Lower Limb

NL04The sciatic nerve supplies all EXCEPT:

A. Biceps femoris
B. Semimembranosus
C. Gluteus maximus inferior gluteal nerve, L5 S12 (muscular collateral branch of sacral plexus)
D. Adductor magnus the only adductor it supplies (rest obturator)
E. Semitendinosus
E&F 196
SCIATIC NERVE
In reality made up of common peroneal and tibial nerves
Leaves the posterior pelvic wall through the greater sciatic foramen (sacro spinous ligament is the lower border of the GSF) below
piriformis and enters the region of the buttock just medial to the half-way point between the ischial tuberosity and the greater
trochanter. The nerve then descends vertically down the mid line of the back of the leg as far as the apex of the popliteal fossa.

Branches:
1. Muscular
a. semitendinosus
b. semimembranosus
c. Adductor Magnus (rest of adductors are supplied by obturator)
d. biceps femoris
2. Articular
a. Hip joint
3. Terminal
a. Common peroneal
b. tibial

NL12 [ou] (type A) The sciatic nerve:

A. Sensory supply (whole) of the lower limb below the knee except for saphenous nerve distribution (femoral)
B. From dorsal division of anterior rami of L5-S3 (And It was L5-S3 , NOT L4-S3) L4,5 S1,2,3. II
think this implies that the posterior rami are still cutaneous, as they are in the thoracolumbar region. It also implies that the anterior rami
divide into dorsal and ventral divisions, much like in the brachial plexus.
C. Supply sensory input for knee joint articular supply to knee is posterior division of femoral nerve, and articular
division of common peroneal and posterior tibial). While not technically the sciatic nerve, Hiltons law states that there should be articular
branches, since the hamstring flexes the knee.
D. Reliably located using paraesthesia during nerve block not a sensory nerve in itself, but terminal branches are
E. Has common peroneal, posterior tibial & obturator branches not obturator (L234 branch of lumbar plexus)

NL13 [o] Common peroneal nerve:

B. Branch of sciatic nerve along with tibial nerve
NL14 [p] Common peroneal nerve:
A. Supplies biceps femoris supplied by a direct branch of the sciatic nerve
B. Forms lateral plantar nerve a branch of the tibial nerve, along with medial plantar nerve- blocked between medial
malleolus and calcaneus
C. Passes between tibia & fibula divides before this point usually
D. Supplies dorsiflexors of foot supplies terminal branches that do (deep peroneal nerves) best answer

COMMON PERONEAL NERVE:

One of the two terminal branches of the sciatic nerve

Half the diameter of the tibial nerve
Originates at the apex of the popliteal fossa, runs obliquely along the medial border of biceps femoris, then continues lateral to the lateral
head of gastrocnemius. It then winds around the neck of the fibula deep to peroneus longus

Branches are:
1. cutaneous
a. sural communicating arises in the popliteal fossa and crosses lateral gastroc to join sural nerve
b. lateral cutaneous nerve of calf supplies skin over the anterolateral and posterolateral upper calf
2. articular
a. to the knee
3. terminal
a. deep peroneal (anterior tibial)
b. superficial peroneal
DEEP PERONEAL NERVE
Mainly a motor nerve
Originates from the common peroneal nerve between the fibular head and peroneus longus
Goes deep to extensor digitorum longus and runs along the interosseous membrane

Branches are:
1. muscular
a. tibialis anterior (dorsiflexion)
b.

extensor hallucis longus

c. extensor digitorum longus
d. peroneus tertius
2. articular
a. ankle joint
3. terminal
a. medial first web space sensory(accompanies dorsalis pedis on its lateral side, blocked by ankle block)
b. Lateral motor to extensor digitorum brevis and articular to foot joints.

SUPERFICIAL PERONEAL NERVE

Runs between peroneus longus and extensor digitorum longus

Branches:
1. muscular
a. peroneus longus (evertors)
b. peroneus brevis
2. cutaneous
a. lower outer aspect of the leg
3. terminal branches
 a. medial supplies sensation to the medial aspect of the dorsum of the foot and toes (lateral 2nd and medial 3rd
toes) second web space
b. lateral supplies sensation to the lateral aspect of the dorsum of the foot and toes (lateral 3 rd , 4th and medial 5th
toes)

NL15 [u] Which nerve is NOT from L2? See diag below
A. Femoral L2.3.4
B. Obturator L2.3.4
C. Genitofemoral L1.2
D. Lateral cutaneous nerve of the thigh L2.3
E. Ilioinguinal nerve L1, along with iliohypogastric (superficial to ilioinguinal) Rob Franz and the inguinal hernia

LUMBAR PLEXUS

Made up of anterior primary rami of the L1-L4, some individuals also receive contribution from T12 and L5
Relationship of lumbar plexus nerves to iliopsoas important obturator is medial, genitofemoral pierces it from behind, and the rest
emerge seratim (in series) from its lateral border.

Branches of the lumbar plexus

The 3 nerves that emerge from the lateral border of the psoas major muscle are: the iliohypogastric nerve, the ilioinguinal nerve
and the lateral femoral cutaneous nerve.
The femoral nerve emerges between the psoas major and the iliacus muscles
The genitofemoral nerve emerges anterior to the psoas major muscle (pierces the psoas major)
The obturator nerve and the lumbosacral trunk emerge medial to the psoas major muscle

NL01 The femoral nerve:

A. Includes fibers from the posterior divisions of the lumbar nerves Posterior divistions see
yellow diagram above (both femoral & obturator are posterior divisions).
B. Leaves the pelvis through the femoral ring outside the femoral sheath
C. Supplies the area of skin over the knee via intermediate femoral cutaneous nerve
D. Includes fibers from the upper sacral nerves L234

NL02 The femoral nerve:

A. Is derived from upper sacral roots L234
B. Passes out through the femoral canal -
C. Has a cutaneous branch passing over the knee joint
D. Supplies sensation to all the anterior and lateral aspects of the thigh lateral cutaneous
nerve supplies lateral thigh, femoral supplies anterior cutaneous and medial cutaneous. Posterior cutaneous is a branch of the sacral
plexus.

NL03 [#b] The saphenous nerve:

A. Accompanies the saphenous vein in the thigh
B. Comes off the obturator nerve off the femoral
C. Supplies the medial side of the foot
D. Supplies the medial side of the calf
E. Sends a branch to the scrotum

NL04 [@b] The sciatic nerve supplies all EXCEPT:

A. Biceps femoris - true
B. Semimembranosus - true
C. Gluteus maximus supplied by the inferior gluteal nerve a direct collateral branch off the sacral plexus.
The superior gluteal nerve supplies gluteus medius and minimis
D. Adductor magnus - true
E. Semitendinosus - true

NL05 S2 to S4:
A. Supplies upper inner third of thigh
B. Medial to nerve to obturator internus
C. ?
D. ?

NL06 [#] L4 nerve root:

A. Supplies the flexors of the hip - Yes, via femoral nerve
B. The posterior ramus supplies the skin over the buttock no S3-5
C. Supplies the skin of the big toe no, S2
D. Dorsal division of ventral ramus supplies obturator nerve no, anterior

NL07 [:] Sciatic nerve is located midway between the greater trochanter and:
A. Sacral hiatus
B. Ischial tuberosity just medial to the mid point
C. Anus
D. Coccyx
E. ? ischial spine

NL08 [:] Sural nerve:

A. Branch of the posterior tibial nerve branches high
B. Supplies anterior 2/3 of sole supplies lateral foot and 5th toe
C. Crosses lateral malleolus anteriorly crosses posterior to the lateral malleolus
D. Accompany short saphenous vein to foot
E. Supplies all small muscles of foot most small muscles of the foot are supplied by the lateral plantar, except for
the first lumbrical and a couple of thenar muscles which are supplied by the medial plantar. Remember to put the hand on the foot

NL09 [+] Sural nerve:

A. Is a cutaneous nerve
B. Formed from branches of posterior tibial & common peroneal nerves true, via the sural
communicating nerve
C. Accompanies the short saphenous vein behind the lateral malleolus becomes
subcutaneous distal to the middle of the leg and proceeds along witht eh short
saphenous vein behind and below the lateral malleolus to supply the lower
posteriolateral surface of the leg, the lateral side of the foot, and the lateral part of
the fifth toe.
D. Subcutaneous in middle leg
E. Supplies the lateral calf lower lateral calf
F. Supplies all small muscles of the foot cutaneous only

NL10 [>] Dermatomes supplying the outer foot & heel:

A. L4, L5
B. S1, S2
C. ?
D. ?

NL11 [d] Nerves that supply the skin immediately below the inguinal ligament:
A. Genitofemoral n.
B. Subcostal n.
C. Ilioinguinal n.
D. Iliohypogastric n.

NL12 [o] (type A) The sciatic nerve:

A. Sensory supply (whole) of the lower limb below the knee except the saphenous distribution
(posterior division of the femoral)
B. From dorsal division of anterior rami of L5-S3 (And It was L5-S3 , NOT L4-S3)
Im not sure if the sacral plexus is made up of dorsal and ventral divisions?
C. Supply sensory input for knee joint
D. Reliably located using paraethesia during nerve block
E. Has common peroneal, posterior tibial & obturator branches

NL13 [o] Common peroneal nerve:

A. Supplies . . . ?
B. Branch of sciatic n
C. ?? . . tibia & fibula
D. ?

NL14 [p] Common peroneal nerve:

A. Supplies biceps femoris sciatic
B. Forms lateral plantar nerve tibial nerve
C. ?Passes between tibia & fibula
D. Supplies dorsiflexors of foot

TIBIAL NERVE
Originates at the apex (femoral side) of the popliteal fossa, along with the common peroneal nerve.

Branches in the POPLITEAL FOSSA

Muscular
Popliteus
Gastrocnemius
Soleus
Plantaris
Cutaneous
The sural nerve (see below)
Articular
Knee

Branches in the CALF AND FOOT

Muscular
Tibialis posterior
Flexor digitorum longus
Flexor hallucis longus (tom dick and harry)
Soleus dual nerve supply from the tibial nerve
Cutaneous
Medial calcaneal nerve supplies skin over the medial side of the sole of the foot
Articular
To the ankle joint
Terminal
Lateral plantar nerve
medial plantar nerve larger than the lateral

MEDIAL PLANTAR NERVE

Supply is analogous to the median nerve in the hand
Supplies the first lumbrical
Muscular to
Abductor hallicus
Flexor digitorum brevis
Flexor hallucis brevis
Cutaneous
Medial of the sole of the foot and the plantar aspect of the medial 3 toes

LATERAL PLANTAR NERVE

Resembles the ulnar nerve of the hand
Muscular
All the interossei
Lumbricals 234
Adductor hallucis
Flexor digiti minimi brevis
Flexor accessorius
Abductor digiti minimi
(i.e. all the muscles of the sole of the foot not innervated by the medial plantar nerve
cutaneous
lateral of the sole of the foot and the plantar aspect of the lateral 1 toes.

Consider the foot as the hand in the non anatomical position, palm down, and the analogy between the medial plantar and median nerves
is good. Median normally supplies the lateral 2 lumbricals (first and second), and the medial plantar supplies the first lumbrical.
SURAL NERVE (L5,S12) branch of the tibial
Receives the sural communicating branch of the common peroneal
Descends behind the lateral malleolus and runs along the lateral side of the foot to the 5 th toe
Supplies the posterolateral part of the lower third of the calf, as well as the lateral side of the foot and the 5 th toe.

Lower Limb

RL01 For a skin graft to the anterolateral aspect of the thigh you would block:
A. 2 f-breadths medial and above the anterior superior iliac spine
B. 2 f-breadths medial and below the anterior superior iliac spine 2 cm inferomedial to the ASIS (similar to
where the ilioinguinal nerve is blocked)
C. 2cms ?lateral?medial to the femoral artery
D. Caudal to L5
E. At the internal inguinal ring

RL02 For the taking of a skin graft on the lateral aspect of the thigh, it is necessary to block:
A. Femoral nerve
B. Sciatic nerve
C. A 2" line along the tope of the iliac crest anteriorly
D. At a point 1/2 - 1" medial to the anterior superior iliac spine
E. ?

RL03 For a lesion in the knee joint, one may perform:

A. Long saphenous nerve block
B. Obturator and sciatic nerve blocks
C. Femoral nerve block
D. Block of femoral and lateral cutaneous nerve of thigh
RL04 For satisfactory operating conditions on the knee which of the following is satisfactory?
A. Femoral and obturator nerve blocks
B. Saddle block
C. Femoral and sciatic nerve blocks would also need saphenous, obturator and lateral cutaneous
D. Epidural block to L2
E. Sciatic and obturator nerve blocks

RL07 [<] Resection of the great toe nail bed. Anaesthesia by blocking:
1. Superficial peroneal n
2. Sciatic n. most correct?
3. Femoral n.
4. Digital nerves

RL08 [@] A sciatic nerve block gives paraesthesia to:

A. All of the toes
B. Around the ankle - except distribution of saphenous
C. All of the sole of the foot
D. Medial side of the lower leg - saphenous
(see also NL04, NL07)

RL09 [=+>c] Anaesthesia for amputation of great and second toes requires block of:-
A. Saphenous n.
B. Posterior tibial n.
C. Deep peroneal n.
D. Sural nerve little toe and lateral foot branch of the tibial. Tibial nerve supplies all of the sole of the foot, peroneal nerve
supplies all of the dorsum (except the distibution of the saphenous)
RL05 [s] (type A) Effective local anaesthesia for removal of a skin lesion from the medial aspect
of the midcalf would require blockade of:
A. Sciatic nerve
B. Femoral nerve
C. Obturator nerve
D. Saphenous nerve
E. Posterior medial (something) nerve
SAPHENOUS NERVE
Largest cutaneous branch of the femoral nerve and the only cutaneous branch to cross the knee joint. Other cutaneous branches
include intermediate and medial cutaneous nerves of the thigh. It arises in the femoral triangle from the posterior division of the femoral
nerve, and descends the leg with the femoral artery on its lateral side, goes through the canal of Hunter and emerges between sartorius
and gracilis. It then runs down the medial border of the tibia, crosses with the vein in front of the medial malleolus and reaches as far as
the base of the big toe. Supplies an extensive cutaneous area over the medial side of the knee, leg, ankle and foot.

n.b lateral aspect of the mid calf would require block of lateral cutaneous nerve of the calf, which is a cutaneous branch of the common
peroneal nerve.

RL05 [2001-Apr] MCQ-95 [2001-Sep] MCQ-99 and [2002-Mar] MCQ-109

Regional analgesia for the excision of a skin lesion on the medial side of the mid-calf can be
obtained by
1. sciatic nerve block everywhere BUT the medial aspect of the calf (saphenous br of femoral)
2. Caudal epidural block reaching L5 (L3,4 required)
3. Obturator nerve block reaches the knee joint, but not distal to this
4. Femoral nerve block
 ALL OF THE MAJOR BRANCHES OF
THE LUMBAR PLEXUS HAVE ANTERIOR AND POSTERIOR BRANCHES
FEMORAL NERVE
Dorsal division of L234 (ventral division is obturator)
Other dorsal division is lateral femoral cutaneous nerve (L23)
Largest nerve of the lumbar plexus
Supplies the muscles and skin of the anterior thigh
Emerges in the lateral margin of psoas (between psoas and iliacus)
Passes under the inguinal ligament between iliacus and psoas
Breaks into terminal branches within the femoral triangle, stemming from an anterior and a posterior division.

Anterior division Mainly cutaneous

1. muscular branches
a. pectineus
b. sartorius
2. cutaneous branches
a. intermediate cutaneous nerve of the thigh divides into 2 branches that supply the anterior part of the thigh
down to the knee (c.f lateral femoral cutaneous nerve of the lumbar plexus posterior femoral cutaneous is a
collateral branch of the sacral plexus S123)
b. medial femoral cutaneous nerve of the thigh
Posterior division mainly motor
1. muscular branches to quadriceps femoris
2. cutaneous branch saphenous nerve
3. articular branches to hip and knee

OBTURATOR NERVE (L2-4) adductors (look for this twitch on femoral nerve block)
Emerges from the medial border of psoas at the pelvic brim, which it crosses in its downward and forward passage to the obturator canal
(the hole between pubic rami). In this course it passes along the side wall of the pelvis, lateral to the internal iliac vessels and the ureter. It
enters the obturator canal above and anterior to the obturator vessels which are derived from the internal iliacus.
Within the canal, the nerve divides into its anterior and posterior branches.

Anterior branch: Passes into the thigh above obturator externus, descends on adductor brevis to end as a filament which runs along the
femoral artery.
Supplies adductor longus
Gracilis
Adductor brevis (usually)
Articular branch to the hip
Posterior branch: pierces and supplies obturator externus. It descends on adductor magnus behind adductor brevis, which separates it
from the anterior branch of the obturator nerve. Then it descends along the adductor canal to the popliteal fossa, to supply the knee joint.
Supplies adductor magnus (also receives a supply from the sciatic)
Adductor brevis (if not supplied by the anterior branch).

RL05b [r] What dermatome to block for lesion removal on medial aspect of calf?
A. L3 see posterior view
B. L4
C. L5
D. S1
RL06 [q] The medial side of the foot/lower leg can be blocked by:
A. Saphenous nerve block can be blocked subcutaneously either between superior to the medial malleolus from the mid line to
the medial malleolus, or on the anteromedial surface of the tibial tuberosity. Best answer
B. Femoral nerve block
C. Sacral block of L5
RL10 [jr] (type A) For femoral hernia repair under regional need all of the following
blocked EXCEPT:
A. Ilioinguinal.
B. Iliohypoglossal. no such nerve (could this be iliohypogastric?)
C. Femoral
D. Genitofemoral
E. Cutaneous branches of T11 & T12.