Spinal nerves are nerves connected to the spinal cord by the trunk, limbs, and spinal cord, with a total of 31 pairs, including 8 pairs of cervical nerves, 12 pairs of thoracic nerves, 5 pairs of lumbar nerves, 5 pairs of sacral nerves and 1 pair of tail nerves. Each pair of spinal nerves is connected to the anterior root and posterior root on both sides of the spinal cord. Travel inside the spinal canal to the corresponding foramen and converge near that foramen. The posterior root has an oval enlarged spinal ganglion near the intervertebral foramen, which contains the cell bodies of pseudounipolar neurons (sensory neurons) that are clustered and their surrounding protrusions are distributed in the body and internal organs to become sensory nerve endings. The central process is formed and then rooted into the spinal cord and is sensory. The anterior root is mainly composed of motor nerve fibers (somatic, visceral) emitted by the anterior horn of the spinal cord and the lateral horn (motor neurons), which are motorized, so the spinal nerves are mixed nerves.
The spinal nerve contains 4 fibrous components:
(1) Somatic motor fibers: starting from the anterior horn motor cells of the gray matter of the spinal cord, rooting into the spinal nerve through the anterior root, innervating the movement of skeletal muscles.
(2) Somatic sensory fibers: pseudounipolar cells originating from spinal ganglia, in which the central process waits for the root to enter the spinal cord, and the peripheral process adds to the spinal nerve to conduct the sensation of skin, skeletal muscle, joints and ligaments.
(3) Visceral motor fibers: cells originating from the lateral column of the thoracic 1 to thracic 3 spinal cord, through the anterior root and white matter communication branch, or to the corresponding paravertebral ganglia, where neurons are exchanged; or only through the corresponding paravertebral ganglion to other paravertebral ganglia or anterior ganglia, the neurons are exchanged. The postganglionic fibers emitted from the paravertebral ganglia pass through the gray matter communication branch to the spinal nerve, and along with this nerve and its branches, are distributed in the vasculature, glands and smooth muscles. Parasympathetic fibers emitted from the sacral 2 to 4 spinal cord nodes pass through the pelvic visceral nerves to the pelvic plexus, and then distribute to the pelvic organs and part of the colon, and then exchange neurons within the organs.
(4) Visceral sensory fibers: pseudounipolar cells from the spinal ganglia, whose peripheral processes or walk with the spinal nerves, or through the white matter communication branch, through the sympathetic trunk ganglion, do not exchange neurons within the ganglion, and are directly distributed in the internal organs. The spinal nerve of the central process is rooted in the spinal cord and can form a reflex arc of the nerve fibers efferent from the body or internal organs.
In the intervertebral foramen, the front of the spinal nerve is the intervertebral disc and vertebral body, and the posterior is the arthrophyllal joint and the yellow ligament, so the lesions of the intervertebral disc, the vertebral body, the joint joint and the yellow ligament, as well as other structures in the foramen can affect the corresponding spinal nerve and cause sensory and motor disorders.
The spinal nerve trunk is very short and is divided into 4 branches after the foramen:
(1) The anterior branch is large and distributed in the muscles and skin of the anterolateral part of the trunk and limbs. Most of the anterior branches are first intertwined into clusters, and then branched out from the plexus to the corresponding areas (only the anterior branches of the thoracic 2 to 11 nerves remain distinctly segmental). The anterior branches of the spinal nerve form the left and right symmetrical cervical plexuses, brachial plexuses, lumbar plexuses, and sacral plexuses.
(2) The posterior branch (posterior branch) is slender and short, and its distribution has obvious segmentality, which is distributed in the muscles and skin of the dorsal part of the neck. The posterior branch of the C1 nerve is called the subopcipcipital nerve, which is distributed in the deep muscle of the neck; the posterior branch of the C2 nerve is the large occipital nerve, which is distributed in the skin of the occipital part; and the lateral branch of the L1-3 and S1-3 posterior branches are distributed on the skin of the upper and lower buttocks, respectively, that is, the gluteal epithelial nerve and the gluteal median cortex nerve. S4-5 and the posterior branch of the caudal nerve, distributed in the skin around the coccyx.
(3) The meningeal branch is small, returns to the spinal canal through the intervertebral foramen, and is distributed in the paravetum, periosteum, intervertebral discs and ligaments of the spinal cord. The meningal branches of the upper 3 pairs of spinal nerves are also distributed in the dura mater of the posterior fossa.
(4) Communicating branches are small and connected between the spinal nerve and the sympathetic trunk ganglia.
The segmental distribution of spinal nerves refers to the structure of a pair of spinal nerves distributed in their corresponding solitary segments. In the early embryo, in addition to the head, there are pairs of sonods on the dorsal side of the embryonic body, from which the solitus derives muscle segments and dermatomes, etc.; each pair of sonostals has a corresponding pair of spinal nerve distribution. However, in embryogenesis, the segments of the limbs occur, and due to the migration and recombination of the muscle segments, the segmental distribution of the spinal nerve segments of the adult limbs is not obvious, but according to the occurrence process, there are still regularities to follow. The head occipital area and posterior neck are from C2 to 3, the upper limbs are from C4 to T1, the chest and abdomen are from T2 to L1, the lower limbs are from L2 to S3, and the peri-breech is distributed by S4 to 5 nerves. On the thorax, each segment forms a band that is essentially consistent with the intercostal space, which gradually slopes downwards inwards on the abdomen and is inconspicuous in the extremities.
Nerve fibers consist of a myelin sheath (located around the periphery), a neural membrane, and an axon (located in the center). Myelinated nerve fibers are encased outside the finger axons with myelin sheaths and nerve membranes, and myelinated nerve fibers without myelin nerve fibers are only the nerve membrane and no myelin sheath is wrapped.
The myelin sheath of the myelin nerve fiber is not constantly connected, but is regularly divided into several stages (interrupted every 0.2 to lmm). The constricted section between each end is called the Ranvien knot, where the axon is thinner and unseyeline-wrapped. A segment between each segment is called an intercollection, and the inner surface of its myelin sheath has several oblique lobes, in the form of a funnel, called a Schmidt-Lantermann incision. The cellular sheath of each segment of the intercolum comes from one nerve membrane cell. The myelin sheath is white and mainly contains phospholipids, and the myelin sheath of the peripheral nerves is formed from the nerve membrane cells. The myelin sheath is a concentric circular plate layer formed by the bilayer mesangium formed by the cell membrane of the nerve membrane after continuous rotation of the encapsulated axon. The neuromembrane cytoplasm and nucleus that remain outside are the above-mentioned neural membranes.
Myelinated nerve fibers consist of a single nerve membrane cell wrapped around several axons, each with its own mesangium, without rotation, without myelin sheath, and without Ranvien junctions.
On the surface of each nerve fiber there is a thin membrane of connective tissue called an endoneurium. Several nerve fibers converge into a bundle of nerves (fascicle), and the outside of each menstrual bundle is wrapped in a denser membrane called the perineurium. The membrane is composed of connective tissue, dendritic cells and basal membranes, between 1.3 and 100 μm thick, which varies greatly and is proportional to the diameter of the nerve bundle. This special structure plays an important role in protecting nerve fibers, maintaining nerve elasticity and tension, and determining the permeability of nerve bundles. Several nerve bundles converge into the nerve trunk, and on the outside of the nerve trunk there is a loose connective tissue membrane called epineurium. The structural arrangement within the nerve trunk and the identification of its sensory or motor properties have clinical significance for microsurgery.
Position and shape internal structure function line branch distribution
1. Neck plexus
(1) The composition and location of the cervical plexus
Cervical plexus (C1 to 4) consists of the anterior branch of the cervical 1-4 cervical nerve.
The 3 nerves climb in turn. Located in front of the levator scapula and the catenostomy muscle, the anterolateral side of the upper 4 cervical vertebrae, with the sternocleidomastoid muscle and the internal jugular vein in front of it.
(2) Branches of the neck plexus
The cervical plexus emits superficial (bark) and deep branches.
The superficial branch of the cervical plexus is shallow near the midpoint of the posterior border of the sternocleidomastoid muscle, so block anesthesia of the neck skin is often injected at this point. The main branches of the superficial branches are: (1) the small occipital nerve (C2) rises along the posterior margin of the sternocleidomastoid muscle and is distributed in the skin of the upper part of the occipital and upper back of the ear; (2) the large ear nerve (C2 to 3), which rises obliquely over the superficial surface of the sternocleidomastoid muscle and is distributed in the skin of the back of the ear and the parotidal gland; (3) the transverse cervical nerve (C2 to 3), which crosses the superficial anterior branch of the sternocleidomastoid muscle and is distributed in the skin of the anterior neck; (4) the supraclavicular nerve (C3 to 4), which descends at the posterior edge of the sternocleidomastoid muscle, and is divided into three groups of branches of medial, intermediate and lateral nerves, distributed in the upper part of the chest wall , skin on the side of the neck and shoulders.
The main branches of the deep branch of the cervical plexus are the phrenic nerve, the descending branch of the cervical nerve and the muscle branch, which innervate the septum, the sub-hyoid muscle group, the deep neck muscle group, and the levator scapula.
1． The phrenic nerve (phrenic nerve) C3 to 5 anterior branch is the most important branch of the cervical plexus, which is a mixed nerve. It is first on the lateral side of the upper part of the pretoxian muscle, then descends obliquely along the front of the muscle to its medial side, and enters the chest cavity through the upper thoracic cavity between the subclavian movement and the vein. In front of the thoracic cavity transpulmonary root, down the diaphragm between the mediastinal pleura and the pericardium. The diaphragm nerve motor fibers innervate the diaphragm, and the sensory fibers are distributed in the pleura, pericardium, and subdiaphragm peritoneum. Sensory fibers of the right diaphragm nerve are also distributed to the liver, gallbladder, and biliary tract.
Diaphragm nerve injury is characterized by ipsilateral diaphragm dyskinesia, which affects abdominal respiratory movements and, in severe cases, a feeling of asphyxia. Hiccups can occur when the phrenic nerve is stimulated. Inflammation of the gallbladder can irritate the right phrenic nerve endings, and patients sometimes experience right shoulder pain (neck 3, 4, 5 skin areas), resulting in referred pain that may lead to misdiagnosis. The surrounding part of the diaphragm is distributed by 7 pairs of intercostal nerves, similarly, acute pleurisy or pneumonia causes inflammation around the diaphragm, the patient has abdominal muscle rigidity, and the lower pairs of intercostal nerves are distributed with pain or tenderness in the cortical region, and misdiagnosis is acute abdomen. The incidence of the paraphragm nerve in Chinese people is about 48%, mostly unilateral, and the phrenic nerve is often added to the back of the subclavian vein.
2． The descending branch of the cervical nerve (C2-3) and the descending branch of the sublingual nerve (C1 part of the fibers are added) are synthesized at the level of the annular cartilage arch, and the sublingual muscles are innervated by the hair branch.
3． The muscle branches are distributed to the sternocleidomastoid muscle (C2), trapezius muscle, levator scapula (C3 to 4), and middle and posterior oblique muscles (C3 to 4)).
2. Arm plexus
(1) The composition and position of the arm plexus
Brachial plexus (C5~8, T1) composed of the 5 roots of the brachial plexus (C5~T1) are composed of 3 stems: the upper stem (C5, 6) synthesis, the middle stem (C7); and the lower stem (C8 and T1). Each stem is divided into two strands above or behind the clavicle, a total of 6 strands, and then 3 bundles are synthesized, namely the lateral bundle (upper and middle stem anterior strands), the medial bundle (inferior anterior strand) and the posterior bundle (upper, middle and lower posterior strand synthesis), and the three bundles of nerves surround the axillary artery from the outside, inside and back, respectively.
The brachial plexus exits through the oblique space and travels above the posterior subclavian artery and through the back of the clavicle into the axillary cavity. Inside the axillary cavity, located around the axillary artery, the lateral, medial, and posterior bundles of the brachial plexus are formed. The lower brachial plexus is adjacent to the blood vessels and nerves at the apex of the pleura and the root of the neck, including blood vessels such as the head-arm trunk, the left common carotid artery, the left subclavian artery and the cerebral brachial vein; the vagus nerve, the recurrent laryngeal nerve, the septal nerve and the cervical sympathetic trunk.
The brachial plexus is more concentrated behind the midclavian point, the position is shallow, easy to touch, and the needle can be inserted here for brachial plexus block anesthesia clinically, or the axillary approach can be selected to inject needle anesthesia around the axillary artery. According to Chinese data, the types of arm clusters composed of the above numbers and arrangements account for about 83. 8％。
The brachial plexus is widely distributed, distributed in the thoracic upper limb muscles, upper limb band muscles, superficial dorsal muscles, as well as the muscles and skin of the arms, forearms, and hands.
Open injuries are rare in brachial plexus injuries, and occasionally there are penetrating wounds of bit bullets, sharp wounds caused by knife glass, and iatrogenic injuries. Clinically the most common is closed injury. It mainly occurs in the case of body immobilization and excessive hand stretching, or arm immobilization and excessive head movement, such as fetal traction surgery in case of dystocia, upper limbs caught in the machine belt caused by traction, car accidents or direct injuries to the root of the neck and armpits. The main manifestation of brachial plexus injury symptoms is motor and sensory impairment of the nerve root distribution. Injuries to the upper, middle, or lower brachial plexus are more common.
1． Injuries to the upper brachial plexus are common, and external forces act on the patient's head or shoulder to deflect the head and neck to the contralateral side or cause the shoulder to fall downwards, or both, causing traction injury to the upper brachial plexus or causing nerve fiber rupture. It mainly injures the upper trunk or C5 to 6 nerve roots, paralyzing the deltoid muscles (axillary innervation), biceps brachii, humerus muscles (myocutaneous nerve innervation), brachial radial muscles (radial nerve innervation), pectoral large and small muscles (chest nerve innervation), Okashang and inferior muscles (supracepial nerve innervation) and scapula muscles and large round muscles (scapular nerve innervation). The entire upper limb droops, the upper arm is adducted, can not be abducted, externally rotated, the forearm is adducted, straight, can not be rotated anterior, post-rotation or bent. Movement of the hands and fingers is preserved, and there is a narrow sensory barrier area on the outside of the shoulder blades, upper arms, and forearms. Biceps and triceps reflexes are reduced or absent.
2． Injury in the middle of the brachial plexus mainly injures the middle stem or C7 nerve root, paralyzing the muscles innervated by the radial nerve, and the extension of the forearm, wrist, and hand is lost or weakened, while the triceps brachioceps, thumb extensor, and musculotomy are incomplete paralysis. The radial brachial muscle is functionally intact, and forearm flexion is not affected. The radial muscle is paralyzed when the radial nerve is injured. Because in addition to the radial innervation, the brachial radial muscle also comes from the innervation of C5 to 6 nerve root fibers (this is of clinical significance in the differential diagnosis of radial nerve and brachial plexus root injury). Sensory disturbances vary in parts, and patchy sensory loss can often be presented on the outstretched surface of the forearm and the radial side of the back of the hand. Triceps reflexes are reduced or absent.
3． Injuries to the lower brachial plexus can first cause tension or rupture of the nerves in the lower brachial plexus than when they are injured or stretched in the outer amplification position. May also occur after surgery or in connection with lung tumors and other mass lesions. This type of injury is less common than the upper arm type. It mainly injures the inferior stem or the C8 to T1 nerve root, paralyzing the muscles innervated by the median nerve of the head and ulnar nerve. Radial carpal flexor and pre-rotational round muscle function is still preserved (because the branches emitted by the median nerve innervate these two muscles). The internal muscles of the hand are claw-shaped, and there is sensory loss on the medial side of the forearm and the ulnar side of the hand. Finger reflexes weaken or disappear. When the T1 nerve root is damaged, the sympathetic fibers of the superior cervical ganglia are doomed to block, and the ipsilateral Horner sign appears.
(b) Branches of the brachial plexus
The branches of the brachial plexus can be divided into upper and lower parts of the collarbone according to where they are emitted.
1． The supraclavian branches are short muscle branches that originate from the roots and stems of the brachial plexus and are distributed in the deep cervical muscles and some muscles around the shoulder joint (deep neck muscles, superficial dorsal muscles other than trapezius muscles, upper thoracic limb muscles, upper limb band muscles, etc.). Some are also distributed in the shoulder joint. The main muscle branches are:
(1) The thoracic long nerve (C5~7) starts from the root of the brachial plexus, enters the armpit from the back of the brachial plexus, and innervates the muscle along the surface of the anterior serratus (equivalent to the mid-axillary line), accompanied by the decline of the lateral thoracic artery. Injury to this nerve can cause paralysis of the anterior serratus and the appearance of a "pterygium-like shoulder". Patients have difficulty combing their hair.
(2) The scapula dorsal nerve (C5) starts from the root of the brachial plexus, penetrates the catenoid muscle, descends between the scapula and the spine, and innervates the rhomboid muscle and the levator scapula.
(3) The superior scapular nerve (C5~6) starts from the upper brachial plexus, outside the brachial plexus, downward, posterior, and lay outside, to the deep side of the catetotomy muscle through the scapula incision on the lateral side of the upper edge of the scapula, into the upper fossa, and then into the inferior fossa, innervating the supraspinatus muscles, suprasal muscles, shoulder joints and acromicular joints.
2． The subclavian part of the branch is mostly a long branch, originating from the 3 bundles of the brachial plexus, the submyal branch and the skin branch, distributed in the muscles, joints and skin of the upper limbs (the main muscles are: superficial dorsal muscles, upper thoracic limb muscles, upper limb muscles, upper limb muscles, and upper limb muscles except trapezius muscles). The main branches are:
(1) The thoracic and lateral nerves (chest nerves) (C5-T1) start from the medial and lateral bundles, penetrate the beak-locked thoracofacia, and innervate the pectoral muscles of the chest and small. Nerves from the lateral bundle directly innervate the pectoralis major muscle, and nerves from the medial bundle penetrate the pectoralis minor muscles and then innervate the pectoralis major muscles.
(2) The subscapular nerve (C5-7) originates from the posterior bundle and descends along the front of the subscapular muscles, innervating the subscapular muscles and the large round muscles.
(3) Thoracic dorsal nerve (C7~8) starts from the posterior bundle, along the lateral margin of the scapula, with a decrease in the subscapular vessels, innervating the latissimus dorsal muscle. In radical breast cancer resection, when removing the axillary lymph node group, it is necessary to prevent damage to this nerve so as not to affect the patient's actions such as a belt.
(4) The musculocutaneous nerve (C5 to 7) originates from the lateral bundle, obliquely penetrates the beak-brachial muscle downwards, descends between the biceps and the humerus muscle, and issues muscle branches to innervate the berth-biceps, biceps and humerus, and its terminal branch (skin branch) penetrates the deep fascia at the lower end of the lateral sulcus of the biceps and continues to be the lateral skin nerve of the forearm, distributed in the lateral skin of the forearm.
Myocutaneous nerve injury is characterized by discommunicados of the brachiophytes and biceps, loss of biceps tendon reflexes and weakness of the elbow, and skin sensory impairment on the lateral forearm.
(5) The median nerve (C5~T1) is synthesized from the median nerve (C5~T1) from the medial and lateral bundles, which are synthesized by the medial and lateral bundles, descending the medial sulcus of the biceps with the brachial artery, and located on the medial side of the humerus when reaching the elbow fossa. It then enters the center of the forearm through the beginning of the anterior round muscle, accompanies the middle branch of the forearm with the middle branch of the interosseous anterior artery, and descends between the superficial flexor and deep flexor of the finger to the wrist. Here the nerves are superficial, and then the upper part of the wrist is passed through the carpal canal between the palmar tendon and the radial wrist flexor tendon, reaching the palm of the hand on the deep surface of the palmar aponeurosis.
The branches of the median nerve are: the brachial branch (distributed in most of the forearm forearm muscles, with fine branches to the elbow and wrist joint), and the hand part (distributed in the small part of the radial side of the back of the hand and most of the skin on the radial side of the palm).
l) Partial branch of the arm: a small vascular branch that emanates from the arm to the brachial artery, and a branch that emanates on the proximal side of the elbow joint to innervate the pre-rotational round muscle. The branches of the forearm are muscle branches, joint branches, interosseous anterior nerves, palmar skin branches, and communication branches. Muscle branches innervate the radial carpal flexor, palmar long muscle and superficial flexor muscle; joint branches supply the elbow joint and proximal radius joint; the interosseous anterior nerve is emitted when the median nerve penetrates the anterior round muscle, accompanied by the anterior interosseous artery, innerving the radial hemisphere, the thumb long flexor and anterior rotator muscle of the deep flexor muscle, and also supplies the distal radistrel joint, radial wrist joint and wrist joint, etc.; the palmar branch begins on the proximal side of the palmar aponeurosis and passes through the aponeurosis, divided into lateral skin branch and medial skin branch. The lateral skin branch supplies the fish skin and is linked to the lateral skin nerve of the forearm; the medial skin branch supplies the palmar skin and is associated with the palmar branch of the ulnar nerve; the communication branch can have multiple branches, often starting from the proximal side of the forearm, sometimes from the interosseous anterior nerve, and the medial side is between the shallow and deep flexors, and the ulnar nerve is added behind the ulnar artery, so the presence of the communication branch can explain the irregular nerve distribution of the hand muscle.
2) Hand branch: the median nerve is on the proximal side of the flexor support band, on the radial side of the finger shallow flexor tendon, and in the carpal canal between the flexor support band and the tendon, if in the flexor support band and the anterior space of the carpal bone, the nerve may be compressed. On the distal side of the flexor support band, the nerves expand and flatten. Usually divided into several branches, the muscle branch is the median nerve re-branch (otter branch), which is spontaneously emitted on the radial side of the lower edge of the flexor support band, which is thick and short, travels on the lateral side of the superficial branch of the radial artery and enters the fish, innerving the analeumatic muscle (except for the adductor muscle). Muscle branches can arise from the carpal tunnel and penetrate the flexor support band, which has surgical clinical significance. The median nerve is finally divided into two terminal branches, the median and lateral. The lateral branch continues to be the 1st metapolar total nerve, descending to the metacarpal head, and then divided into three phalangeal intrinsic nerves, distributed on both sides of the thumb and the posterior radius of the skin and the first worm-like muscle; the medial branch is divided into two general knuckle-sided nerves, and each is divided into two phalangeal intrinsic nerves, distributed in the palmar skin adjacent to the epiphalangeal, middle and ring fingers. The 2nd metapolar total nerve also branches to the 2nd vermiform muscle. All phalangeal intrinsic nerves are distributed in the middle and distal skin on the back of the fingers. The medial branch also receives a communication branch from the ulnar metaphalangeal total nerve.
The body surface projection line of the median nerve in the arm is represented by a line between the beginning of the brachial artery and the slightly medial point of the intercondylar line.
The projection line of the median nerve on the surface of the forearm is slightly medial from the midpoint of the intercondylar line of the elbow fossa, following the connection between the carpal flexor tendon and the palmar tendon on the radial side of the forearm.
After the injury of the median nerve, it is mainly manifested as the forearm cannot be rotated forward, the ability to flex the wrist is weakened, the fist cannot be clenched, and the sensation of 3 and a half fingers on the radial side of the palm is lost, so that the function of the hand is seriously affected, and the disability is very serious.
When the upper arm is damaged, the muscles innervated by the median nerve are completely paralyzed. The forearm cannot be rotated forward. Thumbs, signs, and middle fingers cannot be bent, and fists are clenched weakly. The thumb cannot be palmed and outreached. The interichthysteum atrophises, and the thumb becomes flattened with the palm of the hand, which is called a flat hand or ape hand.
When the injury is located 1/3 or 1/3 of the lower arm, the function of the anterior round muscles, wrist flexor, and finger flexor muscles can still be preserved, and the movement disorders are limited to thumb abduction, flexion, and palming.
If compressed in the carpal tunnel, symptoms of carpal tunnel syndrome such as sensory impairment and atrophy of the fish interichthynic muscle group can occur.
After median nerve injury, sensory impairment disappears mainly in the patellar half of the palmar surface, the turtal skin of the three halves of the palmar radial side, and the middle and distal skin on the back of the fingers.
(6) The ulnar nerve (C8~T1) starts from the medial bundle, descends first on the medial side of the axillary artery in the upper arm, then descends on the medial side of the humerus, and the more it is located at the midpoint of the upper arm, it passes through the medial muscle septum to the back of the arm, descending to the ulnar nerve groove between the medial epicondyle of the humerus and the ulna ulnar beak. The ulnar nerve is close to the bone surface here, and the position is superficial, so it is susceptible to stimulation and injury. Then descend down between the ends of the ulnar carpal flexor point and into the forearm, and descend between the ulnar carpal flexor and deep flexors and the medial side of the ulnar artery to the radial side of the pea bone, and finally through the outside of the pea bone into the palm of the hand. On the forearm 1/3, the ulnar nerve is far away from the ulnar artery, but the ulnar nerve on the distal side of the forearm is close to the medial side of the ulnar artery. The ulnar nerve mainly innervates the small ulnar side of the forearm anterior group muscle, the skin on the ulnar side of the hand, and the elbow and wrist joints.
The superficial side of the ulnar nerve through the flexor support band (transverse wrist ligament) is divided into shallow and deep terminal branches.
The branches of the ulnar nerve are:
l) Joint branches: emanating from between the medial epicondyle and the beak of the eagle, reaching the elbow joint, the number is uncertain, one or more branches.
2) Muscle branches: emanating from the near elbow, innervating the ulnar wrist flexor muscle and the ulnar half of the deep flexor muscle, respectively, usually with two branches.
3) Palmar branch: it starts about in the middle of the forearm; it descends above the ulnar artery and supplies the artery, and after communicating with the metacarpal branch of the median nerve, penetrates the deep fascia and stops at the skin of the palmar, sometimes supplying the short palmar muscle.
4) Dorsal support of the hand: it is emitted about 5 cm near the wrist, and is turned to the dorsal side through the deep side of the ulnar carpal flexor muscle to the distal side, and is distributed on the back of the back of the ulnar side and the ulnar side of the ulnar side and the skin on the back of the proximal segment of the ulnar side.
5) Shallow branch: it travels on the deep surface of the palmar aponeurosis, distributed on the skin of the palmar surface of the small fish and 1 and a half fingers on the ulnar side, and extends to the skin on the back of the distal segment of the finger. This branch supplies the palateral bregitus muscle.
6) Deep branch: accompanied by the deep branch of the ulnar artery, innervates the small antheloid muscle, the 3rd and 4th worm muscles, the adductor muscle and all interosseous muscles.
In addition, the ulnar neurovascular branch from the forearm and hand also supplies the ulnar and metacarpal arteries.
The ulnar nerve also emits joints to the radial carpal joint, inter-carpal joint, wrist-metacarpal joint, and inter-metacarpal joint.
The ulnar projection of the body surface in the arm is represented by a connection from the initial end of the brachial artery (the lower margin of the latissimus dorsal muscle) to the posterior to the epicondyle in the humerus.
The ulnar nerve is projected on the surface of the forearm as a line from the back of the medial epicondyle of the humerus to the lateral margin of the pea bone.
Ulnar nerve injuries usually occur in 4 locations, namely the posterior endodyle, the elbow, the wrist, and the hand.
Often due to old fractures caused by elbow arthritis, the ulnar nerve thickened, the lifting angle increased, so that the ulnar nerve groove becomes shallow and lost, or when the posterior part of the epicondyle is damaged, the movement disorder is manifested as wrist flexion ability and the role of the ring finger and the little finger are weakened. Due to the paralysis of the ulnar wrist flexor muscles, the radial muscles have antagonistic effects, and the hand is biased towards the radial side. At the same time, the adductor muscle is paralyzed, the thumb cannot be adducted, and the paper clamp test is positive, and the conjugated muscle has antagonism, so the thumb is in a state of abduction. Due to the excessive contraction of the extensor muscle, the metacarpophalangeal joints are overextended, and the distal interphalangeal joints of the 4th and 5th fingers are flexed, showing a "claw-shaped hand". In the late stages, the atrophy of the small fish becomes flat, the interosseous muscles atrophy and depression, the metacarpal bones appear deep grooves, and the fingers cannot be combined or separated.
Cubital tunnel syndrome has an elbow tube behind the ulnar side of the elbow joint, and the ulnar nerve is located in the tube formed by the ulnar carpal flexor muscle attached to the tendon arch between the humerus and ulna. Although the clinical symptoms of cubital canal syndrome are similar to those of the ulnar nerve sulcus injury, the elbow joint is usually normal in the cubital canal syndrome, moving freely, with a normal angle of lift, and the ulnar nerve sulcus feels normal, not accompanied by elbow subluxation.
When the ulnar nerve is injured 1/3 or 1/3 in the forearm, it is not affected because the branches of the ulnar carpal flexor and deep flexors have been emitted at a higher position. Therefore, only the small muscles of the hand are paralyzed, and the sensory disturbance area is mainly in the skin of the palmar surface of the ulnar side of the back of the hand, the small fish and the ulnar side.
When a cut wound or other injury on the palateral side of the wrist causes the ulnar nerve to be injured in the wrist: Since the dorsal and palmar branches of the hand begin with the ulnar nerve trunk in the middle of the forearm, when the ulnar nerve is injured here, the dorsal branch and palmar skin of the hand are not affected and function normally, but the small muscles of the hand innervated by the ulnar nerve are injured.
Deep branches of the ulnar nerve can be pressed against the pea and hook bones often in the hand due to frequent grip of vibrating tools or locomotive handles when used with a hammer, involving the small otter muscles, the 3rd and 4th worm muscles, the adductor muscles, and all interosseous muscles, but the sensory branches are often undamaged.
(7) Radial nerve (C5 to T1) starts from the posterior bundle, is enlarged, is located in the axillary fossa, is located behind the axillary artery, and is concomitant with the deep brachial artery outwards, first on the deep surface of the triceps brachial muscle, and then circumnavigating outward along the radial nerve groove of the humerus, and wearing the lateral muscle septum above the lateral epicondyle of the humerus, to the between the brachiosome and the brachiocroid, which is divided into shallow and deep terminal branches. The radial nerve branches are distributed throughout the muscles behind the upper limbs, the skin (except the semi-skin on the ulnar side of the dorsal hand), and the elbow and wrist joints. Branches of the radial nerve are: the skin branch (which originates at the axilla and is distributed in the skin behind the arm and forearm), and the muscle branch (innervation of the triceps brachiophyllum, the radial muscle, and the extensor radial carpal longus).
The superficial branch of the radial nerve is a branch of the skin, which passes through the deep side of the radial muscle, descends along the lateral side of the radial artery, leaves the artery in the middle of the forearm, at the lower 1/3 junction (about 7 cm above the wrist), and descends to the back of the hand, distributed on the skin on the back of the radial half of the dorsal hand and the back of the proximal segment of the two half-fingers on the radial side of the back of the hand.
The deep branch of the radial nerve is relatively thick, mainly the muscle branch passes through the lateral pivotal muscle of the radius neck to the back of the forearm, and descends to the wrist between the shallow and deep extensor groups of the forearm, and its branches innervate the extensor muscle groups of the forearm such as the posterior spin muscle and the radial short extensor muscle.
The radial nerve is the most vulnerable of all the nerves in the brachial plexus. The upper radial nerve is close to the radial groove on the dorsal side of the brachial nerve, from the median upper arm to the lateral side, so the fracture of the middle humerus, the fracture dislocation near the elbow joint, and the cutting injury on the dorsal side of the radial side of the forearm can injure the interosseous dorsal branch of the radial nerve, and may also be compressed when the bone scab is formed after fracture. In addition, the use of arms instead of pillows during sleep, long-term abduction of the upper limbs during surgery, and improper placement of tourniquets on the upper limbs can cause radial nerve damage. Lead poisoning and alcoholism can selectively damage the radial nerve.
The main motor impairment after radial nerve injury is extensor paralysis of the forearm, which manifests as wrist drooping, and when the forearm is raised, it is in a "hanging wrist" state. Different effects can occur depending on the site of radial nerve injury. Clinically, radial nerve injury at the distal end of the elbow joint is called low radial nerve injury. Radial nerve injury proximal to the elbow is called high radial nerve injury.
High-level injury, that is, when the axillary radial nerve emits injuries above the triceps branch of the brachial muscle, the symptoms of complete radial nerve palsy occur: all extensor muscles of the upper limb are paralyzed, the elbow, wrist, and metacarpophalangeal joints cannot be straightened, and the forearm cannot be rotated when it is straightened, usually in the anterior position. A "hanging wrist" state appears. Due to the paralysis of the radial brachial muscle, the forearm cannot flex the elbow when it is rotated in the anterior position, the abductor longus and the extensor muscle are paralyzed, so that the thumb cannot be straightened and abducted, and due to the role of the tuft muscle innervation of the ulnar nerve, the thumb is adducted to the indicating finger. Typical "droopy" deformities are present.
In 1/3 of the humerus, i.e. when the following injuries are issued from the triceps branch, the triceps are well functioned.
When the injury is at the lower end of the humerus or 1/3 of the forearm, the function of the radial, posterior, and extensor brachiocarp muscles is preserved.
When less than 1/3 of the forearm is injured, the branches to the extensor muscle are partially ejected on the forearm. Only the extended finger dysfunction and no hanging wrist state,
When the injury is close to the wrist joint, because each motor branch has been emitted, it does not produce motor symptoms of radial nerve palsy.
Radial nerve sensory disorders, which overlap with adjacent nerve distributions, are usually limited to the "tiger mouth area" on the back of the thumb and the 1st and 2nd metacarpal space, i.e., loss of semi-cutaneous sensation on the radial side of the back of the hand.
(8) The axillary nerve (C5 to 6) starts from the posterior bundle of the brachial plexus, passes through the posterior wall of the armpit and the posterior brachial artery through the quadrilateral foramen, and wraps around the back of the brachial surgical neck under the shoulder capsule to the deep surface of the deltoid muscle. Muscle branches innervate deltoid, small round, and shoulder joints. The branches of the skin protrude from the posterior margin of the deltoid muscle and are distributed on the skin above the shoulders and the outside of the arms.
When the humeral surgery neck fracture, shoulder dislocation, posterolaolar heavy object injury or sharp object injury, lateral shoulder surgery longitudinal splitting of the deltoid muscle, or using the axillary crutch can damage the axillary nerve and lead to deltoid paralysis, the arm can not be abducted, the shoulder joint active abduction function is lost, and the skin sensation on the surface of the deltoid muscle is lost. In the later stages, deltoid muscle atrophy occurs, the shoulder process is obvious, resulting in the loss of the shape of the rounded shoulder, and the shoulder joint is relaxed and subluxated. The scapula forms a straight angle to the outside of the upper arm, showing a "square shoulder" deformity.
(9) Medial brachial cutaneous nerve (C8~T1) starts from the medial brachial cutaneous nerve (C8~T1) and is distributed in the skin on the medial side of the arm.
(10) Medial antebrachial cutaneous nerve (C8~T1) emanates from the medial anterior brachial cutaneous nerve (C8~T1) from the inner bundle of the brachial plexus and is distributed in the skin of the anterior medial lateral side of the forearm.
3. Thoracic nerve
There are 12 pairs of anterior branches of the thoracic nerve, and each thoracic nerve is immediately divided into 4 branches after it is emitted from the corresponding intervertebral foramen: anterior branch, posterior branch, meningeal branch and communication branch. Most of the anterior branches of the thoracic nerve do not form plexuses. Maintain marked segmentality (except for most of the brachial plexus in the first pair and a small part of the lumbar plexus in the 12th pair). The anterior branches of the thoracic nerve pairs 1-11 are located in the corresponding intercostal nerves, called intercostal nerves. The anterior branch of the 12th pair of thoracic nerves is located below the 12th rib, so it is called the subcostal nerve. The upper 6 pairs of intercostal nerves are in the posterior wall of the chest, located in the corresponding intercostal space, forward in each intercostal groove, and located below the intercostal arteries and veins, along the lower edge of each rib to the front of the axillary. To the lateral thoracic lateral wall, each intercostal nerve separates the lateral skin branch, which is distributed on the skin of the lateral wall of the chest, and when it reaches the lateral border of the sternum, it is shallow and is anterior branch, distributed in the skin of the chest wall. The intercostal nerve is in front of the axillary front and gradually leaves the lower edge of the ribs in the center of the intercostal area. The upper 6 pairs of intercostal nerves all reach the anterior end of each intercostal space and are distributed only on the chest wall. The lower 5 pairs of intercostal nerves and subcostal nerves enter the abdominal wall obliquely downwards, between the abdominal oblique muscle and the transverse abdominal muscle, each branch of the lateral skin branch, distributed in the lateral wall skin of the abdomen, the main trunk enters the rectus abdominis sheath medially. It also crosses the anterior wall of the sheath near the white line to become anterior branch of the skin, distributed in the anterior wall of the abdomen.
The anterolateral groups of the intercostal nerve inner, outer and abdominal muscles innervate the intercostal, external and abdominal muscles are mainly: the ventral oblique muscle, the internal oblique muscle, the transverse abdominal muscle and the rectus abdominis muscle. Skin branches are distributed on the skin of the chest and abdominal wall. In addition, the branches of each intercostal nerve along the route are distributed in the parietal pleura, parietal peritoneum, and breast.
The anterior branches of the thoracic nerve and L1 are prominently distributed in the thoracic and abdominal wall skin, arranged from top to bottom as follows:
Nerve segment name distribution of the body surface plane T2 sternal horn T4 papilla T6 clenival t8 rib arch T10 umbilicus T12 umbilicus and pubic bone joint upper margin junction midpoint or anterior superior iliac spine L1 inguinal canal skin
The above signs are often used clinically to check for skin sensory segment disorders and anesthesia planes. In addition, adjacent intercostal nerves have overlapping upward and downward branches, so when an intercostal nerve is damaged, it does not cause the loss of sensation in the dermatoids, but only hypoesthesia.
Fourth, the waist bush
The lumbal plexus (T12-L4) consists of some of the fibers of the anterior branch of the thoracologic 12th thoracic nerve, the anterior branch of the lumbar 1st to 3rd lumbar nerve, and most of the anterior branch of the lumbar 4th lumbar nerve. In short, it consists of 12 chest to 4 anterior branches of the waist.
The lumbar plexus is located within the deep-faced muscle of the psoas major muscle, in front of the lumbar transverse process. Here is the psoas major muscle space, the anterolateral wall is the psoas major muscle, the posterior lateral side is the psoas muscle, the upper boundary to the twelve ribs, down along the lumbosacral stem and the presacral space of the pelvic cavity. The branches of the hair innervate the iliopsoas muscles (iliac and psoas major muscles), psoas muscles, abdominal wall muscles, anterior thigh and medial muscles, as well as the skin of the lower limbs.
Branches of the lumbar bush
1． The ilioperitoneal nerve (T12 to L1) protrudes from the lateral margin of the upper part of the psoas major muscle, obliquely down to the top of the iliac crest, through the transverse abdominal muscle and moves forward between this muscle and the intra-abdominal oblique. It is divided into lateral and anterior branches. Lateral skin branches penetrate the abdominal oblique muscles and the abdominal lateral oblique muscles, and are distributed on the skin of the lateral buttocks. The anterior skin branch is about 2 cm medial on the medial superior iliac spine, penetrates the abdominal oblique muscle, along the ventral lateral tendon membrane deep and facing the medial direction, about 3 cm above the shallow ring of the inguinal canal, and penetrates the ventral extraterrestrial oblique tendon membrane distributed in the skin of the pubic area. Its muscle branches innervate the intra-oblique, extraterrestrial oblique, and transverse abdominal muscles.
2． The ilioinin-inguinal nerve (L1) is below the ilioperitoneal nerve, and its behavior is similar to that of the sub-ilioperitoneal nerve, moving between the abdominal wall muscles, about the middle of the inguinal canal accompanied by the spermatic cord, and from the shallow ring of the inguinal canal, distributed in the inguinal region, the scrotum (or labia majora) and the upper part of the inner thigh of the skin, and its muscle branches innervate the intra-oblique and transverse abdominal muscles.
The iliopernal nerve and the iliac inguinal nerve are important nerves that walk in the inguinal area, and damage to these two nerves should be avoided during inguinal hernia repair, so as not to cause abdominal muscle atrophy and cause recurrence of hernia.
3． The reproductive femoral nerve (L1 to 2) protrudes from the front of the psoas major muscle and walks downwards, separating the femoral and reproductive branches. The femoral branch penetrates the deep surface of the inguinal ligament and is distributed in the triangular skin of the femoral triangle. The reproductive branch enters the inguinal canal in conjunction with the spermatic cord (the round ligament of the uterus in women) and is distributed in the skin of the scrotum (in women, labia majora), and the muscle branches innervate the cremasteri muscle.
4． The lateral femoral cutaneous nerve (L2 to 3) emanates from behind the lateral margin of the lumbar major muscle, obliquely crosses the anterior hip muscle, reaches about l cm medial superior spine of the anterior hip, and passes through the deep side of the inguinal ligament to the skin of the lateral thigh, and its lower end reaches near the knee joint.
5． The femoral nerve (L1 to 4 or L2 to 4) is the largest branch of the lumbar plexus, emanating from the lateral margin of the psoas major muscle, descending between the psoas major muscle and the iliac muscle, and branching concurrently to the muscle, the femoral nerve is slightly lateral at the mid-inguinal point, through the deep surface of the inguinal ligament to the femoral triangle, in the upper part of the femoral triangle is located on the surface of the iliopsoas muscle, at the lateral finger of the femoral artery, and then divided into several branches:
l) Muscle branch: innervates the seamstress muscle, quadriceps femoris and pubic muscles.
2) Skin branches: distributed on the skin in front of the thigh and knee joints. The longest branch of the skin is the cryptorchium (L3 to 4), with the femoral artery descending into the adductor tube, shallow to the inside of the knee joint to the subcutaneous, accompanied by the large saphenous vein descending along the inner side of the calf to the medial border of the foot, distributed under the patella, the medial side of the lower calf, and the skin of the medial border of the foot.
3) Joint branches: distributed in the hip and knee joints.
Injuries to the femoral nerve are generally rare and are generally shrapnel or surgical injuries. After the injury of the femoral nerve, there is paralysis of the quadriceps and suture muscles, weakness of the hip flexion, and prominence of the patella. When sitting, the knee joint cannot be straightened. Relying on the contraction of the broad fascial tension muscle, the patient can still keep the lower limb in the straight position and can walk, but it is difficult to walk, the pace is small, and it is impossible to run and jump. It is difficult for patients to go up and down stairs and the muscles of the anterior thigh are significantly atrophied. The knee reflex is absent, there is a small numb area above the inner patella, and sometimes there is tenderness in the skin in front of the thigh and in the area of the cryptorchial distribution.
6． The obturator nerve (L2-4) originates from the medial border of the psoas major muscle, travels forward from the lateral wall of the small pelvis, accompanies it above the closed-hole blood vessel, penetrates the closed membrane tube into the femoral part, is divided into two branches, and enters the adductor group of the thigh through the anterior and posterior proceutor muscles. The anterior branch of the anterior branch innervates the external foramen and adductor groups of the thigh, and its skin branches are distributed on the skin on the inner lateral side of the thigh. The anterior branch of the closed-forehole nerve gives out a branch that innervates the thin femoral muscle, which preludes into the long adductor muscle, which penetrates into the muscle approximately in the middle of the femoral. In the clinical operation of using thin femoral muscle instead of the external sphincter, care should be taken to preserve this branch; the posterior branch passes through the external foramen foremen muscle and internalizes the muscle, and then branches are distributed in part of the long adductor muscle and the short adductor muscle. The foramen nerve continues to descend to the knee joint, often with a communicative branch with the cryptorchium nerve.
After the damage of the closed-hole nerve, the clinical manifestations are that the thigh cannot be adducted, and the external rotation and internal rotation are weak. There is a sensory impairment area on the upper part of the inner thigh.
5. Sacral bushes
(1) Composition and location of the sacral clusters
Sacral plexus (L4 to 5, S1 to 5, Co.1) the sacral plexus consists of the lumbosacral stem (L4 anterior branch fibers and the anterior branch of the L5 branch), all the sacral nerve and the anterior branch of the caudal nerve, the sacrum except the lumbosacral stem in front of the sacral joint S1, S1 to 4 from the anterior sacral foramen, each root forming a triangular sacral plexus on the lateral side, the tip facing the sciatic foramen, located in front of the pelvic sacral bone and the piriform muscle.
The sacral clusters branch out over the basin wall and at the hips. Muscles and skin of the perineum, posterior femurs, calves, and feet. There is also Fenzhi to the hip joint. In addition to directly emitting many short muscle branches to innervate the piriform muscle, the internal foramen muscle, the femoral muscle, etc., the sacral plexus also emits the following branches.
(2) Branches of the sacral clump
1． Superior gluteal nerve (L4 to 5, S1) with superior gluteal artery and superior gluteal veins protruding from the pelvic cavity through the supraspinatus, distributed in the gluteus median, gluteus minor muscles, and latissimus fascia.
2． The inferior gluteal nerve (L5, S1 to 2) with sub-gluteal movements and veins protruding from the pelvic cavity through the suborder piriformis muscle is distributed in the gluteus major muscle.
3． Pudendal nerve (S2 to 4) with internal movement of the pudendal region, venous piriformis foramen, through the sciatic foramen into the sciatic anal fossa and then forward, branches distributed in the anus, perineum and external genitalia muscles and skin, its branches are: (1) subrectal nerve (anal nerve): innervation of the external anal sphincter and anal skin; (2) perineal nerve: distributed in the perineal muscles and scrotum (or labia majora) skin; (3) penis (or clitoris) dorsal nerve: distributed in the skin of the penis (or clitoris).
4． Posterior femoral cutaneous nerve (S1-3) protrudes from the pelvic cavity through the piriformis subforamension and shallow out of the lower border of gluteus major muscle, mainly in the skin of the posterior femoral and popliteal fossa.
5． Sciatic nerve (L4 to 5, S1 to 3) is the largest nerve in the whole body, sciatic nerve is divided into tibial nerve and peroneal total nerve position variation is larger, some branch planes are very high, even in the pelvic high branch; the relationship with the piriformis muscle is changeable, most of the piriformis subordere out of the pelvic cavity (66.3%), mutants such as sciatic nerve through the piriformis muscle foramen, or before the pelvic is divided into tibial nerve and total peroneal nerve, the former out of the piriformis foramen, the latter through the piriform muscle or supradate foramen and so on. To the buttocks, located on the deep side of the gluteus major muscle, descend slightly medially from the midpoint of the connection between the sciatic nodule and the large trochanter of the femur to the posterior femoral, descending to the apex of the popliteal fossa on the deep side of the long head of the biceps femoris, divided into two terminal branches of the medial tibia nerve and the lateral total peroneal nerve. The posterior thigh muscles are innervated by the hair muscle branch at the posterior femoral. The branches of the sciatic nerve are: (1) joint branches, which emit small branches from the upper section of the sciatic nerve into the hip joint; (2) muscle branches to the semi-tendon muscle, hemimembranous muscle and femoral biceps.
Body surface projection of sciatic nerve: it can be represented by three-point connection, namely the pelvic point of sciatic nerve (the upper and middle 1/3 junction of the posterior superior iliac spine and sciatic nodule), the midpoint of the ischial nodule and the upper popliteal fossa of the ischia connection. This projection line descends in an arc from the top inward direction to the bottom and the outside, and tender spots often appear on this projection line.
There are many causes of sciatic nerve injury, commonly including lumbar disc herniation and vertebral tumors. Osteoarthritis of the spine, trauma, tuberculosis, and improper compression of nerve roots at the site of intramuscular injection, as well as pelvic fractures and tumor injuries to the sacrum, or caused by firearm injuries to the femoral or buttocks, and sometimes hip dislocation and pelvic fractures can also be combined with sciatic nerve injury.
When the sciatic nerve is ruptured at a high level, the closed-foramen internal muscle and femoral muscle are paralyzed, weakening the external rotation of the thigh, paralyzing the semi-tendon muscle, hemimembranous muscle and biceps femoris muscle, which can make the knee joint rigid and overextended (the role of the quadriceps muscle), and stiffness when walking. The muscles below the knee are completely paralyzed, but the hamstrings are generally not greatly affected. Sensations disappear below the knee except for the distribution of the cryptorchium on the medial calf and in the medial malleolus. There are severe nutritional changes, and there are often deep ulcers on the soles of the feet. For example, the paralysis caused by the injury of the sciatic nerve branch is lighter, and the paralysis caused by the damage to the tibia nerve is more severe.
(1) The tibial nerve (L4~S3) is a direct continuation of the sciatic nerve trunk. It is separated from the sciatic nerve at the upper corner of the posterior posterior 1/3 of the posterior popliteal fossa, descends vertically through the center of the popliteal fossa, descends with the popliteal vessels to the lower edge of the popliteal muscle, passes through the deep surface of the soleus tendon arch, and then parallels with the posterior tibia artery in the shallow and deep muscles of the calf, passes behind the medial malleolus, and divides the deep side of the flexor support band into the plantar nerve and the plantar lateral nerve into the sole of the foot. The muscle branches innermost, intermediate, and lateral group muscles of the plantar are innermost, intermediate, and lateral, and the skin branches are distributed in the plantar skin. The tibia nerve also emits muscle branches to innervate the posterior group muscles of the lower leg in the popliteal fossa and calves, and the skin branch is called the medial gastrocnemius dermal nerve, with a small saphenous vein descending, and the deep fascia is penetrated at the midpoint of the lower leg and the lateral gastrocnemius skin nerve (from the common peroneal nerve) is kissed to form the gastrocnemius nerve, and the posterior arch of the lateral malleolus is forward and distributed behind the calf. Skin on the lateral margin of the foot and the little toe.
Because the tibia nerve is deeper, there is less chance of damage, and the tibia nerve and its branches can be injured in the case of penetrating injury, often between the medial malleolus and the Achilles tendon. After injury, it presents with inability to plantar flexion, weak varus force, and loss of both the Achilles tendon reflex and the plantar reflex. Due to the antagonism of the anterior and lateral group muscles of the calf (peroneal nerve innervation), the foot has a toe-sided valgus, called "hook-shaped foot" deformity, which is followed by the ground when walking, and cannot stand on the tip of the foot. Intrafoote muscle paralysis causes "arched foot" and "claw-toe"-like deformities. Sensory impairment is mainly on the posterolateral side of the calf, the lateral border of the foot, and the toe and dorsal side of the heel and each toe, so it is called a slipper paralysis area. The foot is susceptible to trauma, frostbite and burns, and there are often ulcers on the soles of the feet, which often seriously affect the weight-bearing and walking function of the limbs because the ulcers do not heal.
(2) The commonperoneal nerve (L4 to S2) is separated 1/3 of the lower part of the posterior femoral and then passes along the medial biceps of the femoris through the upper outside the popliteal fossa, reaching between the biceps tendon and the lateral head of the gastrocnemius muscle. The deep side of the long fibula muscle bypasses the outside of the neck of the fibula and is divided into two terminal branches of the superficial peroneal nerve and the deep peroneal nerve. The distribution range of the common peroneal nerve is the skin of the anterior calf, lateral group muscles and lateral calf, dorsal foot, and dorsal toes.
The common peroneal nerve branches are:
l) superficial peroneal nerve: Descends between the long and short muscles of the fibula and the extensor long toe, and the muscle branches innervate the long and short muscles of the fibula. Superficial branches emerge 1/3 under the calf and are distributed on the outer side of the calf, the back of the foot, and the skin of the back of the 2nd to 5th toe.
2) Deep peroneal nerve: penetrate the beginning of the long fibula muscle and the extensor long toe, to the anterior part of the lower leg and the anterior tibial artery, first between the tibia front muscle and the extensor long toe, and then down to the back of the foot between the tibia front muscle and the extensor long muscle. Along the way, branches are distributed on the skin on the back of the anterior group of calf muscles, dorsal foot muscles, and the first metatarsal space.
3) Lateral gastrocnemius cut-off: it separates from the common peroneal nerve at the popliteal fossa, penetrates the deep fascia, branches out of the skin on the lateral side of the calf, and kisses with the medial gastrocnemial skin nerve originating from the tibia nerve to form the sural nerve.
The common peroneal nerve becomes superficial when it bypasses the small head of the fibula, and it is easy to be injured there under the action of external forces. If the fibula is fractured or the lower limb is compressed by plaster and surgical accidental injury, the serious patient is bedridden for a long time, and the lower limb is in the external rotation position, it can also cause compression injury. Paralysis of the tibia, extensor long, fibula long, short muscle, and toe length, and extensor short muscle of the genus extensor of the lower leg innervated by the total peroneal nerve after injury. It is manifested by the inability to flex the affected foot, the inability to extend the toes, the sagging of the foot and the inversion of the foot, forming a deformity of "horseshoe invariating foot". When walking, it has a "cross-threshold gait", similar to a horse step or an arrow step. There are sensory impairments on the anterolateral side of the calf and on the skin of the back of the foot.
Lesion localization diagnosis
Localization diagnosis of spinal nerve injury
Diaphragm nerve damage
2. Injury to the brachial plexus
Myocutaneous nerve injury
Median nerve injury
Ulnar nerve injury
Radial nerve injury
When less than 1/3 of the forearm is injured, the branches to the extensor muscle are partially ejected on the forearm. There is only a function of the extended fingers and no hanging wrist, and when the injury is close to the wrist joint, because each motor branch has been issued, it does not produce motor symptoms of radial nerve palsy.
Third, the waist bush
Femoral nerve injury
Damage to the closed-hole nerve
4. Sacral bushes
Sciatic nerve injury
Tibia nerve injury
Because the tibia nerve is deeper, there is less chance of damage, and the tibia nerve and its branches can be injured in the case of penetrating injury, often between the medial malleolus and the Achilles tendon. After injury, it presents with inability to plantar flexion, weak varus force, and loss of both the Achilles tendon reflex and the plantar reflex. Due to the antagonism of the anterior and lateral group muscles of the calf (peroneal nerve innervation), the foot has a toe-sided valgus, called "hook-shaped foot" deformity, which is followed by the ground when walking, and cannot stand on the tip of the foot. Intrafoote muscle paralysis causes "arched foot" and "claw-toe"-like deformities. Sensory impairment is mainly on the posterolateral side of the calf, the lateral border of the foot, and the toe and dorsal side of the heel and each toe, so it is called a slipper paralysis area.
The foot is susceptible to trauma, frostbite and burns, and there are often ulcers on the soles of the feet, which often seriously affect the weight-bearing and walking function of the limbs because the ulcers do not heal.
Total peroneal nerve injury
The common peroneal nerve becomes superficial when it bypasses the small head of the fibula, and it is easy to be injured there under the action of external forces. If the fibula is fractured or the lower limb is compressed by plaster and surgical accidental injury, the serious patient is bedridden for a long time, and the lower limb is in the external rotation position, it can also cause compression injury. Paralysis of the tibia, extensor long, fibula long, short muscle, and toe length, and extensor short muscle of the genus extensor of the lower leg innervated by the total peroneal nerve after injury. It is manifested by the inability to flex the affected foot, the inability to extend the toes, the sagging of the foot and the inversion of the foot, forming a deformity of "horseshoe invariating foot". When walking, it has a "cross-threshold gait", similar to a horse step or an arrow step. There are sensory disturbances on the anterolateral side of the calf and on the skin on the back of the foot.
Source: Sina Blog Xu Huipeng - Rehabilitation Therapist
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