injuries of the lower extremity下肢神经损伤（ppt39）课件

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 L5, S1, S2,Clinical Principles,Detecting subtle weakness Get up from squat Quadriceps Stand on tip toes Gastrocnemius/Soleus Stand on heels Tibialis Anterior,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),CASE 1,History,20 yo college student involved in an MVA She suffers multiple pelvic fractures She complains of weakness and numbness of the right leg,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,SENSORY LOSS,Localization,Finding Muscle Nerve 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,Common Fibular (Peroneal) Nerve,Common Fib Deep Fib Superficial Fib Per Longus Tib Ant Per Brevis EHL Per Tertius EDB,SENSORY LOSS IN A DEEP PERONEAL (FIBULAR) NEUROPATHY,Final Diagnosis,Sciatic neuropathy with selective involvement of the fibular (peroneal) nerve fibers at the level of the pelvis,CASE 2,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 cant find time to exercise,Exam,He has normal strength in all muscles of his leg Reflexes are normal,SENSORY LOSS,Localization,Finding Muscle Nerve Root Sens loss - - Lat fem L2 cut,Final diagnosis,Lateral femoral cutaneous neuropathy (AKA: Meralgia Parasthetica),CASE 3,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,Exam,He has weakness of: Foot plantar flexion Foot inversion Toe flexion Strength is normal in: Knee flexion Foot dorsiflexion Foot eversion,SENSORY LOSS,Exam,Finding Muscle PN Root 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),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,Final Diagnosis,Tibial neuropathy at the popliteal fossa,CASE 4,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,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,SENSORY LOSS,Localization,Finding Muscle PN Root 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,Femoral nerve,Psoas Iliacus Sartorius Pectinius Rectus Femoris Vastus Lat Vastus inter Vastus Med,Final Diagnosis,Femoral Neuropathy Related to Diabetes Mellitus,CASE 5,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,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,Localization,Finding Muscle PN Root 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,Final diagnosis,S1 radiculopathy related to a herniated disc (“Sciatica”),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 (pe