ANKLE BLOCK ANESTHESIA GREGORY CLARK D.P.M. HEAD, SECTION OF PODIATRY SCRIPPS CLINIC LA JOLLA, CALIFORNIA
A METHOD BY WHICH ONE MAY PROVIDE AN ANESTHETIC BLOCK TO THE FOOT OR ANKLE WITH A MINIMUM OF PATIENT DISCOMFORT
NEUROANATOMY OF THE ANKLE BLOCK POSTERIOR TIBIAL DEEP PERONEAL SUPERFICIAL DORSAL CUTANEOUS SURAL SAPHAENOUS Posterior Tibial Nerve Located Deep to Flexor Retinaculum on medial aspect of ankle. Posterior to Posterior Tibial Artery. Tom, Dick, and Very Nervous Harry Branches include Medial Calcaneal, Lateral Plantar, and Medial Plantar Nerves Innervates plantar aspect of the foot including toes.
Posterior tibial artery Posterior tibial nerve Flexor digitorum longus Tibialis posterior Medial calcaneal nerve Lateral plantar nerve Medial plantar nerve Flexor hallucis longus Deep Peroneal Nerve Located on dorsum of foot between the Extensor Hallucis Longus tendon and the Extensor Digitorum Longus tendon at the level of the cuneiforms. Closely associated with the Dorsalis Pedis Artery. Innervates the first interdigital web space.
Dorsalis pedis artery Deep Peroneal Nerve Extensor hallucis brevis Extensor digitorum brevis Dorsal Cutaneous Nerves Medial and Intermediate Dorsal Cutaneous Nerves. Extremely superficial nerves within the subcutaneous tissues on dorsum of foot. Innervate dorsum of foot to toes.
Superficial peroneal nerve Medial dorsal cutaneous nerve Deep peroneal nerve Intermediate dorsal cutaneous nerve Lateral dorsal cutaneous nerve (branch of sural nerve) Sural Nerve Located on lateral-posterior aspect of ankle posterior to the peroneal tendons. Innervates the lateral aspect of the foot to the fifth digit.
Sural nerve (cut) Sural nerve Saphaenous Nerve Associated with Greater Marginal Vein on antero-medial aspect of ankle and foot. Innervates dorso-medial aspect of foot to first MP joint.
Saphenous nerve Infrapatellar branch of saphenous nerve Medial crural cutaneous branches of saphenous nerve Local Anesthetic Block of the Foot and Ankle
Supplies Required Local anesthetic of choice. (Xylocaine or Marcaine with or without epinepherine Generally 10cc. To 15cc. of solution will suffice. Small-bore 1 1/4-inch needle. Topical anesthetic ti or skin refrigerant.
Steps of Block Position patient supine and comfortable. Provide blocks to nerves: Posterior Tibial: 5cc. Deep Peroneal: 1-2cc. Dorsal Cutaneous: 3cc. Sural: 3cc. Saphenous: 1-2cc. WAIT for blocks to take effect. POSTERIOR TIBIAL
DEEP PERONEAL DORSAL CUTANEOUS
SAPHAENOUS SURAL
COMPLETE AND TOTAL ANESTHESIA OF THE ENTIRE FOOT AND DISTAL ANKLE Digital Anesthetic Block
Many Surgical Procedures of the Foot Can Be Performed Under Local Anesthesia
ALIEN EXCISIONS!
SUMMARY: FOOT AND ANKLE BLOCKS Blocks provide excellent anesthesia of foot and ankle for most ALL procedures Easy and quick to administer Minimal discomfort to patients Increase patient confidence Excellent practice builder THANK-YOU
Small (Short) Saphenous vein Saral nerve Superficial peroneal nerve (Musculo-cutaneous a) Fibular malleolus Dorsal venous arch Perferating or Anastomotic veins Common dorsal digital veins
Lateral cutaneous branch of subcostal nerve (T.12) Lateral cutaneous nerve of thigh, post. branch Lateral cutaneous nerve of thigh, ant. branch Femoral brs. Of genito-femoral nerve (Lumbo-inguinal n.) Genital br. Of genito-femoral nerve (Ext. spermatic n.) Ilio-inguinal nerve Cutaneous branch of obturator nerve Intermediate cutaneous n. of thigh Medial cutaneous nerve of thigh, ant. branch Infrapatellar branch of saphenous nerve Saphenous nerve Cutaneous branchs of (lateral l popliteal l n.) common peroneal nerve (Musculo-cutaneous n.) Superficial peroneal nerve becoming dorsal digital nerves Dorsal lateral cutaneous nerve of foot Deep peroneal nerve (Anterior tibial n.)
Superficial Peroneal Nerve Deep Peroneal Nerve Saphenous Nerve Sural Nerve Nerve Anesthetized in Ankle Block Posterior tibial Deep Peroneal Sural Dorsal Cutaneous Saphaenous
Neuroanatomy of the Foot and Ankle
Mr. Osborne, may I be excused? My brain is full.
Medial plantar Medial plantar nerve Lateral plantar nerve
Lateral cutaneous branch of subcostal nerve (T.12) Lateral cutaneous nerve of thigh, post. branch Lateral cutaneous nerve of thigh, ant. branch Femoral brs. Of genito-femoral nerve (Lumbo-inguinal n.) Genital br. Of genito-femoral nerve (Ext. spermatic n.) Ilio-inguinal nerve Cutaneous branch of obturator nerve Intermediate cutaneous n. of thigh Medial cutaneous nerve of thigh, ant. branch Infrapatellar branch of saphenous nerve Saphenous nerve Cutaneous branchs of (lateral l popliteal l n.) common peroneal nerve (Musculo-cutaneous n.) Superficial peroneal nerve becoming dorsal digital nerves Dorsal lateral cutaneous nerve of foot Deep peroneal nerve (Anterior tibial n.) Superficial Peroneal Nerve Deep Peroneal Nerve Saphenous Nerve Sural Nerve
Small (Short) Saphenous vein Sural nerve Superficial peroneal nerve (Musculo-cutaneous a) Fibular malleolus Dorsal venous arch Perferating or Anastomotic veins Common dorsal digital veins
Posterior tibial artery Posterior tibial nerve Flexor digitorum longus Tibialis posterior Medial calcaneal nerve Lateral plantar nerve Medial plantar nerve Flexor hallucis longus Dorsalis pedis artery Deep fibular (peroneal) nerve Extensor hallucis brevis Extensor digitorum brevis
Mr. Osborne, may I be excused? My brain is full.
Superficial Peroneal Nerve Deep Peroneal Nerve Saphenous Nerve Sural Nerve
Posterior tibial artery Posterior tibial nerve Flexor digitorum longus Tibialis posterior Medial calcaneal nerve Lateral plantar nerve Medial plantar nerve Flexor hallucis longus
Posterior Tibial Nerve
Deep Peroneal Nerve Dorsal Cutaneous Nerves
Sural Nerve