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Blocks Lower limb.pptx

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The document discusses various nerve blocks for the lower extremities, including the fascia iliaca block, PENG block, femoral nerve block, lateral femoral cutaneous nerve block, 3-in-1 block, adductor canal block, sciatic nerve block, popliteal nerve block, and ankle/foot blocks. It provides details on the anatomy, indications, techniques, complications, and considerations for each type of block.

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Lower extremity blocks and anatomy DR RASHMI SYAL
LOWER EXTREMITY NERVE SUPPLY
Blocks Lower limb.pptx
Blocks Lower limb.pptx
Blocks Lower limb.pptx
Lower limb Nerve blocks • FASCIA ILIACA BLOCK • PENG BLOCK • FEMORAL NERVE BLOCK • LATERAL FEMORAL CUTANEOUS NERVE BLOCK • 3 IN 1 COMPARTMENT NERVE BLOCK • ADDUCTOR CANAL BLOCK • SCIATIC NERVE BLOCK • POPLITEAL NERVE BLOCK • ANKLE AND FOOT BLOCK • SUPRAINGUINAL • INFRA-INGUINAL
Fascia iliaca block (FIB) • Compartment block. • Nerves : Femoral nerve and lateral femoral cutaneous nerve (LFCN) • Indication: Analgesia for THR Facilitate positioning for neuraxial blocks in hip fracture patients Analgesia following knee procedures TECHNIQUE LANDMARK GUIDED ULTRASOUND GUIDED SUPRA-INGUINAL (SIFIB) INFRA-INGUINAL (IIFIB)
Fascia iliaca block (FIB) SUPRA-INGUINAL • Position : Supine with hip extended • Equipments : Linear transducer 30-40 ml of local anesthetic (0.2% - 0.25% of Ropivacaine) 8 to 10 cm, block needle Sterile gloves • Confirmation of side • Avoid : Inguinal hernia Femoral artery graft
Fascia iliaca block (FIB) Complications: • Haematoma • Intra-vascular injection • Bowel injury • Failed block
Fascia iliaca block (FIB) INFRA-INGUINAL • Position - supine with leg in neutral position ; equipment similar to SIFIB.
Blocks Lower limb.pptx
Fascia iliaca block (FIB)
Blocks Lower limb.pptx
PENG block • Pericapsular nerve group block - Giron Arango • Plane block • Obturator nerve (ON), accessory obturator nerve (AON) and femoral nerve (FN) - major contribution in innervation of anterior hip capsule Indication: Preoperative and perioperative analgesia for fracture neck of femur Possibly can be used for postoperative analgesia following total hip arthroplasty
PENG block • Position : Supine with hip extended • Equipments : Curvilinear transducer 20 ml of local anesthetic (0.25% Bupivacaine/ 0.375% of Ropivacaine) 8 to 10 cm, block needle Sterile gloves • Confirmation of side Avoid : Patient refusal Allergy/anaphylaxis to LA Significant coagulopathy
PENG block
PENG block COMPLICATIONS: • Vascular puncture • Femoral nerve damage • LAST
PENG block
PENG block
FEMORAL NERVE BLOCK • Predictable relation to the femoral artery at inguinal crease level→ high rates for success • Functional anatomy: nerve roots: L2,L3,L4 • Indications: surgery of the anterior thigh and knee surgery Positioning of patients after intertrochanteric fracture for SAB/EA
FEMORAL NERVE BLOCK
LATERAL FEMORAL CUTANEOUS NERVE • Contributions from L2 & L3 • Sensory supply to the lateral thigh, lateral buttock and knee joint • Indications: Postoperative analgesia for hip surgery Meralgia paresthetica Muscle biopsy of the proximal lateral thigh Technique LANDMARK USG GUIDED
LATERAL FEMORAL CUTANEOUS NERVE - USG
THREE-IN-ONE BLOCK- INDICATIONS • Surgical procedures in the sensory areas of the femoral, lateral femoral cutaneous, and anterior branches of the obturator nerves (eg, skin surgery, muscle biopsy) • Patella surgery • Perioperative pain therapy of hip fractures (additional block of the sciatic nerve is necessary) • Perioperative pain therapy of femoral shaft fractures (with additional block of the sciatic nerve)
Blocks Lower limb.pptx
ADDUCTOR CANAL BLOCK • Saphenous nerve block can be done at the level of adductor canal or at the level of tibial tuberosity • Indications: Saphenous vein stripping Supplementation for ankle surgery in combination with sciatic nerve block • Boundaries: Anterolaterally- vas medialis Medially- sartorius Posteriorly- adductor longus above and Adductor magnus below Contents: 1. Femoral artery & vein 2. Post br of obturator nerve 3. Saphenous nerve 4. Nerve to vastus medialis
SAPHENOUS NERVE – USG ( Adductor canal)
SAPHENOUS NERVE – USG (Below knee)
SCIATIC NERVE • Origin: sacral plexus L4 through S3 roots • Anterior surface of the lateral sacrum and converge to become the sciatic nerve on the anterior surface of the piriformis muscle. • Course: leaves the pelvis through greater sciatic foramen, below the piriformis & passes in the gluteal region (between ischial tuberosity & greater trochanter) then to posterior compartment of thigh. • Termination: 4-10 cm above popliteal crease; it divides into 2 terminal branches: • Tibial • Common peroneal (Fibular)
SCIATIC NERVE BLOCK INDICATIONS: Anesthesia or analgesia for surgery on the lower extremity, usually in conjunction with a lumbar plexus block (femoral nerve block or psoas compartment block). • Surgery on the knee, tibia, fibula, ankle, and foot CONTRAINDICATIONS: Depending on the approach used, sciatic blocks are more or less deep; for deep approaches (Anterior, Parasacral), coagulopathy or anticoagulation is a relative contraindication.
SCIATIC NERVE BLOCK - Techniques TECHNIQUES LANDMARK BASED APPROACH/ USING NS • Classic (Labat) approach • Parasacral (Mansour) approach • Subgluteal (Raj) approach • Anterior (Beck) approach ULTRASOUND (USG)
SCIATIC NERVE BLOCK- Anterior (Beck) approach • Patient supine • Line F is drawn from anterior superior iliac spine (ASIS) to pubic tubercle (PT) • Line G parallel to F is drawn through the GT • F is divided in thirds, and a perpendicular H is dropped from the medial third • The intersection between G and H is the needle insertion point • An alternative approach (Souron and Delaunay) is to mark the femoral pulse in the inguinal crease, and to measure 6 cm in the direction of the patella, and then 2 cm lateral: that is the needle insertion point PEARLS: • If no response, the maneuver is repeated with an assistant putting the lower extremity in internal rotation • If still unsuccessful, repeat with the extremity in external rotation • The last resort is to aim slightly more caudad, or to use a the needle slightly more medial needle insertion point, as the sciatic nerve probably lies posterior to the femur
SCIATIC NERVE BLOCK (POSTERIOR APPROACH): USG guided Subgluteal approaches
Blocks Lower limb.pptx
SCIATIC NERVE BLOCK (ANTERIOR APPROACH): Van der Beek • This is an advanced block, as the nerve is deep and not easily visualized in most patients. • Patient supine, legs slightly abducted. • Place a low-frequency (3–5 Mhz) curved probe perpendicular to the axis of the thigh, 5–10 cm distal to the inguinal crease. • The femoral vessels (much smaller than when performing a FNB, as the scale is different) and the femur can easily be visualized.
SCIATIC NERVE BLOCK (ANTERIOR APPROACH): Van der Beek Techniques to locate the sciatic nerve: • Drawing an imaginary isosceles triangle with the femur as its apex, the femoral vessels as one corner, the sciatic nerve will lie at the other corner
SCIATIC NERVE BLOCK - Complications THE PARASACRAL APPROACH: • Can theoretically lead to pelvic needle penetration. • Usually causes hypoesthesia of the ipsilateral half of the genitalia by blocking the pudendal nerve. DEEP BLOCKS (PARASACRAL, ANTERIOR ESPECIALLY, BUT ALL SCIATIC BLOCKS ARE DEEP IN OBESE PATIENTS) • Can lead to unrecognized bleeding and hematoma formation.
Blocks Lower limb.pptx
POPLITEAL SCIATIC NERVE BLOCK INDICATIONS: • Corrective foot surgery • Foot debridement • Achilles tendon repair • Division sciatic nerve usually occurs between 4-10 cm proximal to popliteal fossa crease. • In popliteal fossa Tibial nerve is lateral & superficial to popliteal artery and vein, and contained in its own tissue (epineural) sheath. • APPROACH: Posterior Lateral
POPLITEAL SCIATIC NERVE BLOCK- Lateral Approach • Obviates the need to place the patient in prone position • Landmarks : Popliteal fossa crease Vastus lateralis muscle Biceps femoris muscle • Needle insertion marked in the groove between the Vastus Lateralis and Biceps Femoris muscles 7-8 cm above the popliteal fossa crease.
POPLITEAL SCIATIC NERVE BLOCK- Lateral Approach • 10-cm, 21-gauge needle is inserted in a horizontal plane perpendicular to the long axis of the leg between the Vastus lateralis and Biceps femoris muscles • Contact made with the femur, needle withdrawn to skin level and redirected posteriorly at angle 30 degree to the horizontal plane with stimulating current of 1.5 mA • Goal: to see the foot movements at current of 0.2-0.5 mA
Blocks Lower limb.pptx
INTERTENDINOUS APPROACH ST BF
Blocks Lower limb.pptx
ANKLE BLOCK • Block of four terminal branches of the Sciatic nerve and one cutaneous terminal branch of the femoral nerve i.e. The Saphenous nerve. • Two deep nerves (Posterior Tibial and Deep Peroneal) • Three superficial nerves (Saphenous, Sural, and Superficial Peroneal). • Distribution of blockade : anaesthesia of the foot & proximally till the level of injection
Blocks Lower limb.pptx
SEPHANOUS NERVE BLOCK SUPERFICIAL PERONEAL N BLOCK
SURAL NERVE BLOCK POSTERIOR TIBIAL N BLOCK
Blocks Lower limb.pptx
Blocks Lower limb.pptx

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Blocks Lower limb.pptx

  • 1. Lower extremity blocks and anatomy DR RASHMI SYAL
  • 6. Lower limb Nerve blocks • FASCIA ILIACA BLOCK • PENG BLOCK • FEMORAL NERVE BLOCK • LATERAL FEMORAL CUTANEOUS NERVE BLOCK • 3 IN 1 COMPARTMENT NERVE BLOCK • ADDUCTOR CANAL BLOCK • SCIATIC NERVE BLOCK • POPLITEAL NERVE BLOCK • ANKLE AND FOOT BLOCK • SUPRAINGUINAL • INFRA-INGUINAL
  • 7. Fascia iliaca block (FIB) • Compartment block. • Nerves : Femoral nerve and lateral femoral cutaneous nerve (LFCN) • Indication: Analgesia for THR Facilitate positioning for neuraxial blocks in hip fracture patients Analgesia following knee procedures TECHNIQUE LANDMARK GUIDED ULTRASOUND GUIDED SUPRA-INGUINAL (SIFIB) INFRA-INGUINAL (IIFIB)
  • 8. Fascia iliaca block (FIB) SUPRA-INGUINAL • Position : Supine with hip extended • Equipments : Linear transducer 30-40 ml of local anesthetic (0.2% - 0.25% of Ropivacaine) 8 to 10 cm, block needle Sterile gloves • Confirmation of side • Avoid : Inguinal hernia Femoral artery graft
  • 9. Fascia iliaca block (FIB) Complications: • Haematoma • Intra-vascular injection • Bowel injury • Failed block
  • 10. Fascia iliaca block (FIB) INFRA-INGUINAL • Position - supine with leg in neutral position ; equipment similar to SIFIB.
  • 14. PENG block • Pericapsular nerve group block - Giron Arango • Plane block • Obturator nerve (ON), accessory obturator nerve (AON) and femoral nerve (FN) - major contribution in innervation of anterior hip capsule Indication: Preoperative and perioperative analgesia for fracture neck of femur Possibly can be used for postoperative analgesia following total hip arthroplasty
  • 15. PENG block • Position : Supine with hip extended • Equipments : Curvilinear transducer 20 ml of local anesthetic (0.25% Bupivacaine/ 0.375% of Ropivacaine) 8 to 10 cm, block needle Sterile gloves • Confirmation of side Avoid : Patient refusal Allergy/anaphylaxis to LA Significant coagulopathy
  • 17. PENG block COMPLICATIONS: • Vascular puncture • Femoral nerve damage • LAST
  • 20. FEMORAL NERVE BLOCK • Predictable relation to the femoral artery at inguinal crease level→ high rates for success • Functional anatomy: nerve roots: L2,L3,L4 • Indications: surgery of the anterior thigh and knee surgery Positioning of patients after intertrochanteric fracture for SAB/EA
  • 22. LATERAL FEMORAL CUTANEOUS NERVE • Contributions from L2 & L3 • Sensory supply to the lateral thigh, lateral buttock and knee joint • Indications: Postoperative analgesia for hip surgery Meralgia paresthetica Muscle biopsy of the proximal lateral thigh Technique LANDMARK USG GUIDED
  • 24. THREE-IN-ONE BLOCK- INDICATIONS • Surgical procedures in the sensory areas of the femoral, lateral femoral cutaneous, and anterior branches of the obturator nerves (eg, skin surgery, muscle biopsy) • Patella surgery • Perioperative pain therapy of hip fractures (additional block of the sciatic nerve is necessary) • Perioperative pain therapy of femoral shaft fractures (with additional block of the sciatic nerve)
  • 26. ADDUCTOR CANAL BLOCK • Saphenous nerve block can be done at the level of adductor canal or at the level of tibial tuberosity • Indications: Saphenous vein stripping Supplementation for ankle surgery in combination with sciatic nerve block • Boundaries: Anterolaterally- vas medialis Medially- sartorius Posteriorly- adductor longus above and Adductor magnus below Contents: 1. Femoral artery & vein 2. Post br of obturator nerve 3. Saphenous nerve 4. Nerve to vastus medialis
  • 27. SAPHENOUS NERVE – USG ( Adductor canal)
  • 28. SAPHENOUS NERVE – USG (Below knee)
  • 29. SCIATIC NERVE • Origin: sacral plexus L4 through S3 roots • Anterior surface of the lateral sacrum and converge to become the sciatic nerve on the anterior surface of the piriformis muscle. • Course: leaves the pelvis through greater sciatic foramen, below the piriformis & passes in the gluteal region (between ischial tuberosity & greater trochanter) then to posterior compartment of thigh. • Termination: 4-10 cm above popliteal crease; it divides into 2 terminal branches: • Tibial • Common peroneal (Fibular)
  • 30. SCIATIC NERVE BLOCK INDICATIONS: Anesthesia or analgesia for surgery on the lower extremity, usually in conjunction with a lumbar plexus block (femoral nerve block or psoas compartment block). • Surgery on the knee, tibia, fibula, ankle, and foot CONTRAINDICATIONS: Depending on the approach used, sciatic blocks are more or less deep; for deep approaches (Anterior, Parasacral), coagulopathy or anticoagulation is a relative contraindication.
  • 31. SCIATIC NERVE BLOCK - Techniques TECHNIQUES LANDMARK BASED APPROACH/ USING NS • Classic (Labat) approach • Parasacral (Mansour) approach • Subgluteal (Raj) approach • Anterior (Beck) approach ULTRASOUND (USG)
  • 32. SCIATIC NERVE BLOCK- Anterior (Beck) approach • Patient supine • Line F is drawn from anterior superior iliac spine (ASIS) to pubic tubercle (PT) • Line G parallel to F is drawn through the GT • F is divided in thirds, and a perpendicular H is dropped from the medial third • The intersection between G and H is the needle insertion point • An alternative approach (Souron and Delaunay) is to mark the femoral pulse in the inguinal crease, and to measure 6 cm in the direction of the patella, and then 2 cm lateral: that is the needle insertion point PEARLS: • If no response, the maneuver is repeated with an assistant putting the lower extremity in internal rotation • If still unsuccessful, repeat with the extremity in external rotation • The last resort is to aim slightly more caudad, or to use a the needle slightly more medial needle insertion point, as the sciatic nerve probably lies posterior to the femur
  • 33. SCIATIC NERVE BLOCK (POSTERIOR APPROACH): USG guided Subgluteal approaches
  • 35. SCIATIC NERVE BLOCK (ANTERIOR APPROACH): Van der Beek • This is an advanced block, as the nerve is deep and not easily visualized in most patients. • Patient supine, legs slightly abducted. • Place a low-frequency (3–5 Mhz) curved probe perpendicular to the axis of the thigh, 5–10 cm distal to the inguinal crease. • The femoral vessels (much smaller than when performing a FNB, as the scale is different) and the femur can easily be visualized.
  • 36. SCIATIC NERVE BLOCK (ANTERIOR APPROACH): Van der Beek Techniques to locate the sciatic nerve: • Drawing an imaginary isosceles triangle with the femur as its apex, the femoral vessels as one corner, the sciatic nerve will lie at the other corner
  • 37. SCIATIC NERVE BLOCK - Complications THE PARASACRAL APPROACH: • Can theoretically lead to pelvic needle penetration. • Usually causes hypoesthesia of the ipsilateral half of the genitalia by blocking the pudendal nerve. DEEP BLOCKS (PARASACRAL, ANTERIOR ESPECIALLY, BUT ALL SCIATIC BLOCKS ARE DEEP IN OBESE PATIENTS) • Can lead to unrecognized bleeding and hematoma formation.
  • 39. POPLITEAL SCIATIC NERVE BLOCK INDICATIONS: • Corrective foot surgery • Foot debridement • Achilles tendon repair • Division sciatic nerve usually occurs between 4-10 cm proximal to popliteal fossa crease. • In popliteal fossa Tibial nerve is lateral & superficial to popliteal artery and vein, and contained in its own tissue (epineural) sheath. • APPROACH: Posterior Lateral
  • 40. POPLITEAL SCIATIC NERVE BLOCK- Lateral Approach • Obviates the need to place the patient in prone position • Landmarks : Popliteal fossa crease Vastus lateralis muscle Biceps femoris muscle • Needle insertion marked in the groove between the Vastus Lateralis and Biceps Femoris muscles 7-8 cm above the popliteal fossa crease.
  • 41. POPLITEAL SCIATIC NERVE BLOCK- Lateral Approach • 10-cm, 21-gauge needle is inserted in a horizontal plane perpendicular to the long axis of the leg between the Vastus lateralis and Biceps femoris muscles • Contact made with the femur, needle withdrawn to skin level and redirected posteriorly at angle 30 degree to the horizontal plane with stimulating current of 1.5 mA • Goal: to see the foot movements at current of 0.2-0.5 mA
  • 45. ANKLE BLOCK • Block of four terminal branches of the Sciatic nerve and one cutaneous terminal branch of the femoral nerve i.e. The Saphenous nerve. • Two deep nerves (Posterior Tibial and Deep Peroneal) • Three superficial nerves (Saphenous, Sural, and Superficial Peroneal). • Distribution of blockade : anaesthesia of the foot & proximally till the level of injection