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Principles 2 > Lower Extremity Blocks > Flashcards

Lower Extremity Blocks Flashcards

1
Q

What nerves are blocked in the Fascia Iliaca Block?

A

AKA the 3 in 1 block
-Femoral Nerve
-Lateral Femoral Cutaneous
-Obturator (unreliable coverage)

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2
Q

Why is the Fascia Iliaca block called a Volume Dependent Compartment Block?

A

High volume of dilute LA solution needed to catch all the individual nerves

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3
Q

What are the indications for the Fascia Iliaca Block?

A

-Anterior Thigh
-Knee Surgery
-Hip procedures
-Femur Fx

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4
Q

What are the complications associated with the Fascia Iliaca Block?

A

Very safe block to perform, no major nerve or blood vessels near site of injection.

Complications:
-Block failure
-Hematoma
-Toxicity
-Nerve damage

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5
Q

What are the two approaches to the Fascia Iliaca Block?

A

-Transverse
-Parasagittal

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6
Q

Describe the Transverse Approach to the Fascia Iliaca Block.

A

-Probe is placed in Femoral Crease
-Inject LA just below fascia iliaca, covering iliacus muscle (lateral 1/3 of line between ASIS and pubic tubercle)
-Hope LA will leak towards Lateral Fem Cutaneous nerve (can be blocked individually)

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7
Q

Describe the Parasagittal Approach to the Fascia Iliaca Block.

A

-Start in femoral crease
-Locate ASIS and move medially until “Bow Tie” appears
-Insert needle up and underneath fascia iliaca, driving LA up and underneath fascia
-Goal: Injection of LA below Fascia Iliaca, between Sartorius and Internal Obliques.

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8
Q

What is innervated by the Anterior Division of the Femoral Nerve?

A

-Cutaneous branches: Intermediate and medial femoral cutaneous nerve (cutaneous innervation to anterior thigh)
-Muscular branches: Pectineus and Sartorius muscles

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9
Q

What is innervated by the Posterior Division of the Femoral Nerve?

A

-Motor innervation to the Quadriceps: Rectus Femoris and Vastus muscles (lateralis, medialis, and intermedius)
-Articular Branches: sensory innervation to the knee joint.

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10
Q

What are the indications for a Femoral Nerve Block?

A

-Anterior thigh
-Knee Surgery
-ACL, PCL Patellar tendon
-Total/partial joint
-Has fallen out of favor due to quad weakness and falls (now doing more Adductor Canal Blocks)

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11
Q

What makes up the Femoral Triangle?

A

-Ilioinguinal Ligament
-Adductor Longus muscle
-Sartorius muscle

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12
Q

What is the relevant anatomy for a Femoral Nerve Block?

A

-Femoral Triangle
-NAVEL or VAN

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13
Q

Describe the Nerve Stimulator technique for a Femoral Nerve Block.

A

-Supine (obese may need retraction of pannus)
-Palpate femoral artery in femoral crease
-Insert needle lateral to artery, perpendicular to skin, slightly cephalic
-Goal: Quad twitch (Patellar snap)

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14
Q

What must be pierced for the Femoral Nerve Block to work?

A

The Fascia Iliaca.
-Femoral Nerve runs in the groove created by iliacus and Psoas muscles, below the iliacus fascia
-Won’t soak into nerve itself if it’s above the fascia iliaca.

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15
Q

How would you perform a Femoral Nerve Block? (US)

A

-US probe in femoral crease
-Nerve appears oval or triangular, usually hyper echoic
-Needle is inserted lateral to medial
-LA must be injected below the Fascia Iliaca
-Encircle nerve with LA

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16
Q

What are the indications for a Lateral Femoral Cutaneous nerve block?

A

-Lateral thigh
-Hip procedures
-Tourniquet pain

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17
Q

How do you locate the Lateral Femoral Cutaneous nerve?

A

-LFCN runs between the Tensor Fascia Lata muscle and the Sartorius muscle.
-Find ASIS, palpate ilio inguinal ligament. Orient needle in lateral to medial, slightly caudal fashion and create a fan pattern of LA to try to catch nerve.
-Injection must dissect fascial layer between muscles
-5-10 mL LA
-Sensory only nerve

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18
Q

What does the Obturator nerve innervate?

A

Motor to Adductor muscles:
-Magnus, Longus, Brevis, Gracilis

Sensory:
-Skin: Medial thigh, knee
-Medial knee joint

19
Q

What are the indications for an Obturator nerve block?

A

-Knee surgery
-Amputations
-Tourniquet pain
-TURBT surgery (knee jerk scenario that occurs with obturator nerve stimulation during ablation of tumor)

20
Q

How do you perform an Obturator Nerve Block?

A

-Patient supine, with leg abducted and slightly externally rotated
-Probe 2-3 cm distal to femoral crease
-Interfacial approach: inject LA in a facial plane (between muscles): Longus-Brevis and Brevis-Magnus
-Nerve stimulator will produce adduction for both branches

21
Q

What are the benefits of the Adductor Canal Block?

A

-Blocks sensory to the knee
-Motor sparing (vastus medialis is occasionally blocked tho)
-Decreases opioid usage and patient can still ambulate
-Can be done in combo with a popliteal block for foot/ankle procedures.

22
Q

What are the indications for an Adductor Canal Block?

A

-Knee surgery
-Medial leg/Ankle procedures

23
Q

How do you perform an Adductor Canal Block?

A

-Probe is placed mid-thigh
-Needle is inserted anterior to posterior
-Locate the Superficial Femoral Artery under the Sartorius muscle.
-15-20 mL of LA is injected to displace the Sartorius muscle.
-LA needs to be on both sides of the Superficial Fem. Artery
-Saphenous nerve is not always visible
-Can place continuous catheter above Super. Fem Artery, but absolutely needs to be below Sartorius muscle.
-Can lay catheter up/over artery and use arterial pulsations to move LA around.

24
Q

What does the Sciatic nerve innervate?

A

The longest peripheral nerve in the body.
-Motor innervation to the hamstring muscles and the muscles of the lower leg and foot
-Sensory Innervation to the posterior thigh and the majority of the area below the knee (lower leg and foot, except Saphenous)

25
Q

What are the indications for Sciatic nerve block?

A

-Knee surgery: Adjunct to Femoral or AC
-Surgery of posterior Leg: Hamstring reattachment
-Surgery of lower leg or foot

26
Q

How do you perform a Sciatic Nerve block?

A

-Curvilinear probe may be needed
-Long block needle may be required
-Goal: Twitch of calf, foot, or toes

27
Q

Why is Hamstring twitching not a reliable predictor of Sciatic nerve stimulation?

A

Hamstring innervation leaves the sheath early.
-Could be getting direct muscle stimulation of hamstring muscles themselves.

28
Q

What are the complications that occur with Sciatic Nerve blocks?

A

-Infection
-Hematoma
-Vascular puncture (femoral artery and vein)
-LA toxicity
-Nerve injury: Sciatic nerve is uniquely sensitive to mechanical and pressure injury.

29
Q

How do you prevent nerve injury to the sciatic nerve?

A

-Nerve stimulation and slow needle advancement should be employed
-Never inject on pain or pressure
-Never inject with <0.2 mA
-Avoid using Epi!!
-Use Ropivicaine

30
Q

Describe the Anterior approach to the Sciatic Nerve.

A

-Draw a line in between ASIS and Pubic tubercle (shows you where ilio inguinal ligament lies)
-Feel femoral pulse
-Draw a perpendicular line 4-5 cm from the line for insertion site
-Puts you over the top of lesser trochanter of femur
-Needle inserted perpendicular to skin (may need longer needle -sciatic is very deep)
-Advance until twitch of calf, foot, or toes seen
-Contact with bone: Frequently due to contact with lesser trochanter. Withdraw needle 1-3cm. Internally rotate leg. Re-advance needle to just past bone.
-Elevate heel off of bed to help identify twitches
-Sciatic nerve is prone to injury: Avoid vasoconstrictors, use careful needling, and prevent mechanical injuries of the anesthetized limb)
-Risk of injury to Femoral nerve if it is anesthetized first.

31
Q

Describe the Subgluteal approach to the Sciatic Nerve.

A

-Probe is underneath gluteal fold (a few cm distal from between Greater Trochanter and Ischium Tuberosity)
-Sciatic nerve is located below gluteus maximus, between femur and ischial tuberosity.
-Don’t have to go through gluteus maximus (less tissue, may allow for use of linear probe).
-Less variability
-Search laterally/medially to find nerve.

32
Q

What are the indications for a Popliteal approach to the Sciatic nerve?

A

-Foot or Ankle surgery
-Analgesia adjunct for knee surgery
-Frequently paired with Femoral or Adductor Canal

33
Q

What are the landmarks for the Popliteal approach to the Sciatic nerve? (NS)

A

-Popliteal Fossa Crease
-Lateral: Tendon of Biceps Femoris
-Medial: Tendon of Semitendinous and Semimembranosus
-Measure 7cm from crease
-Needle insertion midpoint between tendons
-Typically 3-5cm deep
-Sciatic nerve can run just lateral to midpoint.

34
Q

How do you perform the Popliteal Approach to the Sciatic nerve? (US)

A

-Probe transverse at popliteal crease
-Identify artery, vein, and tibial nerve (Tibial nerve lays directly above and slightly off center to popliteal artery)
-Move proximally
-Watch tibial and peroneal come together
-Place injection when 2 have converged together

35
Q

What is the indication for an individual Tibial Nerve Block?

A

-Total knee: Avoids the foot drop seen when peroneal nerve is also anesthetized

Care taken to only place LA near tibial nerve leaving Peroneal untouched

36
Q

What is the indication for an Ankle Block?

A

Foot and toe surgery

37
Q

What 5 nerves are blocked in an Ankle Block?

A

-Superficial Peroneal
-Sural
-Saphenous
-Posterior tibial
-Deep Peroneal

38
Q

How do you identify the Deep Peroneal Nerve?

A

-Identify Extensor Hallucis Longus
-Insert needle just lateral, advancing until contact with bone, withdraw 2 mm and inject 2-4 ml of LA

US: runs with anterior tibial artery

39
Q

How do you identify the Posterior Tibial Nerve?

A

Identify medial malleolus, insert posterior to and contact bone, withdraw 2mm and inject 2-4 ml of LA

US: runs immediately posterior to posterior tibial artery

40
Q

The superficial nerve blocks of an Ankle Block are blocked by ?

A

Creating a subcut wheal around the entire ankle.

41
Q

How do you block the Saphenous nerve in an ankle block?

A

Create a Wheel from tibial ridge directed medially to Achilles

US: Small nerve visualized proximal to medial malleolus. Runs with the Saphenous vein

42
Q

How do you block the Superficial Peroneal nerve in an ankle block?

A

Create a Wheel from tibial ridge laterally to lateral malleolus

US: nerve lies superficial to fascia. Probe proximal and anterior to lateral malleolus

43
Q

How do you block the Sural nerve in an ankle block?

A

Create a Wheel from lateral malleolus to Achilles

US: Proximal to lateral malleolus, runs with small saphenous vein

Principles 2 (45 decks)

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