DR JAMILA EL MEDANYDR JAMILA EL MEDANY

OBJECTIVESOBJECTIVES

By the end of the lecture, students should be able to:By the end of the lecture, students should be able to: Describe the formation of sacral plexus (site & root

value). List the main branches of sacral plexus. Describe the course of the femoral & the sciatic nerves List the motor and sensory distribution of femoral &

sciatic nerves. Describe the effects of lesion of the femoral & the

sciatic nerves (motor & sensory).

LUMBAR PLEXUS

Formation: Ventral (anterior) rami of the upper 4 lumbar spinal nerves (L1,2,3 and L4). Site: Within the substance of the psoas major muscle. Main branches: Iliohypogastric & ilioinguinal: to anterior abdominal wall. Obturator: to medial (adductor) group of the thigh. Femoral: to anterior group of the thigh.

FEMORAL NERVE

Origin: from lumbar

plexus (L2,3,4). Course:• Descends lateral to

psoas major & enters the thigh behind the inguinal ligament.

• Passes lateral to femoral artery & divides into anterior & posterior divisions.

Femoral N

MUSCULAR MUSCULAR BRANCHES OF BRANCHES OF

FEMORAL NERVEFEMORAL NERVE

• In abdomen: To iliacus (flexor of hip

joint).• In lower limb: • To anterior

compartment of the thigh:

Flexors of hip joint: sartorius & pectineusExtensors of knee joint: quadriceps femoris.

P

S

CUTANEOUS BRANCHES OF

FEMORAL NERVE

• To antero-medial aspect of the thigh.

• To medial side of knee, leg and foot (saphenous nerve).

INJURY OF THE FEMORAL NERVE

Paralysis of Movement affected

Iliacus Flexion of the hip

Sartorius Flexion and abduction of the hip

Pectineus Flexion and adduction of the hip

Quadriceps femoris

Extension of the knee

SENSORY EFFECT:

• Loss of sensation of the areas

supplied by femoral nerve.

MOTOR EFFECT: Iliacus

Pectinus

sartorius

Quadriceps

FEMORAL NERVE INJURY

MOTOR MOTOR MANIFESTATION:MANIFESTATION:

Wasting of quadriceps femoris.

Loss of extension of knee.

Weak flexion of hip (psoas major is intact).

SENSORY SENSORY MANIFESTATION :MANIFESTATION :

loss of sensation over areas supplied (antero-medial) aspect of thigh & medial side of leg & foot.

SACRAL PLEXUS

Formation: By the ventral

(anterior) rami of a part of L4 & whole L5 (lumbosacral trunk) + S1,2,3 and most of S 4.

Site: in front of the

piriformis muscle.

SACRAL PLEXUS

Main branches:• Pelvic splanchnic

nerves are the sacral part of the parasympathetic system and arise from the second, third, and fourth sacral nerves.

• They are distributed to the pelvic viscera.

Pudendal nerve: to perineum.

Sciatic nerve: to lower limb.

SCIATIC NERVE

It is the largest nerve of the body.

Origin: Sacral plexus (L4,5, S1, 2,3). Course: Leaves the pelvis through

greater sciatic foramen, below piriformis & passes in the gluteal region (between ischial tuberosity & greater trochanter) then to posterior compartment of thigh.

Termination: Divides into tibial & common

peroneal (fibular) nerves in the middle of the back of the thigh

TIBIAL NERVE

Course:• Descends through popliteal

fossa to the posterior compartment of leg, accompanied with posterior tibial vessels.

• Passes deep to flexor retinaculum (behind the medial malleolus) to reach the sole of foot where it divides into 2 terminal branches, (Medial & Lateral planter nerves.

COMMON PERONEAL (FIBULAR) NERVE

Course:• Leaves popliteal fossa & close to

the lateral aspect of neck of the fibula.

Then divides into:1. Superficial peroneal: descends

into lateral compartment of leg.

2. Deep peroneal: descends into anterior compartment of leg.

MUSCULAR BRANCHES OF THE

SCIATIC NERVE• To Hamstrings (flexors of knee &

extensors of hip).• To all muscles in the leg & foot

through:1. Common peroneal: TO Muscles of anterior & lateral

compartments of leg (Dorsiflexors of ankle, Extensors of toes, Evertors of foot).

2. Tibial: TO Muscles of posterior

compartment of leg & intrinsic muscles of sole (Planterflexors of ankle, Flexors of toes, Invertors of foot).

Cutaneous BRANCHES OF SCIATIC NERVE

• To all leg & foot • EXCEPT: • areas supplied by

saphenous nerve (blue), branch of femoral nerve.

• The sciatic nerve is most most frequently injuredfrequently injured by…?

I- I- Badly placed intramuscular injections in the gluteal region.

• To avoid this, injections into the gluteus maximus or medius should be made… into the upper outer upper outer quadrant of the buttock. quadrant of the buttock.

• Most nerve lesions are Most nerve lesions are incomplete,incomplete, and and in 90% of in 90% of injuries, the common injuries, the common peroneal (part of the nerve) peroneal (part of the nerve) is the most affected.is the most affected. Why? - The common peroneal nerve fibers lie superficialsuperficial in the sciatic nerve.

CAUSES OF SCIATIC CAUSES OF SCIATIC NERVE INJURYNERVE INJURY

II-Posterior dislocation of the hip joint

The following clinical features are present:Motor:

• The hamstring muscles are The hamstring muscles are paralyzed,paralyzed, but weak flexion weak flexion of the knee is possible. of the knee is possible. Why? - because of the action of the sartorius (femoral nerve) and gracilis (obturator nerve).

• All the muscles below the knee are paralyzed, and the weight of the foot causes it to assume the plantar-plantar-flexed position,flexed position, or Foot Foot Drop.Drop.

FOOT DROP• It is a peripheral nerve injury that affects a

patient’s ability to lift the foot at the ankle. While foot drop injury is a neuromuscular disorder, it can also be a symptom of a more serious injury, such as a nerve compression or herniated disc.

• Symptoms of foot drop• Inability to point toes toward the body

(dorsi flexion)• Pain• Weakness• Numbness (on the shin or top of the foot)• Loss of function of foot

• High-stepping walk (called Steppage gait or Footdrop Gait)

•SENSORY SENSORY MANIFESTATION:MANIFESTATION:Sensation is lost below below the knee,the knee, except for a except for a narrow area down narrow area down the medial side of the the medial side of the lower part of the leglower part of the leg and along the medial border of the foot as far as the ball of the big toe, which is supplied by the saphenous nerve (femoral nerve).

SCIATICA • Sciatica describes the condition in which patients have pain along the sensory distribution of the sciatic nerve.

• Thus the pain is experienced in the posterior aspect of the thigh, the posterior and lateral sides of the leg, and the lateral part of the foot.

Sciatica can be caused by: Prolapse of an intervertebral disc, with pressure on

one or more roots of the lower lumbar and sacral spinal nerves,

Pressure on the sacral plexus or sciatic nerve by an intrapelvic tumor, or

Inflammation of the sciatic nerve or its terminal branches.

Common Peroneal Nerve Injury

The common peroneal common peroneal nervenerve is in an exposed exposed positionposition as it leaves the popliteal fossa it winds around neck of the fibula to enter peroneus longus muscle, (Dangerous Position).

The common peroneal nerve is commonly injuredIn Fractures of the neck of the fibula and By pressure from casts or splints.

• The following clinical features are present:Motor: Motor:

• The muscles of the anterior and lateral The muscles of the anterior and lateral compartments of the leg are compartments of the leg are paralyzed,paralyzed,

• As a result, the opposing muscles, the plantar flexors of the ankle joint and the invertors of the subtalar joints, cause the foot to be cause the foot to be Plantar Flexed Plantar Flexed (Foot Drop) and Inverted,(Foot Drop) and Inverted, an attitude

referred to as EquinovarusEquinovarus..

Common Peroneal Nerve Injury

Tibial Nerve Injury

• The tibial tibial nervenerve leaves the popliteal fossa by passing deep to the gastrocnemius & soleus.

• Because of its deep and protected position, it is rarely injured. rarely injured.

Complete division results in the following clinical features:Motor: All the muscles in All the muscles in the back of the leg the back of the leg and the sole of the and the sole of the foot are paralyzed. foot are paralyzed. The opposing muscles DorsiflexDorsiflex the foot at the ankle joint and and Evert the footEvert the foot at the subtalar joint, an attitude referred to as

CalcaneovalgusCalcaneovalgus..

SUMMARY The lumbar plexus is formed by ventral (anterior)

rami of L1,2,3 and most of L4L1,2,3 and most of L4, in the substance of psoas major muscle.

The sacral plexus is formed by ventral (anterior) rami of a part of L4 & whole L5 (lumbosacral trunk) + S1,2,3 S1,2,3 and most of S4, in front of piriformis msucle.

The femoral nerve, a branch of lumbar plexus (L2,3,4). Its injury (L2,3,4). Its injury leads to weak flexion of hip &loss flexion of hip &loss of extension of knee as well as loss of sensation of skin of antero-medial aspects of the thigh, medial side of knee, leg and foot.

SUMMARYSUMMARY The sciatic nerve The sciatic nerve is a

branch of sacral plexus (L4,5, S1,2,3). Its injury (L4,5, S1,2,3). Its injury leads to affection of Flexion of knee, Flexion of knee, Extension of hip, all Extension of hip, all movements of leg & movements of leg & footfoot, as well as loss of sensation of skin of leg skin of leg & foot (& foot (Except areas Except areas supplied by saphenous supplied by saphenous branch of femoral branch of femoral nerve).nerve).

SCIATIC NERVE INJURYSCIATIC NERVE INJURY MOTOR EFFECT:MOTOR EFFECT:• Marked wasting of the

muscles below the knee.• Weak flexion of the knee

(sartorius & gracilis are intact).• Weak extension of hip

(gluteus maximus is intact).• The foot assumes the position

of Foot Drop Foot Drop (planter flexed position) by its weight.

SENSORY EFFECT:SENSORY EFFECT:• Loss of sensation below knee

(EXCEPT medial side of leg & foot).

Test your knowledge!Test your knowledge!

Which of the following is supplied by the femoral nerve ?a) Extensors of hip.b) Skin of dorsum of foot.c) Hamstrings.d) Extensors of knee. Injury of common peroneal nerve common peroneal nerve leads to:a) Loss of dorsiflexion of ankle.b) Loss of inversion of foot.c) Loss of extension of knee.d) Loss of flexion of toes.

THANK YOUTHANK YOU