REVIEW: LOWER LIMB

Kulathida Chaithirayanon

LATERAL FEMORAL CUTANEOUS NERVE (L2-3)

- has a pure sensory function. - emerge from the lateral psoas muscle, passing obliquely over iliacus, to course toward ASIS -enters thigh by passing above or through the most lateral portion of the inguinal ligament - next passes over or through the proximal sartorius muscle - innervate the anterolateral thigh.

Rare case; a backpack belt tightly positioned across the iliac crest,

Femoral nerve (anterior division of L2-4)

Muscular branches Iliacus --> hip flexor Pectineus --> hip adduct and flex 1. Sartorius --> flex hip & flex knee 2. Quadricep femoris --> knee extensor
Cutaneous branches 1. Anterior cut. N of thigh 2. Saphenous; give off infrapatellar Branch and medial cutaneous n of leg In adductor canal; n to vastus medialis & saphenous

Iliacus syndrome
Femoral nerve is entrapped during its initial course within pelvis & groin, Affecting iliopsoas (hip flexor) and quadricep femoris (knee extensor) Groin and thigh pain may also occur. Sensory symptoms involve the anteromedial thigh and medial lower leg.

Anterior rami of L1-2

Partial lesions, patients first note difficulty going down stairs as their ability to lock their knee to support their weight is compromised.

Femoral nerve lesion: loss of knee extension 1. At lumbar plexus: weakness of hip flexion (iliopsoas, rectus femoris, and sartorius muscles) in addition to loss of knee extension (quadriceps femoris muscle) 2. At inguinal ligament: loss of knee extension (quadriceps femoris muscle) 3. Loss of sensation over anterior thigh and medial leg and foot 4. May occur during catheterization of femoral artery

Anterior Thigh Muscles

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Obturator nerve
(anterior divisions of L2, 3, 4) - unite within the posterior psoas muscle, forming the obturator nerve. - descends through iliopsoas to emerge medially near the upper sacroiliac joint.
- courses along pelvis, lying lateral to the ureter & internal iliac vessels, & bending anteroinferiorly to follow the lateral pelvic wall. It next passes anterior to the obturator vessels while lying on the obturator internus muscle, to reach the obturator groove and then it enters the obturator canal.

Obturator mononeuropathies are exceedingly rare in both adults & children. Various pathophysiologic mechanisms include pelvic & hip fractures, rarely obturator hernias, malignancies, surgery involving the hip and pelvis,

- descends to the medial thigh, supplying the obturator externus, pectineus, adductor longus, adductor brevis, adductor magnus (pelvic part) & gracilis m., as well as hip and knee joints & medial thigh.

Injury to Obturator Nerve 1. Difficulty adducting thigh (e.g., crossing legs while sitting) 2. Decreased sensation over upper medial thigh 3. May occur from compression by uterus during pregnancy, obstetric procedures, or pelvic disease

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Tendon of adductor Magus attach adductor Tubercle of femur: Tibial n.

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Medial Thigh Muscles

Greater sciatic foramen Piriformis Sciatic nerve Superior and inferior gluteal nerve and vessels Pudendal nerve, internal pudendal vessels Posterior cutaneous nerve of thigh Nerve to obturator internus Nerve to quadratus femoris

Lesser sciatic foramen Obturator internus Nerve to obturator internus Pudendal nerve, internal pudendal vessels (entring perineum)

Superior gluteal nerve

(posterior divisions of L4, L5, S1) primarily L5 in origin - emerges above the piriformis muscle to innervate gluteus medius; PA/ greater trochanter gluteus minimus; AI/greater trochanter tensor fasciae lata;ASIS, iliac crest/ iliotibial tract - abduct and medial rotate hip.

Superior gluteal nerve

Superior gluteal nerve --> Weakness of abductors (gluteus medius and minimus) on the the weight bearing limb can lead to a gluteal lurch during walking, and this is known as a positive Trendelenburg sign.

A, Normally, when weight is borne on one (e.g., the right) limb (during the stance phase of walking), the pelvis tends to sag on the free, or swing (left), side (because of gravity). This is counteracted by abduction of the hip on the stance (right) side, chiefly by strong contraction of the (right) gluteus medius, which acts on the pelvis from a fixed femur. B, When abduction of the (right) hip is interfered with on the supported side (positive Trendelenburg's sign), e.g., by dislocation, fracture, or paralysis, the pelvis sags (arrow) on the unsupported side.

Inferior gluteal nerve

(posterior division of L5, S1-2) -emerges below the piriformis muscle - innervate: gluteus maximus (P gluteal line/ iliotibial tract), primary extend thigh and assits lateral rotate Both gluteal nerves provide an important clinical localization for electromyographer because, in the patient presenting with a sciatic neuropathy, the absence of denervation in the gluteal muscles provides support for a localization of the lesion immediately at or distal to the sciatic notch.

Injury to Superior Gluteal Nerve 1. Loss of thigh abduction and medial rotation (gluteus medius, gluteus minimus, tensor fasciae latae muscles) 2. Causes positive Trendelenburg sign 3. Gluteus medius gait: trunk leans toward affected side during stance phase to compensate for loss of hip abduction Injury to Inferior Gluteal Nerve 1. Weakened hip extension (gluteus maximus), most noticeable when climbing stairs or standing from a seated position 2. Gluteus maximus gait: trunk leans backward on affected side when walking to compensate for loss of hip extension

Superior gluteal nerve (L4-5, S1)

Nerve to obturator internus (L5, S1,S2)

Obturator internus Superior gemellus

Inferior gluteal nerve (L5, S1,S2) Nerve to quadratus femoris (L4, L5, S1)
Inferior gemellus Quadratus femoris

Posterior cutaneous n of thigh (S1-3) (lie medial edge

of sciatic n)

Skin of buttock, posterior thigh & popliteal fossa

Pudendal nerve (S2-4)

Main motor and sensory nerve of perineum

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Hip extension and abduction, dependent on gluteal nerve

Lateral rotators --> greater traochanter -Piriformis; anteior sacrum -Superior gemellus; ischial spine -Obturator internus; obturator mb & pubic ramus -Inferior gemellus; superior ischial tuberosity -Quadratus femoris; lateral ischial tuberosity

Piriformis : S1,2

Muscles gluteal region

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Sciatic nerve
- is also accompanied by the inferior gluteal artery (IGA), providing primary blood supply 1. Common fibular (peroneal), derived from posterior divisions of the anterior rami of the L4-S2 roots 2. Tibial derived from anterior divisions of the anterior rami of the L4-S3 nerve roots. After passing through sciatic notch, SN descends into the thigh, where it innervates all posterior thigh muscles with the exception of the short head of biceps femoris, - semitendinosus (L5, L4-S2), - semimembranosus (L5), Biceps femoris (long head) (S1, 2), Distal (ham) part of adductor magnus (L5)

Posterior Thigh Muscles

Sciatic n. compressed by posterior dislocation femur

Common fibular n (compressed in Piriformis syndrome)

Posterior cut n of thigh (often simultaneously Damaged with sciatic n

At knee, CFN descends along the lateral popliteal fossa, initially overlapped by medial biceps femoris tendon; it passes between the biceps tendon & lateral gastrocnemius head & behind fibular head to wind around the fibulas bony surface - passes between 2 heads of fibularis longus - divides into 1.Superficial peroneal; fibularis longus (L5) & brevis (L5), skin of lateral leg & dorsum of foot except 1st dorsal webbed space bet great toe & 2nd toe 2.deep fibular n. Common fibular n.: subject to trauma at neck of fibular, leading to footdrop (loss of dorsiflexion & eversion) & paresthesia in lateral leg and dorsum of foot. --> STEPPAGE GAIT

Deep fibular nerve (DFN)

-pass obliquely downward around proximal fibular neck, between fibularis longus & EDL (L5, S1), to then descend lateral to tibialis anterior (L4, 5) & medial to extensor digitorum longus & brevis (L5, S1) & extensor hallucis longus (L5, S1) with anterior tibial artery - innervates anterior compartment of leg; tibialis anterior, extensor hallucislongus, extensor digitorum longus, fibularis tertius - innervate dorsum of foot; extensor hallucis brevis & extensor digitorum brevis -Innervated skin of webbed space between great toe and second toe

Compressed deep fibular n.: patient may have footdrop & paresthesia in skin of webbed space between great toe and second toe

Sleeping on ones side on a hard surface, resting directly on the fibular head, and thereby compressing this nerve as it winds around the fibular neck. This typically occurs in a narcotized, often alcoholically intoxicated individual not moving during deep sleep. Anorectic malnourished adolescents often sit for long periods with legs crossed, compressing their fibular heads and the CFN, and leading to a footdrop. When this occurs among patients who are on strict diets, it is known as slimmers palsy. Occupations requiring prolonged squatting, such as farm laborers,strawberry pickers, and carpet layers, may compress this nerve between the biceps femoris tendon and lateral gastrocnemius origin. Very occasionally, iatrogenic mechanisms lead to compression injuries and footdrop; these include too tightly applied casts at the fibular head, Buck traction, Velcro straps, and intravenous footboards Entrapment. Sometimes a progressive footdrop develops secondary to common or deep fibular nerve entrapment at the knee. The proximal tendon of the fibularis longus rarely entraps the fibular nerve within the fibular tunnel at the fibular head. Mass lesions, including schwannomas, hemangiomas, bony exostoses,osteochondromas, perineuromas, or intraneural ganglia or synovial cysts within the popliteal fossa, may variably entrap the fibular nerves.

Anterolateral leg Muscles

Tibial nerve
-branch from sciatic nerve to supply posterior compartment and articular branches to knee and ankle joint -In popliteal fossa, descends superficial to popliteal vessels -In posterior compartment, descends with posterior tibial artery deep to gastrocnemius lateral (L5, S1) and medial (S1, 2) and soleus (S1, 2) - subsequently run between flexor digitorum longus (L5, S1) and flexor hallucis longus - curve anteroinferiorly and posteriorly to the medial malleolus. -enters tarsal tunnel, proceeding into the foot deep to flexor retinaculum between flexor hallucis longus and flexor digitorum longus tendons. -terminates, dividing into medial and lateral plantar nerves that innervate all intrinsic foot muscles (S1, 2) and provide the sensation for the plantar surface of the foot.

Medial plantar nerve (// median nerve) -originates under the flexor retinaculum, traveling deep to the abductor hallucis, innervate abductor hallucis, flexor digitorum brevis and flexor hallucis brevis (S1, 2) and 1st lumbrical . At tarsometatarsal joints; this nerve ends by dividing into 1. proper plantar digital nerve; supplies the medial great toe 2. three common plantar digital nerves --> plantar digital n

Lateral plantar nerve (// ulnar nerve)

-pass outward to innervate flexor digitorum brevis, quadratus plantae, & abductor digiti minimi (S1, 2) At 5th metatarsal bone; 1. superficial branch; splits into proper and common plantar digital nerves and innervate flexor digiti minimi and interossei muscles (S1, 2) of the 4th intermetatarsal space. 2. deep branch supplies adductor hallucis, second to fourth lumbricals, and the medial three interossei (S1, 2).

Lateral sural cutaneous nerve supplies the skin and fascia on the lateral and adjacent parts of the anteroposterior leg.

Sural nerve (cutaneous branch)

medial sural cutaneous n of tibial n + fibular communicating branch of lateral sural cutaneous n of common fibular n - passover and lateral to the Achilles tendon - provides cutaneous innervation to the posterior lateral lower leg, the lateral ankle, heel and foot. - courses with small saphenous vein in posterior leg.

Posterior Leg Muscles

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Head of fibula

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Injury to the perineal branches of the sacral plexus nerves leads to sensory loss on the scrotum or labia majora.

Hermiated Disc Between C4 and C5

Compressed nerve root C5

Dermatome affected C5 Shoulder Lateral surface of UL C6 thumb

Muscles affected

Movement weakness Abduction of arm

Nerve and reflex involved Axillary nerve Biceps jerk

Deltoid

C5 and C6

C6

Biceps Brachialis Brachioradialis Triceps Wrist extensors

Flexion of forearm Supination/pronat ion

Musculocutaneous Biceps jerk Brachioradialis jerk

C6 and C7

C7

C7 Posterior surf of UL Middle & index fingers

Extensionof Radial nerve forearm Triceps jerk Extension of wrist

Hermiated Disc Between L3 and L4

Compresse d nerve root L4

Dermatome affected L4 Medial surf of leg Big toe L5 Lateral surf of leg Dorsum of foot

Muscles affected

Movement weakness Extension of knee Dorsiflexion of ankle (patient cannot stand on heels) Extension of toes Plantar flexion of ankle (patient cannot stan on toes) Flexion of toes

Nerve and reflex involved Femoral nerve knee jerk Common fibular nerve No reflex loss

Quadriceps

L4 and L5

L5

Tibialis anterior Extensor hallucis longus Extensor digitorum longus Gastrocnemius Soleus

L5 and S1 (most common)

S1

S1 Posterior surface of lower limb Little toe

Tibial nerve ankle jerk

Ligament of Hip joint

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Limit extension and medial rotation of hip joint

Superficial Inguinal Lymph Nodes Lie in superficial fascia just inferior to inguinal ligament and receive lymph vessels that parallel great saphenous vein and its tributaries Deep Inguinal Lymph Nodes Lie deep to fascia lata along femoral vein and receive lymph from deep structures and popliteal nodes

Lymph passes through superficial or deep inguinal lymph nodes en route to external iliac nodes.

How does one test for an ACL injury?

Anterior cruciate ligament; start at the anterior tibia and extend posterolaterally to lateral condyle of femur Anterior drawer sign, where the tibia moves anteriorly in relation to the femur. The ACL normally prevents hyperextension of the knee (anterior movement of tibia when knee is flexed) A hyperextension at the knee joint will stretch the ACL Posterior cruciate ligament; starts at posterior tibia and extends anteromedially to medial condyle of femer prevent; excessive posterior mvt for tibia when knee is flexed. (posterior drawer sign) A hyperflexion injury at the knee joint will stretch the PCL What is the unhappy triad? injury to the ACL, tibial collateral ligament, and medial meniscus.

59. medial collateral ligament

a. b. posterior dislocation tibia c. lock d. passive abduction e. lateral rotation full extension f. abduction full extension

Medial collateral ligament; extend from medial epicondyle of femur to tiba, preventing abduction at the knee joint. Torn of MCL --> abnormal passive abduction of extended leg Lateral collateral ligament; extend from lateral epicondyle of femur to head of fibular, preventing adduction at the knee jt. Torn of LCL --> abnormal passive adduction of extended leg

 50 Posterior Translocation femur a. Flexion, medial rotation, adduction b. Flexion, lateral rotation, adduction c. Flexion, lateral rotation, abduction d. Extension, lateral rotation, abduction e.Extension, medial rotation, abduction

Nerve Femoral nerve (L2-4) Obturator nerve (L2-4) Tibial (L4-S3) (courses posterior to medial malleolus

Deficit in Motion Loss of knee extension/knee jerk Loss of hip addction Loss of plantarflexion because the tibial nerve supply the posterior compartment of thigh and leg Loss of foot inversion, flexion of toe, sensory loss on sole fo foot Deep peroneal: muscles of anterior leg compartment. Loss of dorsiflexion, causing foot drop (Pt cannot stand on heels foot slap) Superficial peroneal: supply peorneus longus and brevis. Loss of eversion

Deficits in sensation/course Paresthesias of anterior/medial thigh and medial leg Plantar surface of foot Patient will present with foot dorsiflexed and everted Patient can not stand on toe

Common peroneal (L4-S2) divides into superficial and deep branches at neck of fibula

Deep; 1st web space

Superficial: dorsal surface of foot except 1st web space

FED TIP

(Fibular nerve Everts and Dorsiflexes the foot) (Tibial nerve Inverts and Plantarflexes the foot)

94. 35 (foot drop) nerve A. tibial nerve B. femoral nerve C. superficial peroneal nerve D. deep peroneal nerve E. common peroneal nerve Ans: D extensor leg deep peroneal nerve

1. 20 (KC) A. T12-L1 B. L1-L2 C. L2-L3 D. L3-L4 E. L4-L5 D

What is the primary function of the gluteus maximus muscle? What powerful flexor of the thigh at the hip attaches to the lesser trochanter?

Strongest extensor of the thigh at the hip. Especially important when walking uphill, climbing stairs, or rising from a sitting position. This muscle is innervated by inferior gluteal nerve Iliopsoas muscle.

Movements at hip joint a. Flexion: iliopsoas, rectus femoris, tensor fasciae latae, sartorius, pectineus, adductor longus, adductor brevis b. Extension: gluteus maximus, hamstrings c. Abduction: gluteus medius, gluteus minimus, tensor fasciae latae, sartorius d. Adduction: adductor magnus, adductor longus, adductor brevis, pectineus, gracilis e. Medial rotation: gluteus minimus, gluteus medius, tensor fasciae latae f. Lateral rotation: obturator internus, obturator externus, piriformis, quadratus femoris, superior and inferior gemelli

Knee deformities Common in very young children and usually correct spontaneously with growth; pathological in adolescents and adults a. Genu valgum (knock-knee): tibia is deviated laterally at knee, stretching medial side of joint and compressing lateral side; it predisposes to lateral dislocation of patella b. Genu varum (bowleg): tibia is deviated medially at knee, stretching lateral side and compressing medial side of knee Genu valgum: knock-knee. Genu varum: bowleg Movements at knee joint a. Flexion: hamstrings, sartorius, gracilis, and gastrocnemius; popliteus unlocks fully extended knee joint b. Extension: quadriceps femoris c. Medial rotation (of leg): popliteus, semitendinosus, and semimembranosus d. Lateral rotation (of leg): biceps femoris

NAVEL

CHARACTERI STIC Incidence

FEMORAL HERNIA
More common in women on the right side, esp middle aged and elderly persons

Course through Abdominal wall

- Protrudes through femoral ring (canal) below inguinal ligament - Protrudes below and lateral to pubic tubercle and medial to femoral vein
Prone to early strangulation

Complications