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Anesthesia Principles II > Lower Extremity Blocks > Flashcards

Lower Extremity Blocks Flashcards

1
Q

name innervations of these areas (clockwise rotation)

A

genitofemoral
ilioinguinal
obturator
anterior femoral cutaneous
saphenous
lateral femoral cutaneous

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2
Q

name the blocks of the LE

A

femoral plexus block
fascia iliaca block
single nerve blocks
femoral nerve
obturator nerve
later femoral cutaneous nerve

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3
Q

Which block is also known as the 3 in 1 block?

A

fascia iliaca block

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4
Q

what nerves are blocked in the fascia iliaca block?

A

femoral nerve
lateral femoral cutaneous nerve
obturator (unreliable coverage)

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5
Q

which block is a volume dependent compartment block?

A

fascia iliaca block

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6
Q

what volume is used for fascia iliaca block?

A

40-60ml of LA

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7
Q

fascia iliaca block indications?

A

anterior thigh
knee surgery
hip procedures
femur fx

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8
Q

name these structures

A

top to bottom:

lateral femoral cutaneous nerve
inguinal ligament
femoral nerve

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9
Q

why is the fascia iliaca block so safe?

A

no major nerve or blood vessels near site of injection

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10
Q

complications fo fascia iliaca block?

A

block failure
hematoma
toxicity
nerve damage

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11
Q

position for fascia iliaca block?

A

supine

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12
Q

can fascia iliaca block be perfomed reliably under non US techniques? what are these techniques?

A

no

these unreliable techniques are the pop pop technique and NS technique

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13
Q

what two appraoches wit US probe can be used for fascia iliaca block?

A

transverse and parasagital

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14
Q

describe transverse approach to fascia iliaca block

A

probe placed transverse over femoral artery and slid lateral

injection is placed around lateral 1/3 of lien betwen ASIS and pubic tubercle

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15
Q

where will you see lateral femoral cutaneous nerve when doing transverse approach to the fascia iliaca block? Can it be blocked individually?

A

between sartorius and tensor fascia lata muscle

yes

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16
Q

name this view and structures

A

medial view with tranverse probe for fascia iliaca block

(clockwise)
femoral artery
femoral nerve
ilacus muscle
fasci iliaca

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17
Q

name this view and structures

A

Middle view (between medial and lateral) with transverse prove for fascia iliaca block

ilacus muscle and sartorius muscle

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18
Q

name this view and structures

A

lateral view with tranverse probe for fascia iliaca block

tensor fascia lata muscle, lateral femoral cutaneous nerve, and sartorius muscle

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18
Q

describe parasagittal approach to fascia iliaca block

A

locate ASIS and move prove medially until target appears. “bow tie” appearance

needle approach from inferior edge of probe

goal: injection of LA below fascia iliaca between sartorius and internal obliques

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19
Q

name this block and technique

A

parasagittal approach for fascia iliaca compartment block

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20
Q

name this block with the technqiue and each structure

A

fascia iliaca block with US parasagittal approach

abdominal muscle
iliacus
fascia iliaca
sartorius

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21
Q

which nerve block is very easy to learn because of consitent anatomy, superficial location, and it is easy to find?

A

femoral nerve block

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22
Q

two main divisions of the femoral nerve?

A

anterior and post divisions

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23
Q

divisions of the anterior division of the femoral nerve and their function?

A

cutaneous branches:

intermediate and medial femoral cutaneous nerves, cutaneous innervation to anterior thigh

muscular branches
pectineus and sartorius

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24
Q

divisions of post division of femoral nerve and their function?

A

motor innervation to quadriceps
rectus femoris
vastus lateralis
vastus medialis
vastus intermedius

articular branches: sensory innervation to knee joint

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25
Q

what makes up the femoral triangle

A

sartorius m. adductor longus m. ilioinguinal ligament?

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26
Q

indications for femoral nerve block?

A

ant thigh surgery
knee surgery, ACL, PCL, patellar tendon

total/partial joint: has fallen out of favor because of quad weakness and falls. Adductor canal used instead

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27
Q

what is in the femoral triangle?

A

VAN
vein artery nerve from medial to lateral

or lateral to medial NAVEL (nerve, artery, vein, lymph nodes, empty space)

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28
Q

is the femoral nerve block easy via NS technique

A

yep

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29
Q

positioning for femoral nerve block?

A

patient is supine, obese may need panniculus retraction

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30
Q

femoral nerve block technique under NS

A

femoral artery palpated in femoral crease

needle inserted lateral to artery and perpendicular to skin, slightly cephalic

looking for quad twitch or patellar snap

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31
Q

what is this?

A

femoral nerve block under NS

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32
Q

what is this?

A

femoral nerve block under NS

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33
Q

anatomically where does femoral nerve run?

A

in groove created by iliacus and psoas muscles

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34
Q

what to do if you get no response for femoral nerve block when using NS?

A

you are either too meidal or too lateral, try again

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35
Q

what to do if you hit bone during femoral nerve block when using NS?

A

you are too deep, withdraw to level of the skin and repeat the procedure

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36
Q

what to do if you get local twitch for femoral nerve block when using NS?

A

direct stim of the iliopsoas or pectineus m., needle is too deep or too cranial, re try the procedure

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37
Q

what to do if you get sartorius muscle twitch with femoral nerve block when using NS?

A

needle tip is slighty anterior and medial, redirect needle laterally and deeper,

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38
Q

what to do if you get vascular puncture with femoral nerve block when using NS?

A

needle is too medial, withdraw and insert 1cm laterally

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39
Q

how to do US guided femoral nerve block?

A

place probe in femoral crease, insert needle lateral to medial in the in plane fashion

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40
Q

how might femoral nerve appear under ultrasound?

A

oval or triangular (actually a ton of different nerves all together), usually hyperechoic

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41
Q

name this block

A

femoral nerve block under ultrasound

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42
Q

where must LA be injected for femoral block?

A

below facia iliaca

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43
Q

name this block, and is this the first or second needle position?

A

femoral block, first needle position, inject 1/2 LA here

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44
Q

name this block and the needle position. (ist or second)

A

fem block 2nd needle position

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45
Q

name the structures

A

femoral block

femoral vein
femoral artery
femoral nerve
iliacus muscle

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46
Q

indications for lateral femoral cutaneous nerve block?

A

lateral thigh
hip procedures
trourniquet pain

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47
Q

are non-US techniqes reliable for lat fem cutaneous block?

A

no, but they are still used a lot

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48
Q

name this block

A

lateral femoral cutaneous block

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49
Q

what position for lateral femoral cutaneous block?

A

can be supine or lateral

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50
Q

if you use NS with lat fem cutaneous block what is the goal?

A

paresthesia to lateral thigh

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51
Q

where does LFCN run?

A

between tensor fascia lata muscle and sartorius m.

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52
Q

what voluem for LFCN block?

A

5-10cc LA

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53
Q

what do you want the injected LA to do in LFCN block?

A

dissect facial layer between muscles

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54
Q

name this block

A

obturator nerve block

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55
Q

what does obturator nerve innervate?

A

motor: adductor magnus, longus, brevis, and gracilis

sensory: medial thigh, knee, medial knee joint

56
Q

indications for obturator nerve block?

A

knee surgery
amputations
touriquet pain
TURBT surgery (avoid knee jerk from obturator nerve stimulation when ablating tumors)

57
Q

What are we looking at?

A

adductor longus muscle

adductor brevis muscle

adductor magnus muscle

pectineus

ant and post branches of obturator nerve

58
Q

where is ant branch of obturator nerve located?

A

between adductor longus, brevis, and pectineus muscles

59
Q

where is post branch of obturator nerve located?

A

between adductor brevis and magnus

60
Q

function of ant branch of obturator nerve?

A

motor to adductors

sensory to medial thigh/knee

61
Q

fucntion of post branch of obturator nerve?

A

primarily motor to abductors

sensory: articular branches to medial knee joint

62
Q

position for obturator nerve block?

A

pt supine with leg abducted and slightly ext rotated

63
Q

technique for US obturator nerve block?

A

probe 2-3cm distal to femoral crease

be careful of femoral vessels

5-10cc LA in each location, facial plane between longus and brevis, and facial plane between brevis and magnus

64
Q

what with NS produce with obturator block?

A

adduction for both branches

65
Q

name everything

A

femoral vein
femoral artery
adductor longus m.
ant branch of obturator nerve
adductor brevis m.
post branch obturator nerve
adductor magnus m.
pectineus m
femur

66
Q

how was adductor canal block originally described?

A

alternate approach to saphenous

67
Q

what does adductor canal block block?

A

sensory to the knee

motor sparing, vastus medialis occasionally blocked though

68
Q

adductor canal block indications?

A

knee surgery
medial leg/ankle procedures

69
Q

why do surgeons love adductor canal blocks?

A

pt can still get up and walk but get the benefit of the block

70
Q

what block is the adductor canal block used with and for what procedures?

A

used with popliteal approach to sciatic nerve

used for medial foot and ankle procedures

71
Q

name the nerve

A

saphenous nerve

72
Q

pt position for adductor canal block?

A

pt supine with leg abducted and slightly ext rotated

73
Q

us technique for adductor canal block?

A

probe is transverse, mid thigh

needle approach ant to post

want to have SFA directly under the middle of the sartorius m.

74
Q

volume for adductor canal block?

A

15-20ml

75
Q

name this block

A

adductor canal

76
Q

what needs to happen with injection and where should it be for adductor canal block?

A

needs to displace sartorius m upward.

should be on both sides of superficial femoral artery

continuous catheter can be placed above SFA but absolutley needs to be below sartorius m.

77
Q

is the saphenous nerve always visible during adductor canal block?

A

no :(

78
Q

name the block and structures

A

adductor canal block

sartorius m.

SFA

saphenous nerve

79
Q

name the structures

A

sartorius m.
femoral artery
adductors
vastus medialis
saphenous n.

80
Q

largest nerve in the body?

A

sciatic nerve

81
Q

sciatic nerve function?

A

motor: hamstrings, muscles of lower leg and foot

sensory: post thigh, lower leg and foot (except saphenous)

82
Q

what nerve does the majority of innervation below the knee?

A

saphenous n.

83
Q

what nerve innervates these areas?

A

sciatic nerve

84
Q

what determines extent of sciatic nerve blockade?

A

all about where you place the needle, hamstring motor branches early, tibial and peroneal may emerge as entierly seperate nerves

(the higher you go the more likely you are to get hamstrings)

85
Q

name the missing nerves

A

peroneal division of sciatic nerve
tibial division of sciatic nerve

common peroneal nerve
tibial nerve

86
Q

Indications for sciatic nerve block?

A

knee surgery
adjuct to femoral or AC
surgery of post leg
hamstring reattachment
surgery of lower leg or foot

87
Q

set up condisderations for sciatic nerve block?

A

may need crvilinear prove
long block needle (100-150mm) may be needed

88
Q

goal with NS technique for sciatic nerve block?

A

twtich of calf, foot, or toes

hamstring inervation leaves sheath early so it is not a reliable predictor

89
Q

name the six approaches for sciatic nerve block

A

anterior
transgluetal
subgluteal
mid femur
popliteal
tibial nerve

90
Q

describe technqiue for NS guided anterior approach to sciatic nerve block?

A

line b/t ASIS and pubic tubercle
femoral pulse identified
4-5cm perpendicular from line

advance needle until twitch of calf, foot, or toes

might contact bone (lesser trochanter)
withdraw needle 1-3cm, internally rotate leg, readvance needle just past the bone

91
Q

What is this showing?

A

anterior approach to sciatic nerve block

92
Q

what is this?

A

anterior approach to sciatic nerve block

93
Q

pearls for ant approach to sciatic nerve block?

A

elevate heel off bed to help identify twitches

sciatic nerve is prone to injury, avoid vasoconstrictors and he only uses ropivicaine

hit sciatic nerve first and then femoral

94
Q

what is this?

A

anterior approach to sciatic nerve block

95
Q

US technique for ant. sciatic nerve block?

A

probe transverse
curvilinear probe
needle in plane
use long needle 150mm
needle can go medial to lateral or lateral to medial

be aware of FA/FV
sliding or tilting probe prox/distal may help visualize sciatic nerve
needle can be hard to drive this deep

96
Q

volume for ant approach to sciatic nerve block?

A

15-20ml

97
Q

indications for ant approach to sciatic nerve block?

A

any sciatic nerve indication

pt unable to turn lateral or prone

98
Q

what is this?

A

ant approach to sciatic nerve block

99
Q

name this

A

transgluteal approach to sciatic nerve block

100
Q

NS technique for transglueteal sciatic nerve block?

A

lateral oblique position
ID greater trochanter, and PSIP
needle insertion 4cm distal to midpoint
block leg flexed over bottom with foot free to show twitch

101
Q

troubleshooting transglueteal sciatic nerve block:

local twitch of glueteus

needle hits bone but no local twitch of gluteus

needle hits bone, sciatic twitch not elicited

needle placed deep (8-10cm) twitches not elicited; bone is contacted

hamstring twitch

twitches of foot/toes

A

needle to superficial, keep advancing needle

needle is inserted too close to the attachment of the fluteus muscle to the iliac bone: stop and check landmarks

needle missed teh plane of the sicatic nerve and is stoped by the hip joint or ischial bone: with draw needle and redirect it more medially or laterally

needle passed through sciatic notch, withdraw th needle and redirect slightly superiorly

stimulation of main trunk of sciatic nerve: accept and inject

stimulation of sciatic nerve: accept and inject

102
Q

what is this?

A

US trans glueteal approach to sciatic nerve block

103
Q

describe trans-gluteal approach to sciatic nerve block

A

lateral position, hips flexed

probe between greater trochanter and ischium tuberosity

needle inserted from lateral aspect of the probe

104
Q

where is sciatic nerve when looking at US using transglueteal approach?

A

predicitably between femur, ischial tuberosity, and below gluteus maximus

105
Q

what volume for transgluteal sciatic nerve block?

A

15-20ml, ensure good LA coverage

106
Q

name the block and structures

A

trans-gluteal sciatic nerve block

gluteus maximus m.
ischial tuberosity
sciatic nerve
femur

107
Q

tell me about the sub-gluteal US approach to sciatic nerve?

A

very similar to tranglueteal, you just place probe a few cm distal.

pros: less tissue, may allow for linear probe, less variability, only need to search lateral and medially to find the nerve

108
Q

what is this?

A

sub-gluteal US approach to sciatic nerve block

subq tissue
GMM

need help with what else we are looking at here…

109
Q

indications for popliteal approach to sciatic nerve with NS

A

foot or ankle surgery, analgesia adjunct for knee surgery

110
Q

what position for popliteal sciatic nerve block?

A

lateral or prone

111
Q

volume for popliteal sciatic block? what LA?

A

30-40, ropivicane with no epi

112
Q

popliteal appraoch to sciatic nerve is commonly paired with what blocks?

A

femoral or addutor canal

113
Q

describe NS technique for popliteal block

A

find crease of popliteal fossa
find lateral tendon of biceps femoris
find medial tendon of semitendinosus m.
measure 7cm from crease, mark midpoint between both lines
insert needle at midpoint between both tendons, typically about 3-5cm deep

114
Q

what are we looking at?

A

popliteal NS block

115
Q

what are we looking for when using NS with politeal block?

A

TIPPED

Tibial inversion, plantar flexion

peroneal eversion, dorsiflexion

116
Q

position for popliteal block?

A

supine, lateral, or prone

117
Q

what volume for popliteal block?

A

20-30cc

118
Q

describe USG popliteal block

A

probe is tranverse
start at popliteal crease
ID artery, vein, tibial nerve
move proximally
watch tibial and peroneal come together
place injection when the 2 have converged

119
Q

what are we looking at?

A

popliteal block
common peroneal nerve
tibial nerve
popliteal artery

120
Q

what are we looking at?

A

popliteal block

sartorius m.
semimembranosus muscle
popliteal artery
sciatic nerve
biceps femoris m.

121
Q

indication for tibial nerve block?

A

total knee

122
Q

why do a tibial block?

A

avoid the foot drop you get if peroneal n, is also blocked

123
Q

volume for tibial block?

A

5-8ml

124
Q

needle insertion for tibial block?

A

from medial site
be careful to only place LA near tibial and not peroneal nerve

125
Q

5 nerves to block in ankle blocks?

A

superficial:
superficial peroneal
sural
saphenous

deep:
posterior tibial
deep peroneal

126
Q

what needle to use with ankle blocks?

A

25g 1.5” needle

127
Q

how do you do a deep peroneal block?

A

ID extensor hallucis longus
insert needle just lateral advancing until contact with bone, withdraw 2mm and inject

128
Q

volume for deep peroneal block?

A

2-4cc

129
Q

how to do posterior tibial block?

A

id medial malleolus,
insert post and contact bone, withdraw 2mm an dinject 2-4ml of LA

130
Q

what volume with post tibial block?

A

2-4cc

131
Q

name the nerves that innervate each area

A

boom

132
Q

how do you block superficial ankle nerves?

A

create subQ wheel around the entire ankle

saphenous: wheel from tbial ridge medially to achelies

superficial peroneal: wheel from tibial ridge laterally to lateral malleoulus

sural: wheel from lateral malleolus to achilles

133
Q

deep peroneal nerve runs with what? and turns into what?

A

runs with ant tibial artery, turns into dorsalis pedis distally

134
Q

what does post. tibial nerve run with?

A

immediately post to post tibial artery

135
Q

what volume to block deep peroneal and posts tibial arteries?

A

2-4ml

136
Q

what are we looking at?

A
137
Q

what are we looking at?

A

Anesthesia Principles II (14 decks)

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