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Nerves of the Lower Limb SLIDESMANIA.COM Aaron Campbell Learning Outcomes Describe the origin, course, relations Identifythe sciatic nerve and Identifythe tibial nerve and distribution of the sciatic, the two terminalbranchesof and common fibular nerve femoral and obturator nerves this nerve describethe origin, course and relations SLIDESMANIA.COM Identifythe medial and lateral Describe the cutaneous plantar nerves anddescribe innervation of the the origin, courseand relations lower limb of these nerves Lumbar Plexus • Nerve network composed of fibres from L1-L4 ANTERIOR rami • Posterior rami innervate skin and deep muscles of back • “ I, I Get Leftovers On Friday” SLIDESMANIA.COM Lumbar Plexus • 1 – IlioinguinalandIlio-hypogastricnerves • 1,2 – Genitofemoral nerve • 2,3 – Lateral femoral cutaneous nerve • 2,3,4 – Obturator and Femoral nerve SLIDESMANIA.COM Lumbar Plexus • 1 – IlioinguinalandIlio-hypogastricnerves • 1,2 – Genitofemoral nerve • 2,3 – Lateral femoral cutaneous nerve • 2,3,4 – Obturator and Femoral nerve SLIDESMANIA.COM Sacral Plexus • Nerve network composed of fibres from L4-S3 ANTERIOR rami • Posterior rami innervate skin and deep muscles of back • “SIPPS” SLIDESMANIA.COM Sacral Plexus Nerve Origin Innervation Sup Gluteal L4, L5, S1 Gluteus med, min + TFL Nerve to QF/GI " " QF, GI Inf Gluteal L5, S1, S2 Gluteus Max Nerve to OI/GS " " OI, GS Post Cut N of S1-3 Buttocks and posteromed thigh cut innervation Thigh Pudendal S2-4 Structures/m's of perineum, ext anal and urethral sphincters; sensory to ext genitalia SLIDESMANSciatic L4-S3 Knee flexors + ALL m's of leg Sacral Plexus SIPPS • Superior Gluteal Nerve • Inferior Gluteal Nerve • Posterior Cutaneous Nerve of Thigh • Pudendal Nerve • Sciatic Nerve SLIDESMANIA.COM Lumbar Plexus SIPPS • Superior Gluteal Nerve • Inferior Gluteal Nerve • Posterior Cutaneous Nerve of Thigh • Pudendal Nerve • Sciatic Nerve SLIDESMANIA.COM Femoral Nerve Describe the origin, course,relations and distribution ofthe sciatic,femoraland obturator nerves SLIDESMANIA.COM Femoral Nerve • Largest branch of lumbar plexus • Originates within psoas major • Descends posterolateral through pelvis • Passes deep to inguinal ligament, enters FEMORAL TRIANGLE lateral to femoral vessels (“NAVY )” 1. Divides into muscular branches to anterior thigh muscles 2. Sends articular branches to hip and knee 3. Gives several cutaneous branches to ANTMEDIAL side of thigh • Terminal branch = SAPHENOUS NERVE SLIDESMANIA.COM Saphenous Nerve • Terminal CUTANEOUS branchoffemoralNerve • Arises in femoral triangle • Descendsthroughfemoraltriangle lateral to femoral sheath • Accompanies femoralart and vein through ADDUCTORCANAL • As BVs go throughadductorhiatus, nerve becomessuperficial • Runsantinf to supplyskinand fascia ofANTMED knee,leg and foot • Runsalongside GREATSaphenous Nerve SLIDESMANIA.COM Obturator Nerve Describe the origin, course,relations and distribution ofthe sciatic,femoraland obturator nerves SLIDESMANIA.COM Obturator Nerve • Derived from fibres of L2-4 • Exits pelvis via OBTURATOR foramen 1. Innervates muscles MEDIAL compartment of thigh 2. Gives cutaneous branches to MEDIAL thigh SLIDESMANIA.COM Sciatic Nerve Identifythe sciaticnerve and the two terminal branchesofthis nerve SLIDESMANIA.COM Sciatic Nerve • Derived from fibres of L4-S3 • Largest nerve in human body • Actually two nerves running in same connective tissue sheath • Rami converge at piriformis inf border to form the Nerve • Runs infLAT under cover of Gluteus maximus, MIDWAY between greater trochanter and ischial tuberosity 1. Post Thigh Muscles 2. ALL leg and foot muscles 3. Skin of most of leg and foot 4. Articular branches to ALL joints of lower limb SLIDESMANIA.COM Sciatic Nerve • Derived from fibres of L4-S3 • Largest nerve in human body • Actually two nerves running in same connective tissue sheath • Rami converge at piriformis inf border to form the Nerve • Runs infLAT under cover of Gluteus maximus, MIDWAY between greater trochanter and ischial tuberosity 1. Post Thigh Muscles 2. ALL leg and foot muscles 3. Skin of most of leg and foot 4. Articular branches to ALL joints of lower limb SLIDESMANIA.COM Sciatica Sciatica refers to the symptoms associated with irritation of thesciatic nerve. - Unilateral pain radiating from buttocks down the thigh - Pain describes as “electric” or “shooting” - Paraesthesia - Numbness - Motor weakness •Herniated disc •Spondylolisthesis (anterior displacement of a vertebra out of line with the one below) •Spinal stenosis Bilateral sciatica is a red flag for cauda SLIDESMANIA.COM equina syndrome. Piriformis Syndrome - Compression of the sciatic nerve by the piriformis muscle. - Similar symptoms to sciatica - Pain can be exacerbated by INTERNAL ROTATION - Analgesia - Physio - Piriformis Muscle Release SLIDESMANIA.COM Tibial and Common Fibular Nerves Identifythe tibialnerve and commonfibularnerve describe the origin, courseand relations SLIDESMANIA.COM Tibial Nerve • Medial (tibial side), largest terminal branch of sciatic • Most superficial but still deep and protected • BISECTS the fossa • Exits at inf angle • Travels with posterior tibial artery • Continues as medial and lateral plantar nerves 1. Muscular innervation of posterior compartment 2. Med Sural Cut N given off (joined by sural communicating branch of SLIDESMANIA.COMn fibular N, forming Sural N) 3. Gives off medial calcaneal branch to heel Common Fibular Nerve ● Lateral (fibular side), smaller terminal branch ● Begins at sup angle ● Runs along SUPLAT border/biceps femoris ● Passes over post aspect of FIBULAR HEAD ● Winds around fibular NECK and DIVIDES --> Superficial and Deep Fibular N's SLIDESMANIA.COM Deep Fibular Nerve ● 1 of 2 terminal branches of common fibular N ● Nerve of the anterior compartment ● Accompanies ANT TIBIAL ART ● Exits compartment, continuing across the ankle joint 1. Foot Extensors 2. Intrinsic Foot M's (EDB + EHB) 3. Small area of skin on foot SLIDESMANIA.COM Foot Drop ● Deep fibular nerve innervates anterior compartment ● Responsible for foot dorsiflexion ● Palsy of this nerve causes inability to dorsiflex ● Overused anterior compartment muscles ● Tight shoes • Possible paraesthesiain toes 1 and 2 • Dragging foot SLIDESMANIA.COM • Stomping (can’t lower in controlled manner Superficial Fibular Nerve • Nerve of the lateral compartment of the leg 1. FL + FB 2. Skin on distal ant surfaceof leg 3. Skin of Dorsum of foot SLIDESMANIA.COM Leg Summary Ant 4 m's Deep Fibular Ant Tibial Compartment N Art Lat 2 m's Superficial Perforating Compartment Fibular N Arts Post 3 + 4 Tibial N Post Tibial Compartment m's Art SLIDESMANIA.COM Innervation of the Foot Identifythe medialand lateralplantarnerves and describethe origin, courseand relations ofthese nerves SLIDESMANIA.COM Medial & Lateral Plantar Nerves ● Continuations of the TIBIAL NERVE 1. Supply ALL muscles of the sole 2. Provide sensation to the sole of the foot SLIDESMANIA.COM Cutaneous Innervation Describe the cutaneousinnervationofthe lower limb SLIDESMANIA.COM Cutaneous Innervation SLIDESMANIA.COM Cutaneous Innervation SLIDESMANIA.COM Cutaneous Innervation SLIDESMANIA.COM Cutaneous Innervation SLIDESMANIA.COM Cutaneous Innervation SLIDESMANIA.COM MCQ’s SLIDESMANIA.COM Q1. Damage to which nerve can result in difficulty extending the knee? A. Sciatic Nerve B. Femoral Nerve C. Obturator Nerve D. Superior Gluteal Nerve E. Tibial Nerve SLIDESMANIA.COM Q1. Damage to which nerve can result in difficulty extending the knee? A. Sciatic Nerve B. Femoral Nerve C. Obturator Nerve D. Superior Gluteal Nerve E. Tibial Nerve SLIDESMANIA.COM Q2. Damage to the tibial nerve in the popliteal fossa may result in: A. Loss of ankle eversion B. Reduced sensation on dorsum of foot C. Inability to stand on one’s toes D. Foot drop E. Loss of sensation between toes 1 and 2 SLIDESMANIA.COM Q2. Damage to the tibial nerve in the popliteal fossa may result in: A. Loss of ankle eversion B. Reduced sensation on dorsum of foot C. Inability to stand on one’s toes D. Foot drop E. Loss of sensation between toes 1 and 2 SLIDESMANIA.COM Q3. If the sciatic nerve was damaged by an IM injection in the buttocks, the patient would have reduced sensation in: A. Anteromedial side of leg B. Anterior thigh C. Medial thigh D. Toes 1 and 2 adjacent sides E. All of the above SLIDESMANIA.COM Q3. If the sciatic nerve was damaged by an IM injection in the buttocks, the patient would have reduced sensation in: A. Anteromedial side of leg B. Anterior thigh C. Medial thigh D. Toes 1 and 2 adjacent sides E. All of the above SLIDESMANIA.COM Thank You! Any Questions? acampbell98@qub.ac.uk SLIDESMANIA.COM