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EXAMINATION OF NERVES OF LOWER LIMB OBJECTIVES At the end of this lecture the students should know: •The sensory and motor nerve supplies of the different regions of lower limb •Examination of nerves of lower limb •Significance of lesions of different nerves of lower limb and what abnormality would appear in case of a lesion Major Nerve supply of lower limbs Through Lumbar and Sacral Plexuses: •Femoral Nerve •Obturator Nerve •Lateral Cutaneous Nerve of thigh •Sciatic Nerve Lumbar and Sacral Plexus Femoral Nerve (L2, L3, L4) •Motor Supply –Iliopsoas (HIP FLEXORS) –Quadriceps Group (KNEE EXTENSORS) •Rectus Femoris •Vastus Medialis •Vastus Lateralis •Vastus Intermedius –Sartorius Muscle •Sensory (Saphenous Nerve) –Skin on the medial aspect of the thigh (inner thigh) and inner calf •Reflex –Knee jerk (requires the quadriceps to be working) Examination Of Femoral Nerve Inspection Look for: • Swelling in the groin & evidence of trauma • Bruising • Wasting of the Quadriceps • Inability to bear weight on the affected leg • Muscle fasciculation, muscle atrophy (QUADRICEPS) • The back (L2-4) for evidence of disease Palpation Palpate the: • Inguinal ligament for pain • Inguinal area (bone and soft tissue) • Spine • Flanks • Quadriceps (for tone) Motor Examination of Femoral Nerve HIP FLEXION (LYING) HIP FLEXION (SITTING) Motor Examination of Femoral Nerve KNEE EXTENSION (LYING) KNEE EXTENSION (SITTING) Motor Examination Of Femoral Nerve KNEE REFLEX (LYING) KNEE REFLEX (SITTING) Sensory Examination of Femoral Nerve •Medial aspect of the thigh through anterior cutaneous branch of Femoral nerve. •Calf through Saphenous nerve Sciatic Nerve (L4, L5, S1, S2) Supplies : ALL OF THE MUSCLES BELOW THE KNEE via: •The Tibial nerve •Common Peroneal nerve. THIGH (Motor) –Hamstring Group (KNEE FLEXORS) –Semimembranosus –Semitendinosus –Long and Short heads of biceps –Adductor Magnus Nerve splits just above popliteal fossa to become tibial nerve and common peroneal nerve Examination of Sciatic Nerve KNEE FLEXION Common Peroneal Nerve (L4, L5, S1) Division of Sciatic nerve Divides into superficial and deep branches •SUPERFICIAL PERONEAL NERVE –Motor •Foot Evertors (Peroneus longus and Peroneus –Sensory •Sural nerve •DEEP brevis) sensation to lateral calf and dorsum of the foot PERONEAL NERVE –Motor •Foot dorsiflexors (Tibialis anterior) •Toe dorsiflexors (Extensor digitorum –Sensory •Small area longus, extensor hallucis longus) of web space between the 1st and 2nd toes Examination of Deep Peroneal Nerve DORSIFLEXION TOE DORSIFLEXION Tibial Nerve (L4, L5, S1, S2) •Division of Sciatic nerve Motor •Foot plantarflexors (Gastrocnemius, Soleus, Popliteus) •Foot Invertors (Tibialis Posterior) •Toe Flexors (Flexor digitorum longus, Flexor hallucis longus) Reflex •Ankle reflex (S1, S2) •Continues on as the Posterior tibial nerve •Supplies the muscles of the foot via the medial and lateral plantar nerves. Examination Of Tibial Nerve TOE PLANTARFLEXION PLANTARFLEXION Ankle Reflex Sensory Examination of Sciatic Nerve COMMON PERONEAL NERVE •Deep peroneal nerve •Superficial peroneal nerve •Lateral sural cutaneous nerve TIBIAL NERVE •Sural nerve •Medial sural cutaneous nerve •Calcaneal nerve •Medial and lateral planter nerve Obturator Nerve (L2, L3, L4) Motor –Adductor group (HIP ADDUCTORS) •Adductor Brevis •Adductor Magnus •Adductor Longus –Gracilis Sensory –Distal medial thigh Examination Of Obturator Nerve Sensory Examination of Obturator Nerve Distal medial thigh Superior Gluteal Nerve • Hip Abduction • • Gluteus medius Gluteus minimus • Nerve root: L4, L5, S1 Inferior Gluteal Nerve • Hip extension • Gluteus maximus • Nerve root: L5, S1, S2