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

http://upload.wikimedia.org/wikipedia/commons/9/9d/Gray832.png

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