CLINICAL NEUROLOGY II & PSYCHIATRY

Assignment 1
Lower Limb
Peripheral Nerve Injuries

Submitted To – Dr Neha Gupta

Submitted By- Saksham Kapoor
A1106618127
Semester- 6 A
 Lower Limb
Peripheral Nerve Injuries
Introduction
The lower limb gets its peripheral nerves from L2 to S2 levels of the spinal cord through the
lumbosacral plexus. These nerves are involved in injury in a multitude of ways

Anatomy
The nerves of the lower limb originate from L2 to S2 spinal levels forming the lumbosacral
plexus that gives rise to the nerves

Main nerves of lumbar plexus are:

1. Femoral Nerve
2. Obturator Nerve
3. Lateral cutaneous nerve of thigh
Main nerves of sacral plexus
1. Superior gluteal nerve
2. Inferior gluteal nerve
3. Pudenal nerve
4. Sciatic nerve which terminates by dividing into:
 Tibial nerve
 Common peroneal nerve

Incidence
There are several large studies on traumatic nerve injuries.1,2 The frequency of the lower
extremity nerve injuries is assessed to approximately 20 to 23% of the overall lesions to the
peripheral nerve system. Peroneal division neuropathy is the most common lower extremity
nerve palsy.

Etiology of Injury
There are various ways in which the lower limb nerves are injured. Some of the common
etiology is listed as follows:
1. Fractures, particularly the hip, femur, tibia, fibula, and, occasionally, the ankle
2. Crush injury
3. Knife assault
4. Gunshot
5. Iatrogenic
6. Traction
7. Blunt trauma
8. Radiation
 1. FEMORAL NERVE
The femoral nerve is one of the major peripheral nerves of the lower limb.

Nerve roots: L2-L4

Motor functions: Innervates the anterior thigh muscles that flex the hip joint (pectineus,
iliacus, sartorius) and extend the knee (quadriceps femoris: rectus femoris, vastus lateralis,
vastus medialis and vastus intermedius),
Sensory functions: Supplies cutaneous branches to the anteromedial thigh (anterior
cutaneous branches of the femoral nerve) and the medial side of the leg and foot (saphenous
nerve).

1.1 Femoral Nerve Injury

Injury of the femoral is uncommon but may be injured by a stab, gunshot wounds, or a
pelvic fracture. The femoral nerve can be damaged during penetrating trauma to the
thigh. It can also be damaged during hip operations, particularly the anterior approach
(not commonly used) where the nerve can be stretched and damaged.
Motor loss
Poor flexion of the hip, because of paralysis of the iliacus and sartorius muscles.
Inability to extend the knee, because of paralysis of the quadriceps femoris
Sensory impairment
Sensory decline over the anterior and medial aspects of the thigh, as a result of engagement
of the intermediate and lateral cutaneous nerves of the thigh
Sensory loss on the medial side of the leg and foot up to the ball of the great toe (first
metatarsophalangeal joint), because of engagement of the saphenous nerve

Patellar tendon reflex

The femoral nerve is responsible for the patellar tendon reflex (tests L3-L4 spinal
component)

Femoral nerve neuropathy

It occurs when the femoral nerve is compressed as it passes under the inguinal ligament,
anterior to iliopsoas.

Causes
Surgery (hysterectomy, pelvic, hip, femoral artery catheterization, arterial bypass,
retroperitoneal tumors, diabetes mellitus ) With increased use of anticoagulant agents,
femoral neuropathy subsequent to spontaneous hemorrhage within the ilio-psoas muscle has
become a serious and more frequent clinical problem.
 2. OBTURATOR NERVE
The obturator nerve is a major peripheral nerve of the lower limb.

Nerve roots: L2-L4

Motor functions: Innervates the muscles of the medial compartment of the thigh (obturator
externus, adductor longus, adductor brevis, adductor magnus and gracilis).
Sensory functions: Cutaneous branches of the obturator nerve innervate the skin of the
medial thigh.
. This procedure can also be carried out under ultrasound guidance.
Damage to the Obturator Nerve
The obturator nerve can be damaged during surgery involving the pelvis or abdomen.
Symptoms include numbness and paraesthesia on the medial aspect of the thigh and
weakness in adduction of the thigh. Alternatively, the patient could present with posture and
gait problems due to the loss of adduction.

Obturator Nerve Block

Obturator nerve block is used in the management of pain after lower limb surgery or for
chronic hip pain. The anaesthetic is injected inferior to the pubic tubercle and lateral to the
tendon of the adductor longus muscle. This procedure can also be carried out under
ultrasound guidance.

Clinical Relevance
Injury to the nerve is rare as it lies deep within the pelvis and medial thigh. It can be
damaged through direct injury to the nerve or to surrounding muscle tissue. Mild damage to
the obturator nerve can be treated with physiotherapy. More severe cases may require
surgery.
Injury may be caused by:
 Nerve being stretched during surgery
 Entrapment within the obturator canal
 Compression during pregnancy
 Car or household accident
 Abdominal surgery
 Athletes may present with pain that may be brought on by exercise, often sports
involving a lot or running and twisting. They may have been predisposed to this injury
by previous pelvic trauma or surgery
Obturator Neuropathy
Symptoms
 Sensory alteration in medial thigh
 Pain & paresthesias may extend from hip to knee along the medial aspect of the thigh
 Extension or lateral leg movement can increase pain
 May have trouble walking or experience leg weakness due to problems adducting the
ipsilateral hip
Signs
 Weak hip adductors on affected side
 Wasting of medial thigh
 Abnormal abduction of hip during ambulation resulting in a circumduction, wide-
based gait
 Area of sensory loss or alteration in the mid and lower third of the medial thigh which
sometimes may extend below the knee
 Ipsilateral loss of the hip adductor tendon reflex (test against asymptomatic leg as is
not always present in healthy population)

Assessment
Needle EMG to confirm acute/chronic denervation of hip adductors excluding other lower
extremity muscles such as iliopsoas or quadriceps
CT, MRI, or ultrasound imaging when intra-pelvic mass lesions are suspected of entrapping
the nerve
 3. SCIATIC NERVE
Nerve roots: L4-S3.
Motor functions : Innervates the muscles of the posterior thigh (biceps femoris,
semimembranosus and semitendinosus) and the hamstring portion of the adductor magnus
(remaining portion of which is supplied by the obturator nerve).
Indirectly innervates (via its terminal branches) all the muscles of the leg and foot.
Sensory functions: No direct sensory functions. Indirectly innervates (via its terminal
branches) the skin of the lateral leg, heel, and both the dorsal and plantar surfaces of the foot.

Injury to the sciatic nerve

Piriformis syndrome- refers to compression of the sciatic nerve by the piriformis muscle. It
is also known as deep gluteal syndrome.
Clinical features include radicular pain, numbness, muscle weakness and buttock tenderness.
The pain can occasionally be exacerbated by internal rotation of the lower limb at the hip.
X-ray and MRI imaging is usually unremarkable but can exclude other pathology such
as spinal compression of the sciatic nerve.
The treatment of piriformis syndrome can be divided into non-operative and operative:
Non-operative – analgesia, physiotherapy and corticosteroid injections
Operative – piriformis muscle release
Foot Drop

Foot drop is caused by disruption to the common peroneal nerve which controls active
dorsiflexion of the ankle leading to a lack of heel strike during gait hence the term foot drop.
Mechanism of Injury
The common peroneal nerve is in a particularly vulnerable position as it winds around the
neck of the fibula. It may be damaged at this site by:
 Trauma or injury to the knee
 Neurological disorders i.e. stroke
 Compression of the fibula head during surgery e.g. tourniquet[2]
 Fracture of the fibula
 Fracture to tibial plateau
 Patellar dislocations (33% chance of nerve damage)[5]
 Ankle inversion injury
 4. TIBIAL NERVE
The tibial nerve is a major peripheral nerve of the lower limb. It has several cutaneous and
motor functions in the leg and foot.
Nerve roots: L4-S3
Sensory: Innervates the skin of the posterolateral leg, lateral foot and the sole of the foot.
Motor: Innervates the posterior compartment of the leg and the majority of the intrinsic foot
muscles.

Tibial nerve injury

Clinical Relevance: Tarsal Tunnel Syndrome

Tarsal tunnel syndrome refers to entrapment and compression of the tibial nerve as it passes
through the tarsal tunnel.

Patients may experience altered sensation in the sensory distribution of the tibial nerve – the
sole of the foot.

The motor function of the nerve can also be affected in severe disease, causing weakness and
wasting of the intrinsic foot muscles.

The management of tarsal tunnel syndrome can be conservative or surgical:

Conservative: Physiotherapy, NSAIDs, corticosteroid injections

Surgical: Tarsal tunnel release (cutting through the flexor retinaculum to decompress the
tarsal tunnel)
Investigations
1. 3T magnetic resonance imaging (MRI) -It can give excellent visualization.
2. Musculoskeletal ultrasonography: It is also good and less expensive than MRI.
3. Electrodiagnostics (EDx). MRI and ultrasonography (USG) help delineate the site of
lesion and extent of physical lesion. EDx will help determine severity, type of lesion,
reinnervation, if any, and differentiate neuropraxia from axonotmesis.

Management
Physiotherapy Management / Interventions
Management is directed towards:

Pain management.
Neuropathic pain affects the quality of life and is a common consequence of nerve
damage. Pain control is of paramount importance. A Physiotherapist can employ other
modalities that show in various studies to be of benefit as complementary medicine for pain
relief.
These include massage-eg aromatherapy massage, in studies, has shown to help manage
neuropathic pain and increase

TENS.-Application of TENS has been found to be of benefit in pain reduction

in neuropathic pain. It was found to be of benefit if used at 100hz in constant mode.

Low Level Laser Therapy (LLLT). Studies have found this to be of benefit in pain relief
and acceleration of healing in treatment of neuropathic pain and neurological deficits as
adjuvant therapy.
Relaxation techniques
Acupuncture
And then strengthening exercise can be done after suppression of the pain