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NERVE INJURIES OF THE LOWER EXTREMITY

NERVE INJURIES OF THE LOWER EXTREMITY. STACY RUDNICKI, MD ASSOCIATE PROFESSOR OF NEUROLOGY. Dermatomes of the Leg. 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

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NERVE INJURIES OF THE LOWER EXTREMITY

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  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 • 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

  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 FindingMuscleNerve Root Ft Dorsiflex TIB ANT PER (FIB) L4,5 Grt toe ext EHL PER (FIB) L5 Toe ext EDL, EDB PER (FIB) L4,5 Foot eversion PER L, B PER (FIB) L4,5 Foot plant flex GASTROC, TIB S1,2 SOLEUS Toe flex FDL/FDB TIB L5,S1 Foot inv POST TIB TIB L4,5 Knee flex MULT TIB/PER L5S1S2

  11. Common Fibular (Peroneal) Nerve Common Fib Deep Fib Superficial Fib Per Longus Tib Ant Per Brevis EHL Per Tertius EDB

  12. SENSORY LOSS IN A DEEP PERONEAL (FIBULAR) NEUROPATHY

  13. Final Diagnosis Sciatic neuropathy with selective involvement of the fibular (peroneal) nerve fibers at the level of the pelvis

  14. CASE 2

  15. 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 can’t find time to exercise

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

  17. SENSORY LOSS

  18. Localization Finding Muscle Nerve Root Sens loss - - Lat fem <<L2 cut

  19. Final diagnosis Lateral femoral cutaneous neuropathy (AKA: Meralgia Parasthetica)

  20. CASE 3

  21. 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

  22. Exam • He has weakness of: • Foot plantar flexion • Foot inversion • Toe flexion • Strength is normal in: • Knee flexion • Foot dorsiflexion • Foot eversion

  23. SENSORY LOSS

  24. Exam FindingMusclePNRoot Ft plant flex GASTROC TIB S1, S2 Toe flex FDL, FDB TIB L5, S1, S2 Foot inv POST TIB TIB L4, L5 Sens loss ---- MP+LP Ft dorsiflex TIB ANT FIB (per) L4,5 Foot ever FIB L, B, T FIB (Per) L5S1 Knee flex MULT SCIATIC L5, S1, S2 (Tib and Fib)

  25. 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

  26. Final Diagnosis Tibial neuropathy at the popliteal fossa

  27. CASE 4

  28. 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

  29. 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

  30. SENSORY LOSS

  31. Localization FindingMusclePNRoot Hip flex IP/Iliacus 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

  32. Femoral nerve Psoas Iliacus Sartorius Pectinius Rectus Femoris Vastus Lat Vastus inter Vastus Med

  33. Final Diagnosis Femoral Neuropathy Related to Diabetes Mellitus

  34. CASE 5

  35. 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

  36. 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

  37. Localization Finding Muscle PNRoot 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

  38. Final diagnosis S1 radiculopathy related to a herniated disc (“Sciatica”)

  39. 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 • Femoral neuropathy - • Nerve adjacent to artery • Spontaneous

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