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Common peroneal nerve
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Femoral nerve
Inferior gluteal nerve
Superior gluteal nerve
Tibial nerve
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This patient with a laceration of the posterior buttock who now presents with a Trendelenburg gait (drooping of the pelvis contralateral to the side of injury when walking) has an injury of the right superior gluteal nerve. The superior gluteal nerve arises from the L4-S1 nerve roots and provides motor innervation to the gluteus medius, gluteus minimus, and tensor fascia latae muscles. Injury to the superior gluteal nerve can occur from direct injury to the nerve (e.g., penetrating trauma). Additionally, iatrogenic injury to the superior gluteal nerve can occur due to a misplaced intramuscular injection to the superomedial region of the posterior buttock. Therefore, the preferred site for intramuscular injections is the superolateral or anterolateral region. Injury to the superior gluteal nerve may present with a Trendelenburg gait due to impaired hip abduction by the gluteus medius muscle. This leads to the pelvis tilting downwards contralateral to the side of the injury and rising upwards on the side ipsilateral to the injury when the ipsilateral leg is planted. Murthy et al. conducted a cadaveric study on the feasibility of using sciatic nerve branches for nerve transfer to the superior gluteal nerve for injury. They found that based on length of the donor segment, using a tibial-innervated hamstring branch of the nerve was feasible. They recommended further clinical evaluation of this nerve transfer for superior gluteal nerve injuries. Incorrect Answers: Answer 1: The common peroneal (fibular) nerve has a superficial and deep component. The superficial component innervates the lateral compartment of the leg, providing foot eversion and sensation to the dorsum of the foot. The deep component innervates the anterior compartment of the leg, providing ankle dorsiflexion and sensation to the first webbed space. This patient has intact sensation of the foot and intact dorsiflexion, indicating intact function of the common peroneal nerve and its branches. Answer 2: The femoral nerve provides sensation to the anterior thigh and is needed for knee extension. It may be damaged following pelvic fractures. This patient's ability to extend the leg is inconsistent with femoral nerve injury. Answer 3: The inferior gluteal nerve provides motor innervation to the gluteus maximus muscle. Injury to this nerve by posterior hip dislocations may lead to an inability to extend the hip. Because this nerve does not supply the hip abductors, this would not present with a Trendelenburg gait. Answer 5: The tibial nerve is required for ankle plantarflexion and sensation of the plantar aspect of the foot. It may be damaged by knee trauma or popliteal cysts. This patient's ability to plantarflex indicates an intact tibial nerve. Bullet Summary: Injury to the superior gluteal nerve may present with a Trendelenburg gait, in which the hip drops contralateral to the side of injury during ambulation due to impaired ipsilateral hip abduction.
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