Presentation on theme: "Ankle Block Soli Deo Gloria Lecture 15"— Presentation transcript:
1 Ankle Block Soli Deo Gloria Lecture 15 Developing Countries Regional Anesthesia Lecture SeriesDaniel D. Moos CRNA, Ed.D. U.S.A.Lecture 15
2 DisclaimerEvery effort was made to ensure that material and information contained in this presentation are correct and up-to-date. The author can not accept liability/responsibility from errors that may occur from the use of this information. It is up to each clinician to ensure that they provide safe anesthetic care to their patients.
3 Introduction to the Ankle Block Common peripheral nerve blockUseful for procedures that do not require a tourniquet above the ankleIndicated for orthopedic and podiatry procedures of the distal footPurely sensory blockPainful blockConscious sedation….don’t over sedate!
4 The ankle block involves blockade of 5 peripheral nerves Posterior tibial nerveSural nerveSuperficial peroneal nerveDeep peroneal nerveSaphenous nerve
8 The remaining nerve is the terminal branch of femoral nerve Saphenous nerve
9 Deep Peroneal Nerve Anatomy Continues as an extension of the common peroneal nerve and enters the ankle between the flexor hallucis longus tendons.
10 Deep Peroneal Nerve provides sensation to the medial half of the dorsal foot (1st & 2nd digits)
11 Deep Peroneal Nerve can be located at the level of the medial malleolus just lateral to the flexor hallucis longusLateralMalleolusMedial MalleolusExtensor Digitorum LongusExtensor Hallucis LongusLocation of deep peroneal nerve
12 Superficial Peroneal Nerve Anatomy Extension of the common peroneal nerve and enters the ankle lateral to the extensor digitorum longus at the level of the lateral malleolus
14 Superficial Peroneal Nerve provides sensation to the dorsum of the foot as well as all five toes
15 Posterior Tibial Nerve Anatomy Extension of the tibial nerve and enters the foot posterior to the medial malleolus, dividing into the lateral and medial plantar nerves.
16 Posterior Tibial Nerve Anatomy Located behind the posterior tibial nerve at the level of the medial malleolusPosterior Tibial NerveMedial Malleolus
17 Posterior Tibial Nerve provides sensation to the heel, medial and lateral sole of the foot
18 Sural Nerve AnatomyExtension of the tibial nerve and enters the foot between the Achilles tendon and lateral malleolus
19 Sural Nerve AnatomyLocated between the Achilles tendon and lateral malleolusLateral MalleolusSural Nerve
20 Sural Nerve provides sensation to the lateral foot
21 Saphenous Nerve Anatomy Terminal branch of the femoral nerve located anterior to the medial malleolus
22 Saphenous Nerve Anatomy Provides sensation to the anteromedial foot
23 Equipment Betadine and alcohol wipes Sterile gloves 4x4 or 2x2’s Sterile towelscc syringes with local anesthetic25 gauge needle 1.5 inch needle
24 Choice of Local Anesthetic Depends on the length of time you wish block to lastLonger acting local anesthetics may take longer for onsetMay wish to mix a local anesthetic that has faster onset with a longer acting local anestheticSodium bicarbonate may help speed onsetNEVER USE EPINEPHRINE!
26 Considerations Be careful with volume- tourniquet effect Caution in patients with peripheral vascular disease and diabeticsCare with patient with infection- risk of tracking infection to healthy tissue and local anesthetic not working due to acidotic tissue
27 Positioning the footPosition the foot so you have access to all 5 nerves
28 Blockade of the Deep Peroneal Nerve, Superficial Peroneal Nerve, and Saphenous Nerve can be blocked in one needle stick.
29 Deep Peroneal Nerve Block Draw a line between the two malleoliIdentify the extensor hallucis longus tendon and the extensor digitorum longus musclePalpate the anterior tibial artery
30 Deep Peroneal Nerve Block Place a skin wheal of local anesthetic lateral to the arteryAdvance the needle perpendicular, aspirating for blood and deposit 3-5 ml of local anesthetic deep to the extensor retinaculumMay choose to fan the injection in this area, avoiding the artery
34 Blocking the saphenous nerve At the site of the deep peroneal nerve blockade bring your needle back and redirect in a medial direction towards the medial malleolus depositing 3-5 ml of local anesthetic
35 Blocking the posterior tibial nerve Warn your patient to hold still in case a paresthesia is elicited. Movement at this time may result in trauma to the nerve.Identify the posterior tibial artery at the level of the medial malleolus and advance the needle in a posterolateral manner slowly.If a paresthesia is elicited withdraw the needle slightly and inject 3-5 ml. Make sure the patient does not have pain as this may imply an intraneural injection.If no paresthesia is elicited than inject 7-10 ml as you withdraw the needle. A paresthesia is not essential to a successful block.
37 Blocking the sural nerve Identify the lateral malleolus and the Achilles tendonInsert needle superficially lateral to the tendon and in the direction of the lateral malleolus.Inject 5-10 ml of local anesthetic subcutaneously as you withdraw the needle
39 Complications Discomfort to the patient Injury to a “numb” foot after dischargeNerve injury or paresthesia’sHematoma and vascular injuryInfectionIntravascular injectionBlock failure
40 Conclusion Easy to administer Effective anesthesia Often performed with much less local anesthetic than what textbooks advocate
41 Metatarsal Block A metatarsal block may supplement an ankle block if a nerve distribution has been missed.Never use epinephrine containing solutions. This can result in ischemia of the digits.Place a small skin wheal at the site of injection on the dorsum of the foot.Advance the needle while injecting local anesthetic parallel to the metatarsal bone. Do not go through the surface of the sole of the foot!
42 Metatarsal BlockThe individual nerves are located closer to the sole of the foot than the dorsum.A total of 3-5 ml of local anesthetic solution may be deposited.The same procedure should occur on the other side of the metatarsal of the location that anesthesia is desired.
44 ReferencesBurkard J, Lee Olson R., Vacchiano CA. Regional Anesthesia. In Nurse Anesthesia 3rd edition. Nagelhout, JJ & Zaglaniczny KL ed. PagesMorgan, G.E. & Mikhail, M. (2006). Peripheral nerve blocks. In G.E. Morgan et al Clinical Anesthesiology, 4th edition. New York: Lange Medical Books.Wedel, D.J. & Horlocker, T.T. Nerve blocks. In Miller’s Anesthesia 6th edtion. Miller, RD ed. Pages Elsevier, Philadelphia, PennWedel, D.J. & Horlocker, T.T. (2008). Peripheral nerve blocks. In D.E. Longnecker et al (eds) Anesthesiology. New York: McGraw-Hill Medical.