Regional Anaesthesia

Regional Anaesthesia

Lower limb anatomy and blocks

Hip and Knee Joint

Hip Joint: Nerve supply Lumbar plexus Femoral nerve through the nerve to the Rectus Femoris Ant division of the Obturator nerve The Accessory Obturator nerve Sacral plexus The nerve to the quadratus femoris The Sup Gluteal nerve

Knee Joint Femoral nerve, through its branches to the VasD esp VasD Medialis Obturator through its post division Scia=c nerve through genicular branches of the Tibial and Common Peroneal

Ankle Joint Scia=c nerve Tibial n Superficial Peroneal n Deep Peroneal n

Lumbo- Sacral Plexus FormaDon and Branches

Lumbo- sacral plexus Lumbar plexus Ant rami L 1-4, Frq include branches from T 12 and occ from L 5 Sacral plexus S 1,2,&3 Sacral nerves Plus branches from the ant rami of L 4,5

Dorsal division Upper and lower divisions L 1 Ventral division Iliohypogastric nerve Lat cut n. of thigh L 2 L 3 Genitofemoral nerve Ilioinguinal nerve L 4 Femoral nerve Branch to lumbosacral trunk Obturator nerve

L 4 L 5 Sup gluteal nerve S 1 Inf gluteal nerve S 2 Sciatic nerve S 3 Post cut n. of thigh S 4 Pudendal nerve

Motor responses if using PNS + US Ant Femoral Sartorius Post Femoral Quads ( Dancing of Patella) Common Peroneal n sdmuladon Dorsiflexion Eversion of the foot Tibial nerve sdmuladon Plantar flexion Inversion of the foot

Genito-femoral nerve Lateral cutaneous nerve of thigh Obturator nerve Femoral nerve Sciatic nerve

Obturator nerve Lateral cutaneous nerve of thigh Femoral nerve Sciatic nerve

Femoral Nerve

PELVIS ILIACUS L 2 L 3 L 4 Femoral nerve RECTUS FEMORIS HIP JOINT Lat circumflex femoral artery PECTINEUS SARTORIUS VASTUS LATERALIS INTERMEDIUS MEDIALIS MED FEMORAL CUT NERVE INTERMEDIATE FEMORAL CUT NERVE KNEE JOINT FEMORAL ARTERY INFRAPATELLAR BRANCH DEEP FASCIA BELOW KNEE SAPHENOUS NERVE

Femoral Nerve above the Inguinal Ligament Femoral Nerve below the Inguinal Ligament Iliac Vessels Femoral vessels Sartorius

Fascia Lata Fatty tissue between the two fascia often mistaken for the nerve Femoral Nerve Facia Iliaca

Fascia Lata Fatty tissue between the two fascia often mistaken for the nerve Femoral Nerve Femoral Artery Facia Iliaca

Ultrasound Guided

Probe Gel Iliopsoas

Saphenous nerve

Sub- sartorial

Not a single nerve but Nerve to Vastus Medialis and Saphenous nerve lie together and a muscular response can be elicited by using PNS Femoral artery

Nerve to Vastus Medialis Saphenous Nerve

LCFN

Lat cut nerve of the thigh

Internal oblique muscle Iliacus Fascia External oblique Aponeurosis ASIS Single pop through fascia lata, deposit LA above and below the fascia to catch the main and the cut branches 1 cm Iliacus Muscle Inguinal ligament Fascia Lata

Fascia Lata Fascia Iliaca ASIS

Obturator Nerve

AL OBTURATOR NERVE

OBTURATOR NERVE L 2 L 3 PELVIS OBTURATOR EXTERNUS L 4 OBTURATOR FORAMEN ADDUCTOR BREVIS THIGH ADDUCTOR PORTION OF ADDUCTOR MAGNUS HIP JOINT ADDUCTOR BREVIS ADDUCTOR LONGUS Ant Div Post Div KNEE JOINT TWIG TO PECTINIUS GRACILIS MEDIAL THIGH SKIN OVER ADDUCTORS

FEMORAL VESSELS OBTURATOR NERVE FEMORAL NERVE PT 2Cms 2Cms

AL Adductor Longus AB Adductor Brevis AM Adductor Magnus

3 in 1 Block!!!

Lat Cut Nerve of Thigh Psoas Major Single injection large volume misses out Obturator as it lies on the medial side ( sometimes within the substance) of the Psoas muscle Iliacus Femoral Nerve Iliopsoas Inguinal ligament Obturator Nerve

SciaDc Nerve

Sciatic nerve Popliteal fossa Tibial nerve Common peroneal Med & lat plantar nerves Sural nerve Superficial Peroneal Deep Peroneal

SciaDc nerve

Approaches to SciaDc Nerve in the Gluteal Region

GT IT PSIS Sacral Hiatus

Gluteus Maximus Sciatic Nerve

Popliteal Fossa

Artery Vein Nerve Medial Lateral Tibial Sural Common Peroneal

Tibial n Semimembranous Biceps Femoris Common Peroneal n Sural communicating branch Medial and lateral heads of Gastronemius Sural n

LA around the nerve

Distal spread of LA around the main baranches

ANKLE

Superficial Peroneal nerves Great Saphenous Vein and Saphenous Nerve Medial Malleolus Dorsal Paedis Artery Deep Peroneal Nerve Lateral Malleolus Post Tibial Artery Tibial Nerve Achilles Tendon Sural Nerve Small Saphenous Vein

Saphenous Sural Superficial Peroneal Deep Peroneal Medial plantar Lateral plantar

Post Tibial

Sural nerve at level of Lat Malleolus Short Saphenous vein

Deep Peroneal at the ankle level Ant Tibial Artery

Cases Anaesthesia and Blocks

82 yrs old padent listed for Dynamic Hip Screw ( DHS)

78 yrs old padent for hemi- arthroplasty

28yr old padent for ORIF of Tibia and Fibula

55 yrs old diabedc padent for amputadon of the big toe of Rt foot