Where is the obturator nerve susceptible to injury

Femoral nerve palsy is the second most common nerve injury associated with THA, accounting for 2. Simmons et al. Weber et al. Other studies agree that recovery from femoral nerve palsies follows a more predictable and less disabling course 12 , 37 compared to sciatic nerve palsies.

Also, prognosis tends to be more favorable than sciatic nerve injuries. Currently, no definitive treatment protocol exists for the management of femoral nerve palsy, except in the case of an acute iliacus hematoma which requires prompt decompression. Obturator nerve palsy is an extremely rare complication of THA. The obturator nerve descends through the pelvis, transects the psoas major muscle, and then passes medially into the pelvic brim before exiting through the obturator foramen.

Diagnosis can be difficult given its low prevalence and lack of serious functional disability. Three patients underwent revision surgery with cement excision and nerve exploration, which led to full improvement in nerve function. Similarly, Weber et al. Given this seemingly recurrent etiology, the use of a bone graft or barrier device was recommended by Weber et al.

Other risk factors for obturator nerve palsies include violation of the anterior quadrant or floor of the acetabulum. Similar to femoral nerve palsy, prevention of known associated risk factors can prevent obturator nerve injuries. Unless an identifiable cause of compression has been identified, a protocol for surgical intervention is not clearly established in the literature.

The superior gluteal nerve exits the pelvis through the greater sciatic notch, exits proximal to the piriformis muscle, and then branches into superior and inferior divisions before innervating the hip abductors.

Injury to the superior gluteal nerve may occur if the gluteus medius is dissected 5 cm proximal to the greater trochanter, 39 and would present with abductor weaknesses and Trendelenburg gait.

Picado et al. This suggested that superior gluteal nerve injuries found on early EMGs can resolve spontaneously. Lateral and anterolateral approaches pose the greatest risk for superior gluteal nerve injury. In addition, no protocol is in place to indicate the need for urgent surgical exploration, except in the setting of a compressing force, where surgery helps achieve decompression.

After originating from the posterior divisions of the anterior rami of the L2 and L3 nerve roots, the lateral femoral cutaneous nerve LFCN runs on the anterior surface of the iliacus muscle within the iliac fascia, eventually entering the thigh medial to the anterior superior iliac spine and then passing over the sartorius muscle before branching.

Based on patient surveys, Homma et al. The designs of these two studies varied significantly, which could have accounted for the differing results. There is a paucity of literature regarding incidence, prognosis and management of this condition, and of the literature that does exist, there is considerable discrepancy.

For certain, LFCN palsies do not pose functional limitations for the patient; however, for management purposes, it remains important to address quality of life issues. Primary prevention is the key to avoiding neural injuries and its potentially catastrophic consequences. This begins with establishing a strong foundation in anatomical knowledge, which should include the ability to recognize anatomical variants.

Medico-legal issues may result from nerve injuries associated with THA. Unwin et al. Other indications for urgent surgical exploration include any findings that suggest a hematoma, which may present as a delayed nerve palsy and would require prompt decompression.

Acute intervention with primary repair clearly has advantages in nerve injuries where there is complete transection; however, when nerves are bluntly divided, delayed exploration by a few weeks offers better outcomes for the reason that the nerve stumps can be sectioned back to healthy neural tissue. Management becomes less clear when pain is absent.

In these instances, the risk of reoperation must be weighed against the potential benefit of exploration. Also, the suspected etiology of nerve injuries must be accounted for.

However, not all etiologies have good results with surgical management. Pritchett et al. They reported that 9 patients had pain relief, and out of 11 patients who had motor symptoms, 7 patients improved. Non-operative treatment generally includes physiotherapy with joint mobilization, extended bracing, and expectant waiting for functional return. During this period, diagnostic testing may be sought in order to provide the patient with more accurate information regarding injury extent and prognosis.

When these methods are exhausted, there is an option for tendon transfer, which has shown promising results. Tendon transfers are not time-sensitive, and are typically performed after 18 months, allowing maximal nerve recovery and tissue equilibrium to develop beforehand.

If tendon transfer is performed earlier, an end-to-side approach should be undergone so as to allow the nerve to continue its recovery after the procedure. Nerve palsies associated with THA are relatively rare, yet the potentially devastating nature of the injury makes it a topic of interest. Although many possible risk factors for nerve injuries have been suggested, previous hip surgery and DDH are the most commonly reported.

Rather than negligence and poor technique, nerve injuries in these cases appear to be associated with the difficulty of the procedure due to anatomical changes. As the field of orthopaedic surgery advances, more patients with these conditions will become surgical candidates for THA, thus, surgeons should be aware of the inherent surgical risks.

As such, it is important for surgeons to evaluate patients for perioperative risk factors. National Center for Biotechnology Information , U.

J Clin Orthop Trauma. Published online Oct Rohit Hasija , a John J. Kelly , b Neil V. Shah , c Jared M. Newman , c Jimmy J.

Chan , d Jonathan Robinson , d and Aditya V. John J. Kelly b St. Neil V. Jared M. Jimmy J. Aditya V. Author information Article notes Copyright and License information Disclaimer. Maheshwari: ude. This article has been cited by other articles in PMC. Abstract Nerve injury is a relatively rare, yet potentially devastating complication of total hip arthroplasty THA.

Background Nerve injury is a relatively rare, yet potentially devastating complication of total hip arthroplasty THA. Risk factors Proper identification of perioperative risk factors associated with nerve injuries in THA may allow surgeons to avoid such complications. Other studies in the literature agree that these risk factors increase patient susceptibility to nerve injury.

Previously, nerve injury in these patients was believed to be due to limb lengthening, but the literature has since dismissed this idea. This is thought to be due to nerve embedment in scar tissue which alters nerve blood supply and increases vulnerability to traction injury. Traction Cementless Surgical Technique Despite cement being an etiology of nerve injury itself by its ability to cause compression and thermal injuries, THAs that involve cementless fixation of the implant are in fact associated with a higher risk of nerve palsy.

Open in a separate window. Table 2 Nerve injuries associated with surgical approach. Prognosis The prognosis of nerve injuries associated with THA can be related to various factors; however, the main prognostic factors are dependent on the initial neural insult, specifically, whether it was a complete or incomplete injury, traction injury and certain patient factors, especially body mass index BMI. Diagnosis and work-Up Nerve injuries are diagnosed clinically in most cases; therefore, the most important diagnostic tool is a well-documented preoperative and postoperative physical exam.

Major nerve-Specific injuries 6. Femoral nerve Femoral nerve palsy is the second most common nerve injury associated with THA, accounting for 2. Obturator nerve Obturator nerve palsy is an extremely rare complication of THA. Superior gluteal nerve The superior gluteal nerve exits the pelvis through the greater sciatic notch, exits proximal to the piriformis muscle, and then branches into superior and inferior divisions before innervating the hip abductors.

Lateral femoral cutaneous nerve After originating from the posterior divisions of the anterior rami of the L2 and L3 nerve roots, the lateral femoral cutaneous nerve LFCN runs on the anterior surface of the iliacus muscle within the iliac fascia, eventually entering the thigh medial to the anterior superior iliac spine and then passing over the sartorius muscle before branching.

Prevention Primary prevention is the key to avoiding neural injuries and its potentially catastrophic consequences. Medico-legal issues Medico-legal issues may result from nerve injuries associated with THA. Management Unwin et al. It'll likely be followed by physical therapy as part of the rehabilitation plan. Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life.

Anatomy Next. Obturator Nerve. Gaillard F, Wong A, et al. Obturator nerve. Radhakrishnan A. The Obturator Nerve. TeachMe Anatomy. Updated January 30, Your Privacy Rights. To change or withdraw your consent choices for VerywellHealth. At any time, you can update your settings through the "EU Privacy" link at the bottom of any page. These choices will be signaled globally to our partners and will not affect browsing data. We and our partners process data to: Actively scan device characteristics for identification.

I Accept Show Purposes. Table of Contents View All. Table of Contents. Associated Conditions. Anatomy of the Femoral Nerve. Symptoms of obturator nerve damage include: Numbness, reduced sensation, or abnormal sensation in the skin of the inner thigh Pain that may extend down the inner thigh and is worsened by walking or spreading the legs Weakness in adduction of the thigh Gait and posture problems linked to loss of adduction ability.

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Related Articles. Timecourse Paralysis is instant when associated with direct trauma through parturition. Paralysis associated with inflammation after parturition, or other space occupying lesions of the pelvis, may be delayed. If the obturator nerves are permanently damaged through tearing or complete transection, the adductor muscles will be permanently paralyzed and the subsequent locomotion will be life-long. If the damage is not permanent, muscle function will partially, or completely recover, but the function may take several weeks or months, during which time the affected animal will be predisposed to uncontrolled abduction of the limbs splits.

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Poulton P J Cattle Pract 21 , Huxley J In Pract 28 , Other sources of information Lameness in Cattle 2nd edn. Ed: Weaver A D. Wright Scientechnica. Related Images Hobbles. Nerves of the bovine pelvis. Obturator and peroneal paralysis after calving. Obturator paralysis. Slaughter: emergency slaughter for human consumption. Wry nose. Wry nose Penile deviation Cytology: nucleated erythrocyte peripheral blood. Cytology: Howell jolly bodies. Cytology: mast cells - mastocytosis.

Cytology: spherocyte - auto-immune hemolytic anemia. Cytology: keratocytes.