Peripheral_nerve_injuries by roshni.pptx

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1. PERIPHERAL NERVE INJURIES Dr. Roshni kachhadiya (PT) MPT (Neurological sciences)

2. Peripheral Nerve Peripheral nerve is a term used to describe the  peripheral nervous   system . The peripheral nervous   system connect the brain and spinal cord to the entire human body.

3. Classification of nerve fibers 1. Depending upon structure : Myelinated Non myelinated 2. Depending upon distribution : Somatic Autonomic

4. 3. Depending upon origin : Cranial nerves (12 pair) Spinal nerves (31 pair) 4. Depending upon function : Motor sensory

5. 5. ERLANGER GASSER CLASSIFICATION : Depending upon length of fibers and rate of conduction of impulses Type Diameter Velocity (m/s) A alpha 12 to 24 70 to 120 A beta 6 to 12 30 to 70 A gamma 5 to 6 15 to 30 A delta 2 to 5 12 to 15 B 1 to 2 3 to 10 C <1.5 0.5 to 2

6. Composition of Peripheral nerve

7. Peripheral neuropathy Peripheral neuropathy refers to the conditions that result when nerves that carry messages to and from the brain and spinal cord from and to the rest of the body are damaged or diseased. Damage to these nerves can impair muscle movement , prevent normal sensation in the arms and legs, and cause pain.

8. Peripheral neuropathy may be classified according to : The number and distribution of nerves affected ( mononeuropathy , mononeuritis multiplex, or polyneuropathy ) Type of nerve fiber predominantly affected (motor, sensory, autonomic) Based on duration chronic or acute

9. Neuropathy affecting just one nerve is called " mononeuropathy " Neuropathy involving multiple nerves in roughly the same areas on both sides of the body (symmetrical) is called "symmetrical polyneuropathy " or simply " polyneuropathy ". When two or more (typically just a few, but sometimes many) separate nerves in disparate areas (asymmetrical) are affected it is called " mononeuritis multiplex", "multifocal mononeuropathy ", or "multiple mononeuropathy "

10. Classification of peripheral nerve injuries (anatomical classification) Based on the extent of damage to nerve Seddon’s Classification Sunderland’s classification

11. 1. Seddon’s Classification Neuropraxia Axonotmesis Neurotmesis

12. Neuropraxia Mildest type Occurs due to temporary compression or stretch of nerve Temporary interruption of conduction without loss of axonal continuity (conduction block) Endoneurium , perineurium and epineurium and are intact.

13. Oedema of axons and displacement of myelin occures . But no wallerian degeneration occures . Sensory and motor problems distal to the site of injury Stimulaion distal to injury - Response present Prognosis – Good Recovery – week or month

14. Axonotmesis More severe stage Loss of continuity of axon and its covering myelin. Rupture of axon or nerve fibers and its covering of myelin, but preservation of the connective tissue framework of the nerve Epineurium and perinurium are intact. Wallerian degeneration occurs below the site of injury. It begins at 2 nd week and complete at 3 rd week after onset of injury. Retrograde degeneration occurs up to proximal node of ranvier .

15. Sensory, motor and sometimes autonomic deficits distal to the site of injury. Stimulation proximal or distal to the site of nerve injuries will produce no response. Recovery depends on rate and extent of regeneration. If lesion is proximal – 3 mm per day If lesion is distal – 1 to 1.5mm per day Prognosis – Better than neurotmesis ( upto months)

16. Neurotmesis Most severe Complete Transaction Total disruption of nerve fiber Epineurium and perineurium are also affected Wallerian degeneration occurs distal to the site of injury Prognosis : Poor compared to axonotmesis and neuropraxia Surgery needed.

17. 2. Sunderland classification Builds upon seddons classification Divides seddon’s last stage into 3 sub categories Total 5 grades

18. First degree : Neuropraxia . Recovery within few hours to weeks without surgical intervention Second degree : Axonotmesis . Recovery within 18 months Third degree : Neurotmesis with preservation of perineurium and epineurium Recovery is poor and incomplete

19. Dr Saleh WaslAllah Alharby www.ksu.edu.sa/DrSalehAlharby

20. Forth degree : Neurotmesis with preservation of epineurium Recovery is poor and incomplete. Nerve Grafting is required Fifth degree : Neurotmesis with complete transection . Recovery is not possible without surgery Bypass / jump Grafting is required

21. Degeneration and regeneration of nerve fibers Pathological changes after peripheral nerve injury includes : Segmental demyelination Degenerative changes 1. Wallerian degeneration 2. Retrograde degeneration 3. Regeneration

22. 1. Segmental demyelination : Focal degeneration of the myelin sheath with sparing of axon Occurs when axon is intact after nerve injury It is the act of demyelinating or loss of myelin sheath

23. Degenerative changes Wallerian degeneration : Wallerian degeneration is the pathological change that occurs in the distal cut end of nerve fiber (axon) after axonal injury. It is also called orthograde degeneration . Wallerian degeneration starts within 24 hours of injury.

24. After injury axonal skeleton disintegrates and axonal membrane breaks apart. It is followed by degradation of myelin and infiltration of miacrophages and schwann cells Neurilemmal sheath is unaffected, but the Schwann cells multiply rapidly and clear the debris from the degeneration So, the neurilemmal tube becomes empty. Later it is filled by the cytoplasm of Schwann cell. All these changes take place for about 2 months from the day of injury.

25. RETROGRADE DEGENERATION It is the pathological changes, which occur in the nerve cell body and axon proximal to the cut end Changes in Nerve Cell Body i . First, the Nissl granules disintegrate into fragments ii. Golgi apparatus is disintegrated iii. Nerve cell body swells due to accumulation of fluid and becomes round iv. Neurofibrils disappear followed by displacement of the nucleus towards the periphery Changes in Axon Proximal to Cut End In the axon, changes occur only up to first node of Ranvier from the site of injury. Degenerative changes that occur in proximal cut end of axon are similar to those changes occurring in distal cut end of the nerve fiber.

26. 3. Regeneration of nerve fiber : It starts as early as 4th day after injury, but becomes more effective only after 30 days and is completed in about 80 days. Regenerative sprouts grow from the proximal cut end of the nerve. Fibrils move towards the distal cut end of the nerve Fiber and Some enter the neurilemmal tube of distal end actually guide the fibrils into the tube. Schwann cells also synthesize nerve growth factors , which attract the fibrils form proximal segment. Axis cylinder is fully established inside the neurilemmal tube (3 months)

27. 6. Myelin sheath is formed by Schwann cells slowly.(1 year) 7. Diameter of the nerve fiber gradually increases. 8. In the nerve cell body , first the Nissi granules appear followed by Golgi apparatus 9. Nucleus occupies the central portion 10. Though anatomical regeneration occurs in the nerve, functional recovery occurs after a long period.

28. Causes Peripheral neuropathy may be either inherited or acquired through disease processes or trauma. Causes of Heriditory neuropathy : - HMSN - Friedrich’s ataxia - Porphyria

29. Causes of acquired peripheral neuropathy include: Physical injury (trauma) : Sudden injury, repeatitive stretch Metabolic and endocrine disease : Diabetic neuropathy, Uremia, reduction in thyroid hormone Small vessel disease Autoimmune disease Infection/ Inflammation : Leprosy, AIDS, Vasculitis , Cancer Toxins : Heavy metals, pestisides Drugs Heavy alcohol consumption

30. FOCAL PERIPHERAL NEUROPATHY

31. Radial Nerve Palsy

32. Supply C5-T1 (Posterior cord) Axilla Triceps Anconeous Arm Brachialis Brachioradialis ECRL Forearm Deep branch : ECRB Supinator Posterior interoosseous nerve ED ECU EDM EPL EI APL EPB Sensory Branch Posterior brachial cutaneous nerve Dorsal antebrachial cutaneous nerve Superficial radial nerve

33. Common neuropathies of radial nerve Radial neuropathy at axilla Radial neuropathy at spiral groove / Retroheumeral radial neuropathy / Saturday night palsy Radial neuropathy at forearm Radial neuropathy at wrist

34. Radial neuropathy at axilla Causes : Crutch palsy Deep penetrating injury in axilla Diptheria involving radial nerve Lead poisoning

35. Sensory – Affected over posterior aspect of arm and forearm

36. Motor – Weakness of all the radial nerve innervated muscles Reflexes – Triceps and Brachioradialis jerk may be diminished or absent

37. Radial neuropathy at spiral groove Causes : Fracture shaft humerus Saturday night palsy  head resting over humerus Tourniquet’s palsy Injection Gunshot/ Glass cut Supracondylar palsy Fibrous arch formed by triceps muscle 2 cm below the insertion of deltoid muscle.

38. Sensory - Affected over posterior aspect of arm and forearm Motor - Weakness of radial nerve innervated muscle except triceps and anconeous

39. Radial neuropathy at forearm Posterior interosseous nerve syndrome Radial tunnel syndrome Supinator syndrome Arcade of frohse syndrome

40. Causes : Tennis elbow (Inflammation of common extensor tendon) Fracture of upper end of radius and ulna Direct bolw to posterior interosseous nerve Fibrous arch covers the post interossei nerve as it passes through supinator muscle and get compressed during forcefull contraction (i.e. Arcade of frohse syndrome ) Compression of the nerve between the two layers of supinator ( i.e Supinator syndrome) Compression due to ganglia, neoplasm, bursae , VIC and fibrosis after trauma

41. Sensory : Sensations are spared (Pure Motor syndrome) Motor : Weakness in distal extensors supplied by radial nerve ED ECU EDM EI EPL EPB APL

42. Radial neuropathy at wrist Superficial radial neuropathy Cheiralgia paresthetica Wrist watch syndrome

43. Cause : Tight wrist watch Tight hand cuffs

44. Symptoms Pure sensory syndrome No muscle involvement Sensory abnormality (burning, numbness, tingling) over dorsal radial aspect of the hand Discomfort may get worsen with palmar and ulnar wrist flexion or forced pronation

45. Deformity in radial nerve palsy Wrist drop Wrist - 45 of palmar flexion Thumb – Palmar abduction and slight flexion MP joints – 30 flexion IP joints – slight flexion

46. Functional Disability Poor grip due to weak wrist extensors as fixators , can not put objects like cup or glass flat on table

47. Trick movements Rebound phenomena : Attempt to produce wrist extension wrist flexor forcefully contracts and relaxes. Attempt to produce extension of DIP of thumb FPL forcefully contracts and relaxes. Dorsal interossei produces MCP extension but fingers will go into abduction as well While doing ulnar deviation wrist goes into flexion Paralysis of triceps – pt use gravitational force for elbow extension

48. Brachial Plexus Injury

49. Brachial Plexus s

50. Causes Traction injury/stretch injury Brachial neurities / neuroma Large cervicle rib Fracture dislocation of scapula, clavicle or upper part of humerus Burner’s or Stringer’s syndrome Vehicular accidents Penetrating wounds Stab wounds

51. Causes Birth injuries Malignancy of cervical lymphnodes Apical lung tumor Radiation induced Congenital abnormality of cervicle spine ( eg . Klippel Fail syndrome)

52. Classification Supraclavicular Preganglionic Postganglionic Infraclavicular Total plexus injury

53. Supra clavicular injury Roots and Trunk Follow the dermatomal and myotomal distribution Infraclavicular Injury Cords and Nerves Follow the nerve pattern (Single or combination)

54. Preganglionic injury Due to avulsion of the root from the spinal cord. Lesion is proximal to dorsal root ganglion Wallerian degeneration doesn’t occur in the sensory axon as the DRG is saperated from the spinal cord.

55. Conduction velocity in sensory axon – intact Conduction velocity in motor axon – lost Prognosis poor

56. Postganglionic injury Lesion distal to DRG. DRG is in contact with spinal cord Wallerian degenration occurs because DRG is in contact with the spinal cord but remaining part of axon is saperated

57. Conduction velocity in sensory axon – lost Conduction velocity in motor axon – lost Good prognosis.

58. Total plexus injury Lesion is very close to the vertebral column. Very rare All the muscles supplied by brachial plexus are paralysed Loss of sensation c5 to t1 dermatome DTR of upper limb - diminished

59. Erb’s Palsy Upper Plexus lesion Injury to C5-C6 nerve root Erb’s Duchenne Palsy

60. Causes Obstetric injury - forceful separation of the head and shoulder during difficult delivery most common cause Forceps / Vaccum delivery Breech presentation Pressure over supra clavicular area Post aenesthetic Paralysis Injection of foreign vaccines and serum

61. Signs and Symptoms Sensory : Affected over C5-C6 dermatome Area of deltoid insertion Lateral aspect of forearm and hand

62. Totally paralysed muscles : Rhomboids Supraspinatus Infraspinatus Biceps Brachi Brachialis Coracobrachialis Teres minor Deltoid Supinator Weak Mucles : Triceps Lattissimus dorsi Serretus anterior Pectoralis major Extensor carpi radialis Motor : Paralysis of dorsalscapular nerve, suprascapular nerve, musculocutaneos and axillary nerve

63. Deformity : Policeman’s tip or Waiter’s tip Shoulder : Extension Adduction Internal Rotation Elbow : Extention Forearm : Pronation Wrist and fingers : usually unaffected

64. Reflexes : Biceps and Brachioradialis Jerk Affected Functional Disability : Difficulty in ADLs that require flexion of shoulder and elbow ( eg . Eating , combing, brushing etc)

65. Klumpke’s Palsy Lower Plexus Lesion Injury to C8 -T1 nerve root Rare compare to UBP injury

66. Causes Traction and fall on abducted arm Breech delivery Operation at axilla Apical lobe tumor Enlarged cervical rib

67. Signs and Symptoms Sensory : Over C8-T1 distribution loss of sensation over medial aspect of arm, forearm, hand, hypothenar eminence

68. Motor : Affects the distribution of median and ulnar nerves Weakness and wasting of the small muscles of the hand and a characteristic claw hand deformity Intrinsic muscles of hand ( interossei , lumbricles thenar and hypothenar ) Wrist flexors (FCU) Finger flexors (FDP, ulnar half) Forearm pronators ( pronator teres )

69. Deformity : Claw hand deformity Flattening of transverse metacarpal arch and longitudinal arch Forearm supinated Wrist extension Hyperextension of MCP joint Flexion of PIP and DIP

70. Horner’s sign : Ptosis Myosis Enophthalmos Anhidrosis This  is because of injury to sympathetic fibers to the head and neck that leave the spinal cord through nerve T1.

71. Functional Disability : Lack of intrinsic grip or lumbrical grip

72. Ulnar nerve injury

73. Medial cord of BP C8-T1

74. Motor distribution At elbow : FCU FDP (last 2 fingers) Wrist : Hypothenar muscles : ADM, ODM, FDM Adductor pollicis FPB Interossei Lumbricals ( 3 and 4)

75. Sensory distribution Palmar cutaneous branch Dorsal cutaneous branch Superficial sensory branch

76. Common neuropathies of ulnar nerve At cervical spine At base of neck At axilla At arm At elbow At Wrist Less Common

77. Causes At cervical spine : PIVD Cervical spondylosis Rheumatoid disease of cervical spine At base of neck : Cervical rib ToS

78. At axilla : Crutch palsy At arm : Tourniquett palsy Fracture of supracondylar region of humerus Hansen’s disease

79. At elbow Cubital tunnel syndrome (Most common cause) Compression of ulnar nerve along cubital tunnel at medial edge of elbow Border of cubital tunnel : Medial epicondyle Olecranon process Tendinous arch joining two heads of FCU

80. Cubitus valgus : In cubitus valgus the floor of cubital tunnel is already elevated which increases the compression on the ulnar nerve. Other causes : Ganglia at elbow Soft tissue tumor Elbow dislocation Fracture of medial epicondyle Hansens disease Typing

81. Sensory deficit : Parasthesia in palmar and dorsal aspect of little and ring finger No involvement of medial border of forearm Aggrevates when elbow is bent

82. Motor deficit : All muscles supplied by ulnar nerve affected FCU FDP (3and 4) Hypothenar muscles : ADM, ODM, FDM Adductor pollicis FPB Interossei Lumbricals ( 3 and 4)

83. At wrist Gayons canal syndrome Compression of the ulnar nerve as it passes through the canal of gayon . Border of Gayons canal Medial border - tendon of FCU and pisiform bone. Lateral borber –Hook of hamate Floor - flexor retinaculum Roof - superficial part of the flexor retinaculum

84. Other cause : Glass cut injury Fracture of the carpal bone Tumor OA

85. Sensory Deficit : Parasthesia in little finger and ulnar aspect of ring finger (Superficial sensory branch) Palmar and Dorsal sensory branch not affected No involvement of medial border of forearm

86. Motor Deficit: Weakness of ulnar intrinsic muscles of hand FCU and FDP are spared

87. Deformity Classical claw hand : ( ulnar claw hand) Hyperextension of MCP joint of ring and little finger 30 degrees Flexion of IP joint of little and ring finger PIP – 25 degree flexion DIP – 10 to 15 degree flexion if lesion at wrist  FDP intact Less flexion if proximal lesion  due to FDP affected

88. Ulnar paradox: Lesion at elbow there will be reduced DIP flexion due to FDP paralysis. Hence reduced appearance of deformity. “The closer to the Paw worse the claw” With reinnervation of the nerve flexion at DIP joint increase giving appearance of increase deformity

89. Functional Disability Lack lumbrical grip Power grip is more affected Due to weakness of adductor pollocis Lack of Pinch grip Lack of spherical grip Due to lack of lateralisation of fingers

90. Trick movements Ulnar deviation combined with wrist extension by ECU Wrist flexion combined with radial deviation by FCR Abduction of finger combined with finger extension by extensor digitorum ADM is the first muscle to recover – first sign of recovery

91. Median nerve injury

92. Lateral and medial cord of brachial plexus (C5-T1)

93. Median nerve

94. Lateral and medial cord of brachial plexus (C5-T1) Axilla to elbow : Pronator teres Palmaris longus FCR FDS Anterior interosseous nerve : FPL FDP (lateral half) Pronator quadratus Distal to wrist (recurrent branch & palmar digital branch): APB FPB OP Lumbricles (1 & 2) Sensory branch Palmar cutaneous Branch Digital cutaneous branch

95. Common neuropathies of median nerve Median neuropathy at axilla and arm Median neuropathy at elbow and forearm Median neuropathy at wrist

96. Median neuropathy at axilla and arm Cause – Axillary aneurysm Traction injury Penetrating injury

97. Sensory – Over the distribution of palmar cutaneous and digital cutaneous branch Skin overlying thenar eminence Loss of sensation over volar aspect of lateral 3 fingers upto the distal phalanx on dorsal side

98. Motor Weakness of all the muscles supplied by median nerve Pronator teres FCR Palmaris longus FPL FDS FDP (lateral half) Pronator quadratus Thenar muscles : APB, FPB, OP Lumbricles to digit 2 and 3

99. Anterior interosseous nerve syndrome Sensation – normal Motor - weakness of FPL, FDP and PQ Pain in forearm and elbow

100. Pinch sign positive

101. Median neuropathy at forearm Pronator teres syndrome Ligament of struthers syndrome

102. Pronator teres syndrome Compression of the median nerve by the fibrous band that connects superficial and deep head of pronator teres muscle. Less common than ant interosseous nerve syndrome and CTS.

103. Other Causes : Compression by bicipital aponeurosis Anomalaus fibrous band connecting pronator teres to tendinous arch of FDS Trauma Muscle hypertrophy VIC

104. Signs and symptoms- Motor : Pronator teres is spared. Rest all muscles supplied by median nerve are involved. The Pronator teres test is an indication of the syndrome—the patient reports pain when attempting to  pronate  the forearm against resistance while extending the elbow simultaneously. Sensory : Loss of sensation over first three fingers and palm

105. Ligament of struthers syndrome Compression of median nerve by lig of struthers

106. Signs and symptoms – Absence of radial pulse on full extention of forearm Weakness of pronator teres + all distal muscles supplied by median nerve Sensory – same as above

107. Median neuropathy at wrist Carpal tunnel syndrome

108. Median neuropathy at wrist Cause – Glass cut injury Carpal tunnel syndrome RA Osteophyte or callus formation Ganglion Thickening of synovium Occupaional Pregnancy Hypothyrodism Myeloma DM Hereditory pressure palsy

109. Signs and symptoms – Pain –hand and fingers Diffuse localised pain that can extend upto elbow Nocturnal parasthesia Aggravating factors – Extreme flexion and extension Relieving factors- Change in the hand position or hand shaking

110. Sensory : Affected over volar aspect of lateral 3 ½ aspect of fingers upto distal phalanx on dorsal side Sometimes the sensation over thenar area remains intact because palmar cutaneous sensory branch that arise proximal to carpal tunnel

111. 4 patterns of Sensory deficit Distal pattern (40%) Complete web space pattern Half web space pattern Distal web space pattern

112. Motor: Weakness of OP, FPB and APB Weakness of OP and FPB – pinch sign Weakness of APB – Bottel sign : The thumb cannot be adequately abducted and opposed.

113. Vasomotor changes: Swelling Colour changes Dryness Coldness

114. Muscle wasting in chronic stage

115. Functional Disability Difficulty in holding small and big objects. Clumsy activity with involved hand Can not appreciate the sensation of the object unless they see the object

116. Deformity Depends on site and extent of lesion Pinch sign/ tear drop Ape hand deformity Partial claw hand Pointing index finger

117. Pinch sign/ tear drop Fromet sign In anterior interosseous nerve syndrome When pt is asked to form tip to tip pinch using index and thumb there will be pad to pad pinch Because of paralysis of FDP and FPL Tear drop appearance instead of ‘ O ’

118. Ape hand deformity Monkey hand deformity Flattening of thenar eminence Lack of oposition of thumb so thumb is held beside index finger due to over action of Adductor Pollicis and EPL

119. Partial claw hand Unupposed action of the extensor digitorum giving rise to hyperextension of MCP joint of index and middle finger and flexion of IP joint of these finger.

120. Pointing Index Finger Higher lesion (even common flexors When asked to make fist the index finger will point forward

121. This happens because when attempt to make fist the profundus tendon of ring finger will pull the middle finger into partial flexion leaving the index finger in extension and pointing forward

122. Trick movement Radial deviation combined with wrist extension by ECR. Wrist flexion combined with ulnar deviation by FCU. Rebound phenomena : Thumb DIP joint flexion by sudden contraction and relaxation of EPL.

123. Long Thoracic Nerve Injury

124. C5-C7 Muscle supply : Serratus anterior

125. Cause : Carrying heavy weights on the shoulder or by strapping the shoulder on the operating table. Followed immunization direct blow Thoracic surgery

126. Symptoms : Shoulder pain Inability to raise the arm over the head Winging of the medial border of the scapula when the outstretched arm is pushed forward

127. Suprascapular Nerve Injury

128. C5-C6 Muscle Supply : supraspinatus and infraspinatus muscles.

129. Cause : Infectious illnesses In gymnasts or as a result of local pressure, from carrying heavy objects on the shoulder (“meat-packer’s” neuropathy). Symptoms : Vague dull and achey pain posterior shoulder Atrophy of these muscles Weakness of the first 15 degrees of abduction ( supraspinatus ) Pain and weakness on external rotation of the shoulder joint ( infraspinatus ).  This movement is similar to that used when reaching backwards to put on a seatbelt in a car.

130. Axillary Nerve Injury

131. This nerve arises from the posterior cord of the brachial plexus (mainly from the C5 root, with a smaller contribution from C6)

132. Muscle supply : teres minor and deltoid muscles Cutaneous branch : S upplies sensation to an area extending from the acromion process to halfway down the outer aspect of the upper arm. Causes of injury : Dislocations of the shoulder joint Fractures of the neck of the humerus Crutches Brachial neuritis

133. Symptoms : Paralysis of abduction of the arm (in testing this function, the angle between the side of the chest and the arm must be greater than 15 degrees and less than 90 degrees) As the deltoid atrophies, the rounded contour of the shoulder is flattened compared to the uninjured side ( Wasting of the deltoid muscle) Sensory impairment over the outer aspect of the shoulder

134. Musculocutaneous Nerve Injury

135. C5 C6 nerve roots. Branch of the lateral cord of the brachial plexus Muscle supply : Biceps brachii , Brachialis coracobrachialis

136. Cause : Fracture of the humerus . musculocutaneous nerve is rarely injured alone, but may be damaged by upper brachial plexus injury Symptoms : Wasting of these muscles Weakness of flexion of the supinated forearm. Sensation may be impaired along the radial and volar aspects of the forearm (lateral cutaneous nerve).

137. Obturator nerve injury

138. Ventral division of second, third and fourth lumbar nerves in lumbar plexus .

139. Adductor Longus Adductor brevis Gracilis Pectineus Adductor Magnus Adductor Brevis

140. Obturator nerve injury Causes : Dislocation of hip joint Pelvic fracture Hernia through obturator foramen Prolonged labor Compression of the nerve against the wall of pelvis by mass of tumor or foetus

141. Signs and Symptoms Sensory Deficits : Sensory alteration over medial aspect of thigh and knee Loss of sensation Parasthesia Pain Pain increases with stretch of nerve (extension, abduction and lateral rotation)

142. Motor Deficits: Anterior division : Adductor longus Adductor brevis Gracilis Pectinius Posterior division : -- Adductor magnus -- Adductor brevis Wasting on the medial side of thigh During ambulation thigh is abnormally abducted and externally rotated results in circumductory and wide based gait

143. Deformity Hip flexion and abduction due to overactivity of tensor fascia lata

144. Femoral nerve injury

145. Dorsal division of ventral rami of L2-L4 Largest Branch of lumbar plexus

146. Anterior Branch : Muscular Branch Cutaneous Branch Posterior Branch -- Muscular Branch -- Articular Branch

147. Anterior Branch : Pectineus Sartorius Posterior Branch : Rectus Femoris Vastus Lateralis Vastus Medialis Vastus Intermedius

148. Anterior femoral cutaneous branch Intermedial femoral cutaneous Medial femoral cutaneous Sephanous nerve

149. Causes Psoas abcess Pelvic anneurysm / neoplasm Fracture of pelvis or femur Hip dislocation Inguinal hernia Complication of spinal anesthesia Prolapse intervertebral disc Lumbar spondylosis or stenosis Neuropathy secondary to diabeties mallitus Hysterectomy Penetrating wounds over lower abdomen

150. Sensory Deficit : Anterior division : Anterior and medial aspect of thigh Saphenus nerve : Medial aspect of leg and foot Loss of sensation, Numbness, tingling, dull ache

151. Pain in the inguinal region That is relieved by hip flexion and external rotation

152. Autonomus zone : Small area superior and medial to patella Coldness Dryness

153. Motor Deficit : Anterior division : sartorius and pectineus Posterior division : rectus femoris , vastus Lateralis , Vastus medialis and vastus intermedius Difficuly in going up and down the stairs. Esp down the stairs Difficulty in walking and knee buckling depending upon severity of injury Reflex : Quadriceps jerk lost

154. Gait Gait : Quadriceps gait Hand on knee gait Trunk leans in forward flexion to extend knee at the beginning of the stance phase to lock the knee when there is quadriceps muscle weakness Use Hands to push knee into extension

155. Deformity Genu recurvatum : -- Because quadriceps is paralysed the patient will try to lock the knee into hyperextension to get the CoG well in Front of knee joint to keep it stable

156. Meralgia Parasthetica

157. Lateral Femoral Cutaneous Nerve It arises from the dorsal divisions of the L2-L3

158. It then passes under the inguinal ligament then into the thigh then divides into two branches : Anterior branch : Anterior and lateral parts of the thigh to knee. Posterior branch : Lateral and posterior surfaces of the thigh from the level of the greater trochanter to the middle of the thigh.

159. Meralgia Parasthetica Entraptment of lateral femoral cutaneous nerve of thigh beneath inguinal ligament Pure Sensory Syndrome Causes : Tight corset/ tight clothing Seat Belt Obesity Pregnancy

160. Signs and Symptoms Pain, Burning and parasthesia on lateral aspect of thigh Worsen on prolonged standing, squatting and walking Hyper sensitivity to heat Tenderness over ASIS No muscle weakness Differentiation from L3 radiculopathy and Femoral Neuropathy is very important

161. Sciatic nerve injury

162. Largest and longest nerve in human body Derived from spinal nerves L4 to S3 from sacral plexus

163. Greater trochenter Ischial Tuberosity

164. Muscular branch : Biceps femoris Semi tendinosus Semi membranosus Adductor magnus Tibial Nerve Common Peroneal Nerve Articular Branch : Hip joint

165. Causes Penetrating wound around pelvis Hip arthroplasty Trauma Fracture of pelvis and femur Hip Joint dislocation IM injection in gluteal region Infection Sitting on hard surface Compression by Neoplasm, lymphoma or foetal head Popliteal cyst

166. Sensory Deficit Complete loss of sensation below knee except saphenous nerve distribution

167. Motor deficit Weakness/ paralysis of following muscles : Biceps femoris Semimembranous Semi Tendinous Hamstring part of adductor magnus Muscles of tibial nerve – Posterior compartment of leg Muscles of common peroneal nerve – Lateral and anterior compartment of leg and foot

168. All the muscles below the knee are paralyzed, and the weight of the foot causes it to assume the plantar-flexed position, or Foot Drop. Clawing of toes with trophic ulceration Due to lack of sensation over foot

169. Gait Steppage gait : ( High stepping)  gait abnormality characterised by foot drop due to loss of dorsiflexion The foot hangs with the toes pointing down, causing the toes to scrape the ground while walking, requires to lift the leg higher than normal when walking.

170. Tibial Nerve Injury

171. Medial popliteal nerve Arise from L4-S3 of sacral plexus Larger division of sciatic nerve

172. Gastrochemius Soleus Popliteus Plantaris Tibialis Posterior FHL FDL Medial Plantar nerve Lateral Plantar nerve

173. Cutaneous Branch Medial Plantar nerve Lateral Plantar nerve Medial Calcaneal Branches

174. Causes Deep penetrating injury to knee or upper leg Dislocation of knee Tarsal tunnel syndrome Compression under flexor retinaculum

175. Tibial nerve can be affected along with sciatic nerve palsy Tibial nerve alone is affected at or below popliteal fossa

176. Sensory Deficits Sole of foot Medial aspect of heel

177. Motor Deficits Following muscles will be paralysed : Gastrocnemius Soleus Plantaris Poplitius Tibialis posterior FHL FDL Intrinsic foot muscles

178. Ankle jerk lost Plantar reflex : non elicitable

179. Deformity Talipes calcaneo valgus Dorsiflexion Eversion Abduction

180. Tarsal Tunnel Syndrome Tibial Nerve is entrapped in tarsal tunnel Formed by thick ligament flexor retinaculum covering tarsal bones

181. Following structures travel through the  tarsal tunnel : Tibial Nerve Tibialis posterior tendon Flexor hallucis longus tendon Flexor digitorum longus tendon In the tunnel, the nerve splits into : Medial plantar nerve Lateral plantar nerve

182. Signs and Symptoms Sensory deficits : Parasthesia and numbness that extend to toes and sole Heel sensation will be spared as the calcaneal branch arise proximal to tarsal tunnel

183. Pain : Perimalleolar pain, Increased with Weight bearing Pain increases at night Motor Deficits : Involves weakness of the muscles that passes through tarsal tunnel Weakness of intrinsic foot muscles Ankle jerk - Normal

184. Common Peroneal Nerve Injury

185. Arise from L4-S2 root Lateral Popliteal Nerve Common fibular Nerve Superficial peroneal nerve Deep peroneal nerve

186. Deep Peroneal Nerva

187. Sensory Branches : Lateral sural cutaneous nerve Superficial peroneal nerve Deep peroneal nerve

188. Causes Compression of the nerve by tight plastar or splint Fracture of neck of fibula/ head of fibula Hansens disease Trauma to knee- damage to fibular collateral ligament Entrapped by fibrous arch as it winds around the neck of fibula Prolonged immobilisation during which leg rest in ext rotation Habitual crossing of legs

189. Sensory Deficits Sensaory deficit is seen over the cutaneous distribution of following nerve Lateral sural cutaneous nerve Superficial peroneal nerve Deep peroneal nerve

190. Deep peroneal nerve palsy Web space between great toe and second toe Superficial peroneal nerve palsy Anterior and lateral aspect of leg Dorsum of foot and toe except the web space area between great toe and second toe

191. Motor deficits Superficial peroneal nerve palsy : Tibialis Anterior EHL EDL EDB Deep peroneal nerve palsy : Peroneous Longus Peroneous Brevis

192. Deformity Equino Varus Deformity Due to over activity of posterior comartment of muscles and invertors Plantarflexed and Inverted Foot Drop Deformity

193. Gait Steppage gait Slapping gait ( each step makes a slapping noise) High stepping Gait Toes drag while walking