of greater trochanter.
Cause :To avoid injury to the sciatic nerve.
Nerve Injuries: Sciatic nerve dysfunction is a condition in
which the sciatic nerve conducts impulses abnormally.
Causes :
1. Pelvic or hip joint fracture.
2. Surgery femur fracture .
3. Gunshot or knife wounds to the leg injection into the buttock .
4. Compression of the nerve from prolonged sitting or lying.
5. Piriformis syndrome (a pain disorder involving the narrow piriformis muscle in the buttocks).
6. Slipped disk.
7. Degenerative disk disease.
8. Spinal stenosis.
9. Tumor.
Sign and symptoms:
1. decreased ability to flex the knee.
2. decreased ability to move the foot and toes in certain directions.
3. numbness, burning, or tingling in the leg.
4. pain in the lower back that may travel to the back of the thigh and calf.
Motor loss : paralyses of hamstring muscles, ischial part of adductor magnus and all muscles of the leg and foot – “flail foot”.
Cutaneous loss : loss sensation below knee except area along medial malleolus and medial side of foot which is supplied by saphenous nerve.
Deformity : “foot drop” due to effect of gravity.
Prevention
Proper lifting techniques are important to avoid a ruptured disk. These techniques can be enhanced by the use of an abdominal support belt. Other preventive measures include the following: regular physical activity rest breaks to interrupt long periods of vibration, such as when driving a car smoking cessation for individuals who smoke weight management for people who are obese.
Treatment
1. following steps to calm your symptoms and reduce inflammation.
Apply heat or ice to the painful area. Try ice for the first 48 - 72 hours, then use heat after that.
Take over-the-counter pain relievers such as ibuprofen (Advil, Motrin IB) or acetaminophen (Tylenol).
While sleeping, try lying in a curled-up, fetal position with a pillow between your legs. If you usually sleep on your back, place a pillow or rolled towel under your knees to relieve pressure as activity limitations.
2. If at-home measures do not help, your doctor may recommend injections to reduce inflammation around the nerve. Other medicines may be prescribed to help reduce the stabbing pains associated with sciatica.
3. Physical therapy exercises may also be recommended. Additional treatments depend on the condition that is causing the sciatica.
4. Non surgical spinal decompression.
5. Massage therapy.
6. Weight loss reduces pressure on spinal nerve.
7. Acupuncture.
Side effect of treatment Side effects of medicines include
allergic reactions and stomach upset. Surgery is associated with a risk of
infection, bleeding, and allergic reaction to anesthesia.
MUSCULOCUTANEOUS NERVE
By :Syarifah Liyana Amira BtSyed Abdullah09-1-224
ROOT VALUE :
L5, S1
One of the two terminal branches of common peroneal nerve
Arise within substance of peroneus longus lateral to neck of fibula
Passes downwards in substance of peroneus longus muscle
It descends between peroneus longus and peroneus brevis
Emerges between two muscles and descends under cover of deep fascia of leg
In lower part of the front of the leg, it pierces the deep fascia and become subcutaneous
ORIGIN COURSE
It terminates by dividing into lateral and medial terminal branches which descend superficial to both extensor retinaculae to reach the dorsum of the foot
located superficially between the lateral malleolus and extensor hallucis longus tendon.
TERMINATION
BRANCHESMuscular branches
Peroneus longus and peroneus brevis
Cutaneous distribution
Supply skin of the lower 2/3 of the antero-lateral aspect of the leg
Skin of medial part of dorsum of foot
Divide into 2 dorsal digital branches
medial side of the big toe
second dorsal interdigital cleft (between 2nd & 3rd toes)
Skin of lateral part of dorsum of foot
Divide into 2 dorsal digital nerves for the 3rd & 4th dorsal interdigital clefts
Medial terminal branch
Lateral terminal branch
INJURY The most common ligaments damaged are the
calcaneofibular and talofibular ligament Loss of blood supply for anterior compartment of
the leg Impaired plantarflexion of foot Impaired eversion of foot Ankle drop (in trauma/surgery) Superfical peroneal nerve block (loss of sensory
over superolateral foot) A peroneal tunnel syndrome (entrapment of the
superficial peroneal nerve in which a fascial tunnel longer than 3 cm was found at the anterior intermuscular septum)
NOTES
Terminal branches of the musculocutaneous nerve supply the dorsum of the foot EXCEPT :
medial border of the dorsum of the foot (supplied by saphenous nerve)
lateral border of the dorsum of the foot & lateral side of the little toe (supplied by sural nerve)
cleft between 1st & 2nd toes (supplied by anterior tibial nerve)
ANTERIOR TIBIAL NERVE
By :Siti Sarah Bt Abd Rahman09-1-227
ORIGIN
One of the two terminal branches of common peroneal nerve.
Arise within peroneous longus ,lateral to the neck of fibula.
COURSES
1. Curves around the neck of fibula deep to the fibers of extensor digitorum longus.
2. Pierces the anterior intermuscular septum to reach the anterior compartment.
3. Descends over the interosseous membrane accompanied by anterior tibial artery.
4. Has TRIPLE RELATION to the anterior tibial artery:
a.In upper third of the leg ,lies lateral to the anterior tibial artery .
b.In middle third of the leg ,lies anterior to the anterior tibial artery.
c.In lower third of the leg ,lies lateral again to the anterior tibial artery.
Anterior tibial artery
Anterior tibial nerve
5. It descend and lies between extensor digitorum longus and tibialis anterior .
6. Between extensor hallucis longus and tibialis anterior .
7. In lower part of the leg ,both anterior tibial nerve and artery are crossed by tendon of
extensor hallucis longus from lateral to medial.
8. Lastly ,becomes superficial and passes deep to the superior extensor retinaculum
with relations: I. Laterally :to tendon of extensor
digitorum longus.II.Medially :to tendon of extensor hallucis
longus.
TERMINATION
At distal border of inferior extensor retinaculum by dividing into medial and lateral terminal branches.
BRANCHES
1. Muscular branches : i. Supply the four extensor muscles. (Extensor digitorum
longus,extensor hallucis longus, extensor digitorum brevis).
2. Articular branches: i. Supply the ankle, intertarsal and tarsometatarsal
joints.
3. Terminal branches: i. Lateral terminal branch: supply extensor digitorum
brevis, joints of the foot .
ii. Medial terminal branch: divides into 2 digital branches that supply the adjacent sides between 1st and 2nd toes.
INJURIES OF ANTERIOR TIBIAL NERVE
Loss of blood supply for anterior compartment of the leg.
Cannot do dorsiflexion and plantarflexion.
Cannot do eversion .
Inability to do extension of toes
Deep Fibular Nerve Entrapment
Definition: excessive use of muscles supplied by the
deep fibular nerve
may result in muscle injury and edema in the anterior
compartment.
may cause compression of the deep fibular nerve and
pain in the anterior compartment
many occur where the nerve passes deep to the
inferior extensor retinaculum and the
extensor hallucis brevis
Pain occurs in the dorsum of the foot and usually
radiates to the web space between the first and
second toes.
called the ski-boot syndrome
POSTERIOR TIBIAL NERVE
By :Wan Ahmad Fathiizuddin Bin Wan Jamaluddin09-1-232
POSTERIOR TIBIAL NERVE
ROOT VALUE L4, L5, S1, S2 & S3
ORIGIN It is the continuation of the medial popliteal nerve
(tibial nerve) at the lower border of popliteus muscle
COURSE
I •It passes under the tendinous arch together with posterior tibial artery
II •Then it descends deep to soleus and the first septum of the deep fascia
III •As it descends, it lies on tibialis posterior, flexor digitorum longus, lower part of the posterior surface of the tibia and ankle joint
In the lower part of the leg, it becomes superficial being covered only by skin, superficial fascia, and deep fascia.
TERMINATION It ends deep to flexor retinaculum by dividing into
medial and lateral plantar nerve
RELATION The posterior tibial nerve has ‘triple relation’ with
the posterior tibial artery
I •At first, the posterior tibial nerve is medial to the popliteal artery.
II •In the upper part of the leg, it crosses superficial to the artery
III •Finally, it continues downwards on the lateral side of the posterior tibial artery.
BRANCHES
MUSCULAR BRANCHES•Deep part of soleus•Flexor digitorum longus•Flexor hallucis longus•Tibialis posterior
CUTANEOUS BRANCHES•Medial calcanean nerve
ARTICULAR BRANCHES•Ankle joint
MEDIAL CALCANEAN NERVE
BRANCHES (CONTINUES)
VASCULAR BRANCHES
• They are symphatetic twigs to the posterior tibial artery and its branches
TERMINAL BRANCHES
• Medial plantar nerve• Lateral plantar nerve
NERVE INJURY
CAUSE
Fractures or other injury to the back of the knee
or lower leg
Pressure from a tumor or abscess
EFFECT
Almost complete loss of the medial longitudinal arch Weak inversion of the foot Weak plantar flexion Loss of flexion of all joint in the big toe Loss of flexion of all joint in the lateral 4 toes Loss of sensory at the plantar surface of the foot
except at the medial part which is supplied by saphenous nerve
MEDIAL PLANTAR NERVE
By :Taqiah Bt Borhan09-1-231
ORIGIN
The medial plantar nerve (internal plantar
nerve), the larger of the two terminal
divisions of the posterior
tibial nerve accompanies the medial plantar artery.
COURSES
Passes deep to Abductor hallucis.
Then it passes forwards between flexor
digitorum brevis and abductor hallucis.
At the base of the 1st metatarsal bone, it
terminates by dividing into digital branches.
Along its course it is related medially to the
medial plantar nerve.
BRANCHESCUTANEOUS
MUSCULAR
ARTICULAR
COMMON DIGITAL NERVE
PROPER DIGITAL NERVE TO THE MEDIAL
SIDE OF THE GREAT TOE
CUTANEOUS BRANCHES
pierce the plantar aponeurosis between the
Abductor hallucis and the Flexor
digitorum brevis and are distributed to the
skin of the sole of the foot
MUSCULAR BRANCHES
1. Abductor hallucis brevis
2. Fexor digitorum brevis
3. Flexor hallucis brevis
4. The first lumbricals
ARTICULAR BRANCHES
supply the articulations of the tarsus and
metatarsus
PROPER DIGITAL NERVE OF THE GREAT TOE
supplies the Flexor hallucis brevis and the
skin on the medial side of the great toe
THREE COMMON DIGITAL NERVE
1st common digital nerve
2nd common digital nerve
3rd common digital nerve
1st : adjacent sides of the great and second toes
2nd : adjacent sides of the second and third
toes, and those of the third, the adjacent
sides of the third and fourth toes.
3rd : receives a communicating branch from
the lateral plantar nerve the first gives a twig
to the first lumbricals
MEDIAL PLANTAR NERVE INJURIES
TARSAL TUNNEL
The tarsal tunnel is a fibro-osseous tunnel
formed by the flexor retinaculum, the medial
wall of the calcaneus, the posterior aspect of
the talus, distal tibia, and medial malleolus
The posterior tibial artery, tibial nerve, and
tendons of the tibialis posterior, flexor
digitorum longus, and flexor hallucis longus
travel in a bundle along this pathway,
through the tarsal tunnel.
“Tom Does Very Nice Hat”
A. The tibial nerve tunnel ( tibial n.)
B. The medial plantar tunnel ( medial plantar n.)
C. The lateral plantar tunnel ( lateral plantar n.)
D. The calcaneal tunnel ( medial calcaneal n.)
TARSAL TUNNEL SYNDROM
Tarsal tunnel syndrome is a compression
neuropathy of the tibial nerve that is situated
in the tarsal canal
Benign tumors or cysts, bone spurs, inflammation
of the tendon sheath, nerve ganglions, or swelling
from a broken or sprained ankle.
Varicose veins can also cause compression of
the nerve.
Lower back problems
TTS is more common in athletes, active
people, or individuals who stand a lot. Flat
feet may cause an increase in pressure in the
tunnel region and this can cause nerve
compression.
SYMPTOMS
Causes a vague pain in the sole of the foot.
Most patients describe this pain as a burning
or tingling sensation.
Typically made worse by activity, especially
standing and walking for long periods.
Symptoms are generally reduced by rest.
Patients may feel pain if they touch theirr
foot along the course of the nerve.
If the condition becomes worse, your foot
may feel numb and pain.
TREATMENT
1. Orthotics and footwear modifications
2. Local steroid or anti-inflammatory
treatment
3. Where conservative measures fail, surgical
exploration may be appropriate.
(Tarsal tunnel release)
Requires an incision behind the ankle extending down to the arch of foot.
I. The ligament over the tibial nerve II. The nerve is followed in the foot, and the
tunnels for the medial and lateral plantar nerves
III. The calcaneal branch which also is released.
Cysts or other space-occupying problems
may be corrected at this time.
If there is scarring within the nerve or
branches, this is relieved by internal
neurolysis.
(Neurolysis is when the outer layer of nerve
wrapping is opened and the scar tissue is removed
from within nerve.)
Complications from this surgery include
bleeding, infection and delayed wound
healing.
LATERAL PLANTAR NERVE
By :Sharifah Firdawina Bt Syid Ayob09-1-223
ORIGIN From posterior tibial nerve passunder cover of flexor retinaculum then divides into medial and lateral plantar nerve.
COURSE It passes laterally between quadratus plantae and flexor
digitorum brevis. Near base of 5th metatarsal bone, divides into
Superficial branches Deep branch
BRANCHES Before it’s division , it supplies
Flexor accessoriesand
Abductor digiti minimi
Cutaneous to skinof lateral part
of sole
supplies :
Skin of lateral side Dorsum of little toe Flexor digiti minimi
brevis 3rd plantar interosseus 4th dorsal interosseus
divides into 2 branches to
supply : Adjoining side of 4th and 5th
toe
Superficial branch
Lateral Plantar Digital Branch
Medial Plantar Digital Branch
DEEP BRANCH Run medially behind plantar arch between 3rd and 4th layer of
muscle
Supplies : - transverse head of adductor hallucis
- 2nd, 3rd, 4th lumbricals
- 1st, 2nd plantar intersosseus
- 1st, 2nd, 3rd dorsal interosseus
NERVE INJURY1. Lateral plantar nerve injury following steroid injection for
plantar fasciitis
Plantar fasciitis is inflammation of plantar fascia
Steroid injection is used to treat severe cases of plantar fasciitis and can cause complication at lateral plantar nerve
2. Lateral plantar nerve entrapment
- lateral plantar nerve becomes entrapped in the heel due to inflammation or repeated injury
- treated by wearing arch supports and taking non steroid anti inflammatory drugs (NSAID)
NERVE DEFORMITY TARSAL TUNNEL
SYNDROME
- compression on posterior tibial nerve that produce symptoms (tingling , burning, numbness and pain ) anywhere along the path of the nerve running from the inside of the ankle into the foot.
Causes- enlarged or abnormal structures that occupies space within
tunnel
- ankle sprain
Treatmentrest, apply ice pack, oral medications
REFERENCES http://en.wikipedia.org/wiki/Femoral_nerve http://www.wisegeek.com/what-is-the-obturat Human anatomy lower limb by Dr. Ayman Ahmed
Khanfour. http://en.wikipedia.org/wiki/Obturator_nerve http://en.wikipedia.org/wiki/Superior_gluteal_nerve http://en.wikipedia.org/wiki/File:Gray832.png Clinical Oriented Anatomy 6th Edition by Moore Dalley
Agur http://en.wikipedia.org/wiki/Sciatic_nerve www.docroberts.com/Exercises.aspx http://en.wikipedia.org/wiki/Medial_plantar_nerve http://en.wikipedia.org/wiki/Tarsal_tunnel_syndrome module 5 musculo-skeletal system www.sportsinjuryclinic.net www.painclinic.org http://en.wikipedia.org/wiki/Medial_plantar_nerve http://en.wikipedia.org/wiki/Tarsal_tunnel_syndrome