26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus...
Transcript of 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus...
![Page 1: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/1.jpg)
Lower Limb Nerves
Clinical Anatomy
![Page 2: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/2.jpg)
Lumbar Plexus
• Ventral rami L1‐L4• Supplies:
– Abdominal wall– External genitalia– Anteromedial thigh
• Major nerves …..
![Page 3: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/3.jpg)
Lumbar Plexus
• Nerves relation to psoas m. :
Obturator n. & lumbosacral trunk ‐‐‐‐‐medial border
Genitofemoral n. ‐‐‐‐anterior surface
Remaining nn. ‐‐‐‐‐lateral border
![Page 4: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/4.jpg)
Lumbar Plexus• Iliohypogastric nerve• Ilioinguinal nerve• Genitofemoral nerve
![Page 5: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/5.jpg)
Lumbar Spinal Nerves Block
Area: anterior superior part of the thigh
• Ilioinguinal and iliohypogastric nerves block – Above the ASIS on the spinoumbilical line
• Genitofemoral nerve block– Lateral to the pubic tubercle
![Page 6: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/6.jpg)
Lateral Cutaneous Nerve of the Thigh
• Lateral cutaneous nerve of the thigh– Relations
• Inguinal ligament
Area: anterolateral side of the thigh
Nerve Block– Just inferomedial to the ASIS
![Page 7: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/7.jpg)
Femoral Nerve
• Largest branch of the lumbar plexus
• Relations– Femoral triangle
![Page 8: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/8.jpg)
Femoral Nerve: Branches
• Muscular branches– Anterior compartment of the thigh (hip flexors and knee extensors)
• Cutaneous branches– Medial cutaneous n. of the thigh
– Intermediate cutaneous n. of the thigh
– Saphenous n.
![Page 9: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/9.jpg)
Femoral Nerve Block
Area: medial side of the lower limb and anterior side of thigh
• Lateral to the femoral a. just below the inguinal ligament
• Midway between ASIS & pubic tubercle
![Page 10: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/10.jpg)
Saphenous nerve
• Relations– In Femoral triangle– Within Adductor canal– Cross Femoral a.– Between Sartorius & gracilistendons
– Accompanies great saphenous v.– Anterior to Medial malleolus
![Page 11: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/11.jpg)
Saphenous Nerve Block• Block at knee: Area: medial side of leg & foot
– At the medial femoral or tibial condyles
• Block at ankle:Area: medial side of foot
– Anterior to medial malleolus
![Page 12: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/12.jpg)
Femoral Nerve Injury
• Results from – Stab or gunshot wound– Complete division is rare
• Paralysis of quadriceps femoris m.– Knee can not be extended against resistance– Patient usually press against the distal thigh during walking
• Loss of sensation along the medial part of the lower limb and the anterior part of the thigh
![Page 13: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/13.jpg)
Obturator Nerve: Branches
• Sensory n. to parietal peritoneum in pelvis
• Devisions– Anterior division– Posterior division
• Muscular branches– Adductors
• Cutaneous branch (medial side of the thigh)
![Page 14: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/14.jpg)
Obturator Nerve Injury
• Rare• Paralysis of the adductor muscles• Loss of sensation of small area of the medial part of thigh
![Page 15: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/15.jpg)
Sacral Plexus
• Ventral rami L4‐S4• Supplies buttocks, perineum & part of lower limb
• Sciatic nerve = L4 to S3 supplies post. thigh & all below knee
![Page 16: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/16.jpg)
Sacral Plexus: Branches
• Sciatic nerve– Largest nerve in the body
• Superior gluteal n.– Gluteus medius and minimus and tensor fascia latae mm.
• Inferior gluteal n.– Gluteus maximus m.
• Nerve to quadratus femorism.– Inferior gemellus m.
![Page 17: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/17.jpg)
Sacral Plexus: Branches• Nerve to the obturator
internus m. Exit from greater sciatic
notch and return from the lesser sciatic notch
– Superior gemellus m.
• Posterior cutaneous n. of the thigh – Buttock & back of the thigh
• Perforating cutaneous n.– Medial side of buttock
• Nerve to the piriformis m.• Pudendal n. (perineum)
![Page 18: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/18.jpg)
Sciatic Nerve: Relations
• Greater sciatic foramen • Piriformis m.• In the posterior thigh:
– Gluteus maximus m. – Biceps femoris m. Supply the hamstring mm.
• At the superior part of the popliteal fossa divides into its terminal branches– Tibial n.– Common peroneal n.
![Page 19: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/19.jpg)
Tibial Nerve: Relations
• Popliteal fossa• Descend through the
posterior compartment of the leg– Gastrocnemius and soleus
mm.– Posterior tibial a.
• Deep to flexor retinaculum
• Divides into medial and lateral planter nn.
![Page 20: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/20.jpg)
Tibial Nerve: Branches in Leg
• Muscular branches– Muscles of the posterior
compartment of the leg and sole of the foot
• Cutaneous branches– Sural n.
• Back of the leg & lateral side of the foot
– Medial calcaneal n.• Skin over medial side of heel
– Planter nerves• Sole of the foot
![Page 21: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/21.jpg)
Tibial Nerve Block
• Block at ankle:Area: sole of the foot• Posterior to the medial malleolus
• Posterior to the posterior tibial a. felt midway between medial malleolus and the heel
![Page 22: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/22.jpg)
Tibial Nerve Injury
• Rare• Paralysis of the muscles in the posterior compartment of the leg and the muscles of the sole– Calcaneovalgus (Dorsiflexion & eversion of foot )
• Loss of sensation on the sole of the foot– Trophic ulcers
![Page 23: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/23.jpg)
Common Peroneal Nerve: Relations
• Traverse the popliteal fossa• Around head of fibula• Traverse the peroneus longus m.
• Divide into terminal branches– Superficial peroneal n.– Deep peroneal n.
![Page 24: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/24.jpg)
Common Peroneal Nerve: Branches• Cutaneous branches
– Sural communicating branch
– Lateral cutaneous n. of the calf
• Muscular branch– Short head of biceps femoris m.
• Superficial peroneal n.• Deep peroneal n.
![Page 25: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/25.jpg)
Superficial Peroneal Nerve: Relations
• Descends in the lateral compartment between peroneus longus & previs mm.
• Extensor retinacula
![Page 26: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/26.jpg)
Superficial Peroneal Nerve: Branches
• Cutaneous branch – Skin over the lower anterior leg and dorsum of foot
• Muscular branch– Lateral compartment
![Page 27: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/27.jpg)
Superficial Peroneal Nerve BlockArea: dorsum of foot and toes (except between the 1st and 2ndtoes and lateral side of little toe)
• Infiltrating the area at a line between the medial and lateral malleoli
![Page 28: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/28.jpg)
Deep Peroneal Nerve: Relations
• Descends in the anterior compartment deep to the extensor digitorum longus m.
• Anterior to the interosseous membrane
• Accompanies the anterior tibial vessels and dorsalis pedis a.
![Page 29: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/29.jpg)
Deep Peroneal Nerve: Branches
• Cutaneous branch– Between 1st & 2nd toes
• Muscular branch– Anterior compartment & extensor digitorum brevis m.
![Page 30: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/30.jpg)
Deep Peroneal Nerve Block
Area: are between the 1st and 2nd toes
• Lateral to the felt dorsalis bedis a. midway between the medial and lateral malleoli
• Between the tendons of extensor digitorumlongus m. and extensor hallucis longus m. (both felt by dorsiflexion)
![Page 31: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/31.jpg)
Common Peroneal Nerve BlockArea: anterior and lateral sides of leg and the dorsum of foot
• Common peroneal nerve felt just below the head of the fibula
![Page 32: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/32.jpg)
Sural Nerve Block
Area: lateral side of foot and little toe
• Between the lateral malleolus and calcaneal tendon
![Page 33: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/33.jpg)
Common Peroneal Nerve Injury• Results from
– Fractures of the neck of the fibula
• Paralysis of the muscles of the anterior and lateral compartments of the leg– Equinovarus (Planter flexion (foot drop) and inversion)
• Loss of sensation on the anterior and lateral sides of leg & dorsum of foot
![Page 34: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/34.jpg)
Sciatic Nerve Injury• Results from
– Penetrating wounds, fractures of the pelvis, or dislocation of the hip bone
– Faulty IM injections in the glutealregion
• Complete injury is rare– 90% of the cases affect the common
peroneal part (more superficial)• Paralysis of the hamstring muscles
and all muscles below knee– Foot droop (planter flexed position)
• Loss of sensation below knee except for the medial part (femoral n.)– Trophic ulcers of the sole
![Page 35: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/35.jpg)
Sciatica
• Pain along the sensory distribution of the sciatic nerve– Posterior of thigh– Posterior & lateral sides of leg– Lateral part of foot
• Results from– Prolapse of an IVD (pressing on the roots of the spinal nerves)
– Pressure on the sacral plexus or sciatic n. by tumor
![Page 36: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/36.jpg)
Cutaneous Innervation of the Lower Limb
Femoral
Lumber plexus
Sacral plexus
Tibial
Common peroneal
12th thoracic
Posterior rami
![Page 37: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/37.jpg)
![Page 38: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/38.jpg)
Dermatomes of the Lower Limb
![Page 39: 26-Lower Limb Nerves - كلية الطب · Lower Limb Nerves Clinical Anatomy. Lumbar Plexus •Ventral rami L1‐L4 •Supplies: –Abdominal wall –External genitalia –Anteromedial](https://reader030.fdocuments.us/reader030/viewer/2022040510/5e54af805132fa462d59125b/html5/thumbnails/39.jpg)
Tendon Reflexes & Segmental Innervation of the Lower Limb Muscles
• Patellar tendon reflex (knee jerk)– L2‐L4– Extension of knee– Tapping on the patellar
tendon• Achilles tendon reflex
(ankle jerk)– S1‐S2– Plantar flexion– Tapping on the Achilles
tendon