Lower Limb Nerves And
Their injuries
DR. Dalia Mahmoud
Biram
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Learning Objectives:
By the end of the lecture the student should be able to:
•Describe the structure and relationships of the plexuses of the lower limb.
•Describe the course, relationships and structures supplied by the major nerves of the lower limb.
•Outline the peripheral nerve lesions, the clinical consequences and giving some examples.
•List the different types of muscle fibers, describe their means of contraction, and the trophic effects
of nerves on muscles
•Describe the denervation and re-innervation of muscles
MSKL 311- Lecture: Lower Limb: Nerves 22
Nerve Plexuses Lumbar Plexus
(L1-L4)
The lumbar plexus is composed of the ventral primary rami of spinal nerves L1-L4, which give rise to two
large nerves, the femoral and obturator nerves, and several smaller branches . The femoral nerve
dorsal divisions (L2-L4) innervates muscles of the anterior thigh, whereas the obturator nerve ventral
divisions (L2-L4) innervates muscles of the medial thigh.
The sacral plexus is composed of the ventral primary rami of spinal nerves L4-S4.
The small coccygeal plexus has contributions from L4-Co1 and gives rise to small anococcygeal
branches that innervate the coccygeus muscle and skin of the anal triangle .
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Branches of the lumbar plexus
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Fig. 13.16
Sacral &Coccygeal plexus
Formation& branches of the
sacral plexus
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Nerves of the Gluteal Region:
A. Posterior view.
B. Site for intramuscular injections.
Seven (7) nerves enter the gluteal region from the
pelvis through the greater sciatic foramen :
• superior gluteal nerve,
• sciatic nerve,
• nerve to the quadratus femoris,
• nerve to the obturator internus,
• posterior cutaneous nerve of the thigh,
• pudendal nerve,
• inferior gluteal nerve.
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Nerves at the Gluteal region
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Femoral nerve
The femoral nerve:
innervates all muscles in the
anterior compartment of the
thigh; in the abdomen, gives rise
to branches that innervate the
iliacus and pectineus muscles;
and innervates skin over the
anterior aspect of the thigh,
anteromedial side of the knee,
the medial side of the leg, and
the medial side of the foot.
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Obturator nerve
•The obturator nerve, like the femoral nerve,
originates from L2 to L4.
•It descends along the posterior abdominal
wall, passes through the pelvic cavity and
enters the thigh by passing through the
obturator canal.
•The obturator nerve innervates:
all muscles in the medial compartment of the
thigh, (EXCEPT the part of adductor magnus
muscle that originates from the ischium and
the pectineus muscle, which are innervated by
the sciatic and the femoral nerves,
respectively); the obturator externus muscle;
and skin on the medial side of the upper thigh.
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Sciatic nerve
•Posterior divisions of L4 to S2 are carried in
the common peroneal part of the sciatic nerve
and the anterior divisions of L4 to S3 are
carried in the Tibial part.
•The sciatic nerve innervates:
all muscles in the posterior compartment of
the thigh;
the part of adductor magnus originating from
the ischium;
all muscles in the leg and foot;
skin on the lateral side of the leg and the
lateral side and sole of the foot.
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Sciatic nerve and
Piriformis muscle
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Tibial nerve: Tibial nerve
A. Posterior view. •The tibial part of the sciatic nerve, either before or
B. Sural nerve. after its separation from the common fibular nerve,
supplies branches to all muscles in the posterior
compartment of thigh (long head of biceps femoris,
semimembranosus, semitendinosus) except the
short head of biceps femoris, which is innervated by
the common peroneal part .
•The Tibial nerve descends through the popliteal
fossa, enters the posterior compartment of leg, and
continues into the sole of the foot.
•The Tibial nerve innervates:
all muscles in the posterior compartment of leg;
all intrinsic muscles in the sole of the foot except
for the first two dorsal interossei muscles, which are
innervated by the deep peroneal nerve; and
skin on the posterolateral side of the lower half of
the leg and medial side of the ankle, foot, and little
toe,
and skin on the sole of the foot and toes.
• In the leg, the Tibial nerve gives rise to:
branches that supply all the muscles in the posterior
compartment of leg; and two cutaneous branches,
the Sural nerve and medial calcaneal nerve. 18
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Common peroneal nerve:
Nerves of the lateral compartment of leg:
A. Posterior view, right leg. B. Lateral view, right leg.
Common fibular nerve
•It innervates the short head of biceps femoris in the posterior compartment
of thigh and then continues into the lateral and anterior compartments of
leg and onto the foot .
•The common peroneal nerve innervates:
all muscles in the anterior and lateral compartments of leg;
one muscle (extensor digitorum brevis) on the dorsal aspect of the foot;
the first two dorsal interossei muscles in the sole of the foot;
and skin over the lateral aspect of the leg, and ankle, and over the
dorsal aspect of the foot and
toes.
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Nerves related to bone
The common peroneal nerve exits by following the
biceps femoris tendon over the lower lateral margin of
the popliteal fossa, and continues to the lateral side of
the leg where it swings around the neck of the fibula and
enters the lateral compartment of leg.
Superficial peroneal nerve:
• Associated with the lateral compartment of leg.
• Originates as one of the two major branches of the
common peroneal nerve
• It descends in the lateral compartment deep to the
fibularis longus and innervates the fibularis longus
and fibularis brevis .
• It enters the foot where it divides into medial and
lateral branches, which supply dorsal areas of the
foot and toes EXCEPT for:
• the web space between the great and second toes,
which is supplied by the deep peroneal nerve;
• the lateral side of the little toe, which is supplied by
the sural branch of the tibial nerve.
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The deep peroneal nerve:
innervates all muscles in
the anterior compartment;
then continues into the
dorsal aspect of the foot
where it innervates the
extensor digitorum brevis,
contributes to the
innervation of the first two
dorsal interossei muscles,
and supplies the skin
between the great and
second toes.
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.Nerves of the foot
•The foot is supplied by the tibial, deep peroneal , superficial peroneal,
sural, and saphenous nerves.
•all five nerves contribute to cutaneous or general sensory innervation;
•the tibial nerve innervates all intrinsic muscles of the foot except for the
extensor digitorum brevis and first two dorsal interossei muscles,
•, which is innervated by the deep peroneal nerve;
•the tibial nerve bifurcates into:
medial plantar nerve;
lateral plantar nerve.
The medial plantar nerve:
• is the major sensory nerve in the sole of the foot .
•It innervates skin on most of the anterior two-thirds of the sole and
adjacent surfaces of the medial three and one-half toes, which includes
the great toe.
•the nerve also innervates four intrinsic muscles-the abductor hallucis,
flexor digitorum brevis, flexor hallucis brevis, and the first lumbrical.
The lateral plantar nerve:
•it innervates all intrinsic muscles in the sole, except for the four
muscles supplied by the medial plantar nerve.
•It also innervates a strip of skin on the lateral side of the anterior two-
thirds of the sole and the adjacent plantar surfaces of the lateral one and
one-half digits.
Lateral and medial plantar nerves. A. Sole of the right foot.
B. Cutaneous distribution 24
Key dermatomes include:
● Inguinal region: L1
● Anterior knee: L4
● Second toe: L5
● Posterior leg and thigh: S1-S2
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Injury to the Superior Gluteal Nerve
• When a person who has suffered a
lesion of the superior gluteal nerve
is asked to stand on one leg, the
pelvis on the unsupported side
descends ,indicating that the gluteus
medius and minimus on the
supported side are weak or
non‐functional.
• This observation is referred to
clinically as a positive Trendelenburg
test.
• Other causes of this sign include
fracture of the greater trochanter
(the distal attachment of gluteus
medius) and dislocation of the hip joint.
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Injury to the Tibial Nerve
• Injury to the tibial nerve is uncommon because of its deep and protected position in
the popliteal fossa; however, the nerve may be injured by deep lacerations in the
popliteal fossa.
• Posterior dislocation of the knee joint may also damage the tibial nerve.
• Severance of the tibial nerve produces paralysis of the flexor muscles in the
leg and the intrinsic muscles in the sole of the foot.
• People with a tibial nerve injury are unable to plantar flex their ankle or flex their
toes.
• Loss of sensation also occurs on the sole of the foot.
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Injury to the Common Fibular Nerve and Foot drop
• Severance of the common fibular nerve results in flaccid paralysis of all
muscles in the anterior and lateral compartments of the leg (dorsiflexors
of the ankle and evertors of the foot).
• The loss of dorsiflexion of the ankle causes foot drop, which is further
exacerbated by unopposed inversion of the foot.
• This has the effect of making the limb “too long” : The toes do not clear
the ground during the swing phase of walking .
Foot drop
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Cutaneous Nerves of the Lower Limb
Regions of skin innervated by peripheral nerves
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Major Motor nerves of the lower limb
(colors indicate regions of motor innervation)
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