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Lower limb Entrapment Lower limb Entrapment SyndromesSyndromes
Dr Andre VlokDr Andre Vlok
Orthopaedic DepartmentOrthopaedic Department
Kalafong hospitalKalafong hospital
20122012
Compression neuropathiesCompression neuropathies
• Normal nerves are subjected to both stretching Normal nerves are subjected to both stretching and compression, but when the norms, and compression, but when the norms, excursion is restricted or there is persistent excursion is restricted or there is persistent compression, irritation of the nerve follows with compression, irritation of the nerve follows with eventual altered microcirculation and fibrosis.eventual altered microcirculation and fibrosis.
• This all leads to impaired nerve conductionThis all leads to impaired nerve conduction
• There are certain anatomic areas where nerve There are certain anatomic areas where nerve are more valuable to compression.are more valuable to compression.
Areas where nerves are at riskAreas where nerves are at riskWhere a nerve goes through a “Where a nerve goes through a “tunneltunnel" or potential " or potential
tunnel ( muscle arch). Not confined to this eg tumor or tunnel ( muscle arch). Not confined to this eg tumor or fracturefractureTunnel too smallTunnel too small – osteophytes, displaced fractures or – osteophytes, displaced fractures or
dislocations.dislocations.Contents too much for tunnelContents too much for tunnel – synovitis, ganglion, – synovitis, ganglion,
aneurysm or tumor etc.aneurysm or tumor etc.Nerve up against bone: Peroneal or ulnar nerve.Nerve up against bone: Peroneal or ulnar nerve.Fluid retention: pregnancy, renal failure, obesityFluid retention: pregnancy, renal failure, obesityDouble crush syndromeDouble crush syndrome
Compression syndromesCompression syndromes
Compression of a Compression of a peripheral nerve once peripheral nerve once it has left the spinal it has left the spinal canal. canal.
Can be compressed Can be compressed by any structure by any structure internally or internally or externally.externally.
In many cases no In many cases no cause is foundcause is found
Double crush syndromeDouble crush syndrome
Nerve compressed in Nerve compressed in more than one place more than one place making it more making it more sensitive to sensitive to compression in another compression in another area.area.
Carpal tunnel and Carpal tunnel and cervical disc lesion.cervical disc lesion.
Principles of nerve compressionPrinciples of nerve compressionClinical picture will Clinical picture will depend on the nervedepend on the nerve involved. involved.Sx are usually progressive if the cause is not addressedSx are usually progressive if the cause is not addressedNeurological fall out: Neurological fall out:
Sensory lossSensory lossMotor lossMotor lossMixed – motor and sensoryMixed – motor and sensoryReflexes may be decreased or absent.Reflexes may be decreased or absent.Features of LMN lesion – muscle wasting, decreased tone and Features of LMN lesion – muscle wasting, decreased tone and
reflexes as well as muscle atrophy.reflexes as well as muscle atrophy.Signs elicited by provocative tests - Tinnel (stretching of nerve)Signs elicited by provocative tests - Tinnel (stretching of nerve)EMG - can be helpful in some cases only.EMG - can be helpful in some cases only.
Principles of nerve compressionPrinciples of nerve compression
Always look for proximal causes – spine or Always look for proximal causes – spine or hip etc. (Double crush)hip etc. (Double crush)
Associated Associated systemicsystemic pathology – DM, pathology – DM, alcoholism, hypothyroidism, renal failure.alcoholism, hypothyroidism, renal failure.
VascularVascular disorders can simulate nerve disorders can simulate nerve compressions.compressions.
Usually Usually chronic disorderchronic disorder but may be due but may be due acute injury – Sciatic nerve compression acute injury – Sciatic nerve compression associated with hip dislocation.associated with hip dislocation.
Presenting features: HISTORYPresenting features: HISTORY
Sensory: numbness, tingling and Sensory: numbness, tingling and sometimes burning sensation in sometimes burning sensation in distribution of nervedistribution of nerve
Motor: weakness to paralysis. Hx of Motor: weakness to paralysis. Hx of stumbling, giving away or clumsinessstumbling, giving away or clumsiness
Sx: may fluctuate but condition is usually Sx: may fluctuate but condition is usually progressiveprogressive
Presenting features: CLINICAL FxPresenting features: CLINICAL Fx
Skin: dry/paleSkin: dry/paleSensory lossSensory lossMuscle weaknessMuscle weaknessDecreased reflexesDecreased reflexes
Features of a LMNFeatures of a LMN
Nerve compressions in the lower limbNerve compressions in the lower limb
Not as common as in upper limb.Not as common as in upper limb.Meralgia paraestheticaMeralgia paraesthetica – LCNT – LCNTFemoral nerve *Femoral nerve *Peroneal nervePeroneal nerve – Common, Deep or – Common, Deep or
SuperficialSuperficialTibial nerveTibial nerve – Tarsal syndrome. – Tarsal syndrome.Sciatic nerveSciatic nerve – Piriformis syndrome. – Piriformis syndrome.11stst branch of lateral plantar nerve branch of lateral plantar nerveSaphenous nerve *Saphenous nerve *(* rare)(* rare)
Lateral Cutaneous nerve of the thighLateral Cutaneous nerve of the thigh(Meralgia Paraesthetica)(Meralgia Paraesthetica)
Entrapment of LCNT by the Entrapment of LCNT by the inguinal ligament & fascia.inguinal ligament & fascia.
Common ++Common ++Associated with: Associated with: obesity,obesity,
pregnancy, trauma (seat belt), pregnancy, trauma (seat belt), surgery to the area, belt.surgery to the area, belt.
Burning sensation in Burning sensation in distribution of nerve – lat distribution of nerve – lat aspect of thigh. Numbness.aspect of thigh. Numbness.
Extension > SxExtension > Sx
TreatmentTreatment
Conservative:Conservative:Diagnostic test – Diagnostic test –
infiltration of the area with infiltration of the area with lignocaine and cortisone. lignocaine and cortisone. If Sx abate then If Sx abate then diagnostic (and Rx).diagnostic (and Rx).
NSAIDS, NeurontinNSAIDS, NeurontinMost resolve after 2-3 Most resolve after 2-3
months.months.Surgery if Sx persist - cut Surgery if Sx persist - cut
tunnel opentunnel open
Peroneal nerve syndromesPeroneal nerve syndromes3 patterns found:3 patterns found:
Common peronealCommon peronealDeep PeronealDeep PeronealSuperfical Peroneal Superfical Peroneal
Lesion affects gait - Drop foot gait, Lesion affects gait - Drop foot gait, <eversion of foot or both<eversion of foot or both
Pain and paraesthesia and weakness. Pain and paraesthesia and weakness. Pain is not prominent. Pain is not prominent.
Causes:Causes:Fracture fibula neck / tumor / Fracture fibula neck / tumor /
osteophytesosteophytesCompression – caliper, POP, Compression – caliper, POP,
position of leg – in OR, ward or position of leg – in OR, ward or traction.traction.
Strawberry pickers kneeStrawberry pickers knee
Common PeronealCommon Peroneal
Compressed at fibular tunnel.Compressed at fibular tunnel. Pain, (usually not significant) and Pain, (usually not significant) and
weakness of lower legweakness of lower leg Tinnel over the nerveTinnel over the nerve Loss of power to all anterior and peroneal Loss of power to all anterior and peroneal
compartments (TA, EHL, EDL, PL, PB, PT)compartments (TA, EHL, EDL, PL, PB, PT) DROP FOOT and cannot evert foot or DROP FOOT and cannot evert foot or
extend toes.extend toes.
Drop footDrop foot
Splint Drop foot
Deep Peroneal nerveDeep Peroneal nerveSensory: loss of sensation on Sensory: loss of sensation on
dorsum of foot between big toe and dorsum of foot between big toe and second toe.second toe.
Pain in foot and particularly with Pain in foot and particularly with activities and sportactivities and sport
Deep Peroneal lesionPeroneal lesion
Motor fallout not common.
If present:They can evert foot
but cannot extend toes, no TA function - very weak dorsiflexion.
If distal lesion then no weakness found.
Superficial Peroneal nervePeroneal nerveSuperficial peronealSuperficial peronealMotor fall out is rare.Motor fall out is rare.Cannot evert foot but can Cannot evert foot but can
dorsiflexion foot and extend toes dorsiflexion foot and extend toes (deep peroneal n. intact)(deep peroneal n. intact)
Loss of sensation on dorsum of foot Loss of sensation on dorsum of foot - sometimes pain.- sometimes pain.
Running, walking and squatting Running, walking and squatting aggregates sx.aggregates sx.
Treatment Treatment Conservative:Conservative:
remove cause if one found.remove cause if one found.Drop foot splint to prevent Drop foot splint to prevent equinus.equinus.
NSAID & analgesiaNSAID & analgesia
If improving continue monitoringIf improving continue monitoring
Surgery:Surgery:After 3-4 months failed After 3-4 months failed
conservative treatmentconservative treatment
Surgical optionsSurgical options Release of compressing Release of compressing
structures.structures. If no nerve recovery then If no nerve recovery then
tendon transfers or tendon transfers or fusionsfusions of certain joints can of certain joints can be done to improve function. be done to improve function.
Objectives of treatmentObjectives of treatment
• Relieve compressionRelieve compression
• Monitor recovery of nerveMonitor recovery of nerve
• Keep and maintain the Keep and maintain the plantegrade position of the plantegrade position of the footfoot
• SplintingSplinting
• Tendon transferTendon transfer
• Fusion of ankle - footFusion of ankle - foot
Tibial nerve SyndromesTibial nerve Syndromes
There is a fibro-osseous There is a fibro-osseous tunnel with N A Vtunnel with N A V
Nerve divides into divisions Nerve divides into divisions in the tunnel:in the tunnel:Med and Lat plantar nervesMed and Lat plantar nervesCalcaneal branchesCalcaneal branches11stst branch of lat. Plantar n. branch of lat. Plantar n.
Causes:Causes:Trauma – ankle#Trauma – ankle#Rheumatoid arhtritisRheumatoid arhtritisTight fitting shoesTight fitting shoes
Tibial nerve syndrome cont.Tibial nerve syndrome cont.
Vague paraesthesia Vague paraesthesia over plantar surface of over plantar surface of foot.foot.
Pain over sole of foot.Pain over sole of foot.Sx worse at night and Sx worse at night and
standingstandingAtrophy of abductor Atrophy of abductor
hallucis.hallucis.Dorsiflexion – eversion Dorsiflexion – eversion
test can precipitate Sx.test can precipitate Sx.
Dorsiflexion - eversion
TreatmentTreatment
Conservative:Conservative:Splint or POP (below – Splint or POP (below – knee cast) 3 to 4 weeks.knee cast) 3 to 4 weeks.
NSAIDS and analgesia.NSAIDS and analgesia.
Surgery;Surgery;Only considered after Only considered after conservative treatment has conservative treatment has failed.failed.
Tunnel is decompressed.Tunnel is decompressed.
11stst branch of Lat. Plantar nerve. branch of Lat. Plantar nerve.
Known as Baxter’s n.Known as Baxter’s n.Medial heel pain and Medial heel pain and
referred pain lat. aspect referred pain lat. aspect of foot.of foot.
15% caused by plantar 15% caused by plantar fasciitis. fasciitis.
Cause of heel pain in Cause of heel pain in 20% of patients.20% of patients.
Sx similar to plantar Sx similar to plantar fasciitis fasciitis
Baxter’s nerve
Piriformis syndromePiriformis syndrome
Irritation of the sciatic Irritation of the sciatic nerve.nerve.
Pain or paraesthesia Pain or paraesthesia down posterior aspect of down posterior aspect of leg – Sciatica. If severe leg – Sciatica. If severe may also have may also have weakness.weakness.
All motor function below All motor function below the knee – not all the knee – not all sensory function.sensory function.
Exclude diagnosisExclude diagnosis