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Regional Anesthesia > Apex- Lower extremity blocks > Flashcards

Apex- Lower extremity blocks Flashcards

1
Q

Which nerves arise from the lumbar plexus? (3)

  • Obturator
  • Posterior femoral cutaneous
  • Sciatic
  • Lateral femoral cutaneous
  • Pudendal
  • Femoral
A

Femoral

Obturator

Lateral Femoral Cutaneous

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2
Q

The lumbar plexus arises from the (anterior/posterior/ventral/dorsal) rami of ____________.

A

anterior/ventral rami of L1-L4

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3
Q

What 6 nerves arise from the lumbar plexus? (mneumonic)

A

I Inevitably Get Lazy On Fridays

Iliohypogastric

Ilioinguinal

Genitofemoral

Lateral femoral cutaneous

Obturator

Femoral

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4
Q

What is another name for the common peroneal nerve?

A

The common fibular nerve

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5
Q

What supplies sensory innervation to:

  • Anterior thigh:
  • Lateral thigh:
  • Posterior thigh:
A
  • Anterior thigh ► Femoral (L2-L4) [Lumbar plexus]
  • Lateral thigh:► Lateral Fem. Cutaneous (L2-L3) [Lumbar plexus]
  • Posterior thigh ► Posterior Fem Cutaneous (S1-S3) [Sacral plexus]
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6
Q

Motor innervation of the lateral cutaneous nerve

A

none

just sensory to the lateral thigh

L2-3

Lumbar plexus

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7
Q

Motor innervation of the femoral nerve

A

Sartorius (Anterior Branch)

Quadriceps (Posterior Branch)

(Sesnory = anterior thigh)

(L2-L4)

[Lumbar Plexus]

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8
Q

Sensory and motor innervation of the obturator nerve

A

Sensory = Distal inner thigh & Part of hip

Motor = Hip Adductors

(L2-L4)

[Lumbar Plexus]

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9
Q

What is the largest nerve in the body

A

Sciatic

(L4-S3)

[Sacral Plexus]

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10
Q

What supplies sensory and motor innervation to the posterior thigh?

A

Sensory = Posterior fem. cutaenous (S1-S3)

Motor = Sciatic

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11
Q

What nerve supplies the vast majority of sensory and motor innervation of the lower leg & foot

A

Siatiac

L4-S3

Sacral plexus

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12
Q

Roots of:

  • Iliohypogastic
  • Ilioinguinal
  • genitofemoral
  • Lateral Femoral cutaneous
  • Obturator
  • Femoral
A
  • Iliohypogastic ► L1
  • Ilioinguinal ► L1
  • Genitofemoral ► L1 + L2
  • Lateral Femoral cutaneous ► L2 + L3
  • Obturator ► L2 + L3 + L4
  • Femoral ► L2 + L3 + L4

(I ineveitably get lit on fridays)

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13
Q

Posterior Femoral Cutaneous vs Sciatic Roots

A

Sciatic - L4-S3

Post fem- S1-S3

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14
Q

match cutaneous innervations with:

Sural

Obturator

Superficial peroneal

Posterior Femoral cutaneous

A

A = Posterior Femoral cutaneous

B = Obturator

C = Superior peroneal

D = Sural

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15
Q

What does the saphenous nerve branch off of?

A

The femoral nerve

-sensory to the medial lower leg

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16
Q

what nerve is the common peronal nerve a branch of?

A

The sciatic ( > superifical and deep peroneal)

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17
Q

What nerve is the tibial nerve a branch of?

A

sciatic ( > Sural and posterior tib)

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18
Q

label

A
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19
Q

What nerve pervices sensory innervation to the medial lower leg

A

Saphenous (branch of femoral)

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20
Q

What nerve supplies sensory innervation to the lateral foot

A

Sural (branch of sciatic > tibial)

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21
Q

Which nerves supplies sensory innervation to the back of the heel?

A

Tibial nerve (branch of sciatic)

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22
Q

fill this sucker in

A
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23
Q

The Psoas compartment block anesthetizes all of the following nerves EXCEPT the:

A. Obturator

B. Lateral Femoral Cutaneous

C. Sciatic

D. Saphenous

A

C. Sciatic

*Lumbar plexus = Obturator, Lat Femoral, & Femoral

  • Saphenous is a division of the femoral so rule that out and your left with sciatic which is from the sacral plexus
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24
Q

The lumbar plexus is contained within a sheath inside the _____ compartment. At this poin the plexus is:

  • Lateral to the ►
  • Anterior to the ►
  • Posterior to the ►
A

Psoas compartment

  • Lateral to the ►Vertebral column (LoVe)
  • Anterior to the ► QUAd muscle (AQUA)
  • Posterior to the ► Psoas muscle (PP​)
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25
Q

A psoas compatment block targets what 3 major nerves of the lumbar plexus?

When is this block useful?

A

Lateral fem cutaneous, Femoral, Obutrator

LFO!!!

-useful when neuraxial anesthesia is contraindicated and/or anesthesia to one lower extremity is preferred

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26
Q

Another name for a Lumbar Plexus Block

A

Psoas Compartment block

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27
Q

Where is the intercristal line is where

A

L4-5 interspace

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28
Q
  1. What the heck are we looking at
  2. Where would you mark the hot spot
A

It’s a psoas compartment block

AKA lumbar plexus block

*3cm caudad from L4 and 5cm lateral from midline

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29
Q

T/F- blockade of the lumbar plexus creates a sympathectomy of the ipsilateral extremity

A

True

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30
Q

Which lower extremity block has the highest complications rates and what are they?

A

Psoas compartment block/Lumbar plexus block

-retroperitonal hematoma and renal capsular injection

(coagulation = contraindication)

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31
Q

What is the contraindication to a lumbar plexus block?

A

coagulopathy

(high risk of retroperitonal hematoma and renal capsular injection)

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32
Q

with a psoas compartment block, volumes greater than ____mls increase risk of bilateral spread and contralateral imb involvement

A

>20mls

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33
Q

Match with:

Femoral vein, Femoral Artery, Femoral Nerve, Fascia lata

A

A + Femoral vein

B + Femoral artery

C + Fascia lata

D + Femoral nerve

VAN (from medial to lateral): Vein > Artery > Nerve

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34
Q

Pick 2 statements that BEST describe the proper technique for performing a fascia iliaca compartment block:

  • Two pops should be felt before injecting the local anesthetic
  • Ultrasound is required
  • Local anesthetic is deposited anterior to the iliopsoas muscle
  • Local anesthetic should be deposited b/t the fascia iliaca and fascia lata
A

-Two pops should be felt before injecting the local anesthetic

-Ultrasound is required

-Local anesthetic is deposited anterior to the iliopsoas muscle

-Local anesthetic should be deposited b/t the fascia iliaca and fascia lata

35
Q

T/F: A femoral nerve block provides almost complete surgical coverage to the lower extremity

A

False

-it provides coverage to the thigh, knee, and medial lower leg

*when combined with sciatic nerve block, it provides almost complete surgical coverage to the lower extremity

36
Q

The femoral nerve arises from the (anterior/posterior) divisions of ___ - ____.

A

Posterior L2-L4

37
Q

label

A

Gray = medial: adductor longus

Black = Superior: inguinal ligament

Brown = Lateral: Sartorius

Remember the borders of the femoral nerve as SAIL:

S= Sartoris muscle (Lateral

A= Adductor longus muscle (Medial)

IL= inguinal ligament

38
Q

The femoral nerve runs:

Deep to the ►

Anterior to the ►

Inferior to the ►

A

Deep to the ► inguinal ligament

Anterior to the ► iliopsoas msucle

Inferior to the ► fascia lata and fascia iliaca

39
Q

Mneumonic to remember the femoral nerve borders

A

SAIL:

S= Sartoris muscle (Lateral

A= Adductor longus muscle (Medial)

IL= inguinal ligament

40
Q

During a femoral nerve block, what should you do if you observe inner thigh twitches and what does that indicate?

A

your stimulating the sartorius muscle

needle is too superficial and/or medial to the femoral nerve

-withdraw and advance in a slighlty lateral direction away from the femoral artery until proper stimulation is achieved (quad contraction “Patellar snap”)

41
Q

Where should the transducer be placed to identify the major anatomical landmarks for a femoral nerve block?

A

inguinal crease

42
Q

Label

A
43
Q

The (anterior/posterior) division of the femoral nerve innervates the quadriceps muscle which is generally found on the (medial/lateral) aspect of the femoral triangle.

A

posterior- lateral

44
Q

What kind of block can be thought of as a femoral nerve block lower in the thigh

A

Adductor Cannal Block

(The femoral nerve is beneath the sartorius muscle at this location).

45
Q

Why is the adductor canal block used instead of just a regular femoral nerve block up higher

A

bc motor nerves branch off higher in the femoral nerve, above the level of the adductor canal - so you can provide analgesia without affecting quad function

46
Q

What is a different approach to the femoral nerve block where the needle insertion point is more lateral and distant from the femoral neurovascular bundle?

A

Fascia Iliaca Block

47
Q

T/F - nerve stimulation or ultrasound is not required when performing a fascia iliaca block

A

True

48
Q

Where is the local anesthetic depostied when doing a fascia iliaca block?

A

inferior to the fascia iliaca but superior to the iliopsoas muscle

49
Q

Which peripheral nerve block can be combined with a sciatic nerve block to enhance the tolerance of a lower leg tourniquet?

  • Sural
  • Common peroneal
  • Saphenous
  • Posterior tibial
A

-Saphenous

(Aa continuation of the posterior branch of the femoral nerve)

50
Q

The combination of what 2 blocks provides complete anesthesia to the lower leg, ankle, and foot.

A

Sciatic (or popliteal) + Saphenous

51
Q

Increasing tolerance of an upper leg tourniquet requires what kind of nerve block?

A

Sciatic + psoas compartment block

or 3-in-1 block (femoral, obturator, lateral, femoral cutaneous)

52
Q

T/F- the saphenous nerve provides no motor innervation

A

true

53
Q

What nerve provides sensory innervation from the medial knee to the medial malleous

A

Saphenous

54
Q

What is the saphenous nerve a terminal branch of?

A

the posterior division of the femoral nerve

55
Q

Which block involves locating the hunters canal and what is that

A

Saphenous nerve

-point where the sartorius, adductor longus, and vastus medialis meet distal to this? idk

56
Q

The sciatic nerve provides motor innervation to the: (select 2):

  • semitendinous
  • biceps femoris
  • quadriceps
  • sartorius
A
  • semitendinosus
  • biceps femoris

(and the semimembranous muscles)

57
Q

T/F- the sciatic nerve is two nerves

A

True

The siatic nerve is 2 nerves contained within a sheath

(Tibial and peroneal nerves

58
Q

What two nerves make up the sciatic nerve

A

the tibial and peroneal

59
Q

label

A

leg anatomy answers

60
Q

What two blocks can be done for a patient having surgery on the leg/knee who may not tolerate sympathectomy from a neuraxial block?

A

Sciatic nerve block and lumbar plexus block

or

Sciatic nerve block & Femoral nerve block (knees)

61
Q

What block has a landmark approach known as the classic or Lambat approach?

A

Sciatic

62
Q

For a sciatic block, the patient is placed in what position with the operative leg in the (dependent/nondepdendent) position and slightly (flexed/exteneded)

A

Sims position

-operative > nondependent position

slightly flexed

63
Q

What should you do if while advancing through the gluteal muscles for a sciatic nerve block, a motor response is encountered

A

continue advancing the needle until plantar or dorsiflexion is elicited

64
Q

For surgical anesthesia with a sciatic nerve block, what is preferred…. plantar flexion or dorsiflexion and which nerve component correleates

-which is foot inversion vs foot eversion?

A

Plantar FLEXION preferred

  • Foot Inversion
  • Tibial nerve component

Dorsiflexion

  • Foot eversion
  • Common peroneal nerve
65
Q

During a sciatic nerve block, how should you redirect your needle if you contact bone?

what about aspirate blood? (& where would it come from?)

A

Bone ► redirect medially

Blood ►redirect laterally (Superior gluteal artery)

66
Q

What nerve does the popliteal nerve block target?

A

The sciatic nerve (in the proximal popliteal fossa)

67
Q

At the proximal popliteal fossa, how is the sciatic nerve positioned to the popliteal artery and vein?

  • borded medially by:
  • borded laterally by:
A

posterior and lateral to the popliteal artery and vein

-borded medially by:

  • The semitendinosus and semimembransoues muscles

-borded laterally by:

  • The biceps formis muscle
68
Q

What forms the apex and base of the triangle when doing a popliteal block

A

Base = popliteal crease at the knee

Apex = convergence of the biceps formis and semitendinousus muscles

69
Q

Label

A
70
Q

Optimal position when placing a popliteal nerve block

A

Prone

71
Q

For a popliteal block, a line is drawn along hte popliteal crease from what to what?

at midpoint, a 2nd line is drawn perpindicular and cephalad _____ cm to the apex of the triange.

-the needle insertion point is ___cm (medial/lateral) to the apex

A

Medial border of the biceps femoris > lateral border of the semitendinousus muscle

  • 7-10cm to apex
  • 1cm laterally
72
Q

When doing a popliteal block, when do you stop advancing the needle?

A

once plantar or dorsiflexion is obtained

(plantar flexion = better [tibial])

73
Q

label

A

Common peroneal nerve and Tibial nerve

Popliteal vein > Popliteal artery

74
Q

If using ultrasound for a popliteal block, which patient position would make the U/S image be inverted?

A

supine - it should be reversed to the proper orientation

75
Q

When doing a popliteal block, what is the desired location for local anesthetic placement?

A

Where the sciatic nerve begins to bifurcate

76
Q

T/F- once the sciatic nerve is identified, the needle should be aimed directly at the nerve

A

False - slighlty to one side

(Remember the goal is not to directly inject the nerve but to bathe it)

77
Q

Match:

  • Dorsum of the foot ►
  • Lateral aspect of the foot ►
  • Web space between 1st and 2nd toe ►
  • Heel ►

With: Superficial peroneal nerve, Deep peroneal nerve , sural nerve, tibial nerve

A
  • Dorsum of the foot ►Superficial peroneal
  • Lateral aspect of the foot ► Sural
  • Web space between 1st and 2nd toe ►Deep peroneal (deep in that web)
  • Heel ► Tibial nerve
78
Q

What 5 nerves does an ankle block anesthetize? Which ones are purely sensory vs sensory + motor

A
  1. Superficial Peroneal
  2. Sural
  3. Saphenous
  4. Tibial (inversion + plantar flexion)
  5. Deep peroneal (eversion + dorsiflexion)

*The S’s are purely sensory

79
Q

label

A
80
Q

What is the medial calcaneal nerve and what does it innervate?

A

It’s a subdivision of the tibial nerve and it innervates the heel

81
Q

Label

A
82
Q

Injecting a ring of local anesthetic from the midpoint of the distal tibia toward the inferior border of the medial malleolus will most likely anesthetize the:

A. Sural nerve

B. Tibial nerve

C. Superficial peroneal nerve

D. Saphenous nerve

A

D. Saphenous nerve

83
Q

T/F- an ankle block can be used for surgies involving the foot and the ankle

A

false- foot BELOW the ankle

Regional Anesthesia (6 decks)

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