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NERVE INJURIES OF THE LOWER EXTREMITY

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She complains of weakness and numbness of the right leg ... Overall, nerves in the leg are less liable to chronic compression/entrapment ... – PowerPoint PPT presentation

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Title: NERVE INJURIES OF THE LOWER EXTREMITY


1
NERVE INJURIES OF THE LOWER EXTREMITY
  • STACY RUDNICKI, MD
  • ASSOCIATE PROFESSOR OF NEUROLOGY

2
Dermatomes of the Leg
3
Root Innervation of the Leg
  • Hip Flexion
  • L 1, 2, 3
  • Knee Extension
  • L 2, 3, 4
  • Foot Dorsiflexion
  • L 4,5
  • Foot Plantar Flexion
  • S1, 2
  • Knee Flexion
  • L5, S1, S2
  • Hip Extension
  • L5, S1, S2

4
Clinical Principles
  • Detecting subtle weakness
  • Get up from squat
  • Quadriceps/Gluteus maximus
  • Stand on tip toes
  • Gastrocnemius/Soleus
  • Stand on heels
  • Tibialis Anterior

5
Reflexes
  • Knee Jerks - evaluates
  • Quadriceps muscle
  • Femoral Nerve
  • Primarily L4 nerve root (also L2, L3)
  • Ankle Jerk - evaluates
  • Gastrocnemius muscle
  • Tibial Nerve
  • Primarily the S1 nerve root (also S2)

6
CASE 1
7
History
  • 20 yo college student involved in an MVA
  • She suffers multiple pelvic fractures
  • She complains of weakness and numbness of the
    right leg
  • She is aware that her right foot is dropped
    relative to the left, and that she must lift her
    foot up higher to clear her toes

8
Exam
  • She has weakness of
  • Foot dorsiflexion
  • Foot eversion
  • Toe extension
  • Strength is normal in
  • Foot plantar flexion
  • Foot inversion
  • Toe flexion
  • There is just a hint of weakness in knee flexion

9
SENSORY LOSS
10
Localization
  • Finding Muscle Nerve Root
  • Involved
  • Ft Dorsiflex TIB ANT FIB L4,5
  • Grt toe ext EHL FIB L5
  • Toe ext EDL, EDB FIB L4,5
  • Foot eversion FIB L, B FIB L4,5
  • Knee flex Mult TIB/Fib L5S1S2
  • Spared
  • Foot plant flex GASTROC, TIB S1,2
  • SOLEUS
  • Toe flex FDL/FDB TIB L5,S1
  • Foot inv POST TIB TIB L4,5

11
Localization
  • Finding Muscle Nerve Root
  • Involved
  • Ft Dorsiflex TIB ANT FIB L4,5
  • Grt toe ext EHL FIB L5
  • Toe ext EDL, EDB FIB L4,5
  • Foot eversion FIB L, B FIB L4,5
  • Knee flex Mult TIB/Fib L5S1S2
  • Spared
  • Foot plant flex GASTROC, TIB S1,2
  • SOLEUS
  • Toe flex FDL/FDB TIB L5,S1
  • Foot inv POST TIB TIB L4,5

12
Common Fibular (Peroneal) Nerve
  • Common Fib Short head BF
  • Deep Fib
  • Superficial Fib
  • Fib Longus Tib Ant
  • Fib Brevis EHL
  • Fib Tertius
  • EDB

13
Differentiating b/w L5 radiculopathy and Fibular
Neuropathy
  • Motor exam
  • Foot inversion - Posterior tibial muscle
  • Spared - Fibular neuropathy
  • Involved - L5
  • Sensory exam

14
Sensory loss in deep fibular, common fibular, and
L5 disease
15
Final Diagnosis
  • Sciatic neuropathy with selective involvement of
    the fibular (peroneal) nerve fibers at the level
    of the pelvis
  • Pearl The fibular component of the sciatic
    nerve is more susceptible to traumatic injury
    than the tibial component - false localization

16
CASE 2
17
History
  • The patient is a 45 yo man who complains of
    burning pain in his right lateral thigh
  • He is otherwise healthy, though over the last 2
    years, he has gained 30 pounds because he cant
    find time to exercise

18
Exam
  • He has normal strength in all muscles of his leg
  • Reflexes are normal

19
SENSORY LOSS
20
Localization
  • Finding Muscle Nerve Root
  • Sens loss - - Lat fem ltltL2
  • cut

21
Final diagnosis
  • Lateral femoral cutaneous neuropathy
  • (AKA Meralgia Parasthetica)
  • Pearls
  • ?This nerve does not come from the femoral nerve
    but rather the L-S plexus
  • ? There is no motor component
  • ? It is trapped as it crosses the pelvic brim,
    and wt loss or gain can precipitate sxs

22
CASE 3
23
History
  • A 27 yo man is shot at multiple sites in the
    thigh, popliteal fossa, and foot
  • He complains of burning pain in the foot and
    weakness of the foot

24
Exam
  • He has weakness of
  • Foot plantar flexion
  • Foot inversion
  • Toe flexion
  • Strength is normal in
  • Knee flexion
  • Foot dorsiflexion
  • Foot eversion
  • His foot has a cocked up appearance and is
    everted compared to the other foot

25
SENSORY LOSS
26
Exam
  • Finding Muscle PN Root
  • Involved
  • Ft plant flex GASTROC TIB S1, S2
  • Toe flex FDL, FDB TIB L5, S1, S2
  • Foot inv POST TIB TIB L4, L5
  • Sens loss ---- MPLP (tib) ltS1
  • Spared
  • Ft dorsiflex TIB ANT FIB (per) L4,5
  • Foot ever FIB L, B, T FIB (Per) L5S1
  • Knee flex HS SHBF SCIATIC L5, S1, S2
  • (Tib and Fib)

27
Exam
  • Finding Muscle PN Root
  • Involved
  • Ft plant flex GASTROC TIB S1, S2
  • Toe flex FDL, FDB TIB L5, S1, S2
  • Foot inv POST TIB TIB L4, L5
  • Sens loss ---- MPLP (tib) ltS1
  • Spared
  • Ft dorsiflex TIB ANT FIB (per) L4,5
  • Foot ever FIB L, B, T FIB (Per) L5S1
  • Knee flex HS SHBF SCIATIC L5, S1, S2
  • (Tib and Fib)

28
Sciatic Nerve in Thigh/ Tibial Nerve in Leg
  • Sciatic Nerve
  • Semitendonous Biceps Long Hd
  • Semi Membranous Biceps Short HD
  • Add Magnus
  • Tibial Nerve Common Fib Nv
  • Gastroc, Med Popliteus
  • Soleus Gastroc, lat
  • Tibialis Post
  • FDL FHL
  • Med Plantar Lateral Plantar
  • AH, FDB, FHB ADM, FDM, AH, Int

29
Final Diagnosis
  • Tibial neuropathy at the popliteal fossa
  • Pearl
  • The appearance of the foot at rest may help
    distinguish b/w a fibular and a tibial neuropathy
    - unopposed action of spared muscles

30
CASE 4
31
History
  • An 81 yo man with diabetes mellitus complains of
    onset of deep aching pain in his right thigh that
    evolved over a few weeks
  • He is having trouble walking because his knee
    gives out
  • He complains of numbness on the top of his leg

32
Exam
  • He has weakness of
  • Hip flexion
  • Knee extension
  • He has normal strength of
  • Hip adduction
  • Hip abduction
  • Foot dorsiflexion/plantar flexion
  • His knee jerk is absent, his ankle jerk is
    preserved

33
SENSORY LOSS
34
Localization
  • Finding Muscle PN Root
  • Hip flex IP/Rec Fem Fem L1,2,3
  • Knee Ext Quads Fem L2,3,4
  • Sens Loss --- Fem L2-4
  • Hip Add ADD L, B, M Obt L2,3,4
  • Add M Sciatic L5, S1
  • Hip Abd Gl Med/Min Sup Glut L5, S1, S2
  • Foot DF Tib ant Fib (Per) L4,5
  • Foot PF Gastroc/sol Tibial S1,S2

35
Localization
  • Finding Muscle PN Root
  • Hip flex IP/Rec Fem Fem L1,2,3
  • Knee Ext Quads Fem L2,3,4
  • Sens Loss --- Fem L2-4
  • Hip Add ADD L, B, M Obt L2,3,4
  • Add M Sciatic L5, S1
  • Hip Abd Gl Med/Min Sup Glut L5, S1, S2
  • Foot DF Tib ant Fib (Per) L4,5
  • Foot PF Gastroc/sol Tibial S1,S2

36
Femoral nerve
  • Iliopsoas
  • Sartorius Pectinius
  • Rectus Femoris
  • Vastus Lat
  • Vastus inter
  • Vastus Med

37
Distinguishing b/w a femoral neuropathy and L2 or
L3 radiculopathy
  • Motor exam
  • Thigh adduction (obturator nerve)
  • Spared with a femoral neuropathy
  • Involved with L2,3 disease
  • Sensory exam
  • Loss extends below the knee (medial foreleg) with
    femoral neuropathy
  • Saphenous nerve

38
Final Diagnosis
  • Femoral Neuropathy Related to Diabetes Mellitus
  • Pearl
  • The femoral nerve is also liable to injury during
    procedures involving the femoral artery or vein

39
CASE 5
40
History
  • A 27 yo body builder complains of a 4 week
    history of low back and leg pain
  • Pain travels down the back of the leg and into
    the sole of the
  • He is unaware of weakness and he continues to
    lift weights

41
Exam
  • His routine strength exam is normal
  • He can stand on his heels with ease
  • He can stand on his tiptoes on the right but not
    on the left
  • His left ankle jerk is absent, right is normal
  • Sensory exam
  • Decreased sensation of the sole of the foot,
    lateral distal leg, and lateral dorsum of the foot

42
Localization
  • Finding Muscle PN Root
  • Stand toes GASTROC/SOL TIB S1,2
  • Abs AJ GASTROC/SOL TIB S1,2
  • Sens --- MP, LP, SU S1
  • Stand Heels TIB ANT FIB L4,5
  • Foot Inv POST TIB TIB L4,5

43
Localization
  • Finding Muscle PN Root
  • Stand toes GASTROC/SOL TIB S1,2
  • Abs AJ GASTROC/SOL TIB S1,2
  • Sens --- MP, LP, SU S1
  • Stand Heels TIB ANT FIB L4,5
  • Foot Inv POST TIB TIB L4,5

44
Differentiating b/w radicular disease and focal
tibial neuropathy
  • Back pain that radiates into the leg highly
    suggestive of radicular process
  • Tibial nerve also innervates the foot inverters
    yet these are spared
  • Spontaneous (ie not associated with penentrating
    trauma) tibial neuropathies would be very unusual

45
Final diagnosis
  • S1 radiculopathy related to a herniated disc
  • Pearl
  • ? The term sciatica is a misnomer - it is really
    a root based process, not one of the sciatic
    nerve
  • ? Particularly in large muscles, weakness may be
    subtle and hence easily missed

46
Final Comments
  • Overall, nerves in the leg are less liable to
    chronic compression/entrapment compared to those
    in the arms
  • Most common entrapment in the leg is a fibular
    (peroneal) palsy at the fibular head
  • May get the common, superficial, or fibular
    (peroneal) nerve
  • Traumatic nerve injuries related to penetrating
    injury / bony trauma (hip / pelvic fxs) are seen
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