Performing the block: Hip and Lower Extremity

Question 1

Femoral Nerve Block Landmarks: NAVEL

Answer 1

Nerve
Artery
Vein
Empty
Lymphatic

Lateral to medial

Question 2

What is the superior border of the femoral triangle?

Answer 2

Inguinal ligament

Question 3

What does the femoral nerve lie within?

Answer 3

fascia iliaca

The artery and vein do not reside in this compartment!!! (Quiz question)

Question 4

Femoral Nerve Ultrasound Technique

Answer 4

1. Palpate the femoral artery
2. Place ultrasound parallel to the inguinal ligament
3. Locate nerve lateral to artery (not compressible)
4. Insert needle in-plane towards nerve until it is under the fascia iliaca ligament
5. Inject 10-20mL of LA

Question 5

Potential complications and side effects: Femoral Nerve Block

Answer 5

• Higher infection risk (espicially with catheter placement)
• Vascular puncture and hematoma (nerve compression)
• Prolonged motor blockade with fall risk

Question 6

Fascia Iliaca block anatomy: Facia Iliaca compartment

2 layers

Answer 6

Lies between the
fascia iliaca
psoas muscle

Question 7

What two fascial layers do we need to go through in the Iliaca block?

Answer 7

1. Fascia lata (superficial)
2. Fascia iliaca

Question 8

What does the fascia iliaca block?

3

Answer 8

• lateral femoral cutaneous
• femoral
• obturator

Question 9

Fascia Iliaca ultrasound insertion technique

Answer 9

• two pops (fascia lata and the fascia iliaca)
• Needle insertion lateral to the femoral nerve and superficial to the ilacus muscle
• Needle positioned further laterally than femoral nerve block
• Large amount of local is administered in the fascia ilaca plane

Question 10

Fascia Iliaca: Infrainguinal verse Suprainguinal

Answer 10

• Infra: historically this was used but was not very effective
• Supra: new technique that more effectively gets the obturator

Question 11

Suprainguinal fascia iliaca landmarks?

Answer 11

Abdominal muscle
Deep circumflex iliac artery
fascia iliaca
iliacus muscle

Superficial to deep

Question 12

What is unzippering?

Answer 12

When the LA is injected the correct plane and it looks like it is being “unzipped”

Question 13

Adductor Canal Block aka?

Answer 13

Saphenous Nerve Block

Question 14

TKA block?

Answer 14

In the past we did femoral but that was a motor blockade so now they are using adductor canal with adjuct intraop LA placement

Question 15

Ankle / Foot Block?

Answer 15

adductor canal with a popliteal adjunct for complete coverage

Question 16

What three muscles make up the adductor canal triangle?

Answer 16

1. Sartorius (Medial)
2. Vastus Medialis (Lateral)
3. Adductor Longus (posterior)

Question 17

What lies in the adductor canal?

Answer 17

Saphenous nerve
femoral artery
femoral vein

Question 18

Performing the block: Adductor canal

Answer 18

• Pt supine and frog leg position
• Transducer on anteromedial mid thigh
• Identify the femoral artery (under the sartorius)
• Insert the needle in-plane on a lateral-to-medial orientation through the sartorius towards the nerve
• The saphenous nerve may be in-between the sartorius and vastus medialis
• Aspirate and inject 5-10mL

Question 19

IPACK Block: define again

Answer 19

Infiltraiton between the popliteal artery and capsule of the posterior knee

Question 20

What block is the IPACK usually combined with and for what surgery?

Answer 20

Adductor canal for TKA

Question 21

IPACK targeted nerves ( 4 of em )

Answer 21

• Articular branches of the tibial nerve
• Articular branches of the obturator
• Articular branches of the common peroneal nerve
• Superomedial and lateral genicular nerves

Question 22

What are we trying to avoid blocking in the IPACK?

Answer 22

The trunks of the tibial and common peroneal because this would cause a motor blockade

Question 23

Which nerve block produces “drop foot” or the inability to lift the front part of the foot off the ground?

Answer 23

Trunk of the common peroneal nerve

Question 24

IPACK landmarks

Answer 24

lateral condyle of the femur
vastus medialis
popliteal artery
Sartorius
semimembranosus

Question 25

IPACK US insertion

Answer 25

1. Probe on medial thigh 1-2 fingers above patella 2. Identify popliteal artery and lateral condyle 3. Insert needle through the vastus medialis 4. Inject 15 mL between the popliteal artery and lateral femoral condyle ## Footnote This is also between the lateral condyle and semimembranosus muscle

Question 26

What are the two approaches to the sciatic nerve?

Answer 26

1. Popliteal approach 2. Transgluteal approach

Question 27

Transgluteal Approach steps

Answer 27

* A line is drawn from the greater trochanter and posterior iliac spine * The midpoint is marked with a perpedicular line caudually * Needle is inserted ≈ 5cm along the perpendicular line ## Footnote All he wants us to know on this

Question 28

Popliteal Approach Steps (Posterior)

Answer 28

* Pt is prone * popliteal fossa crease palpated * biceps femoris tendon palpated (lateral) * semitendinosus muscles palpated (medial) * We are looking for the bifurcation of the sciatic under US here * After identified inject LA here at bifurcation ## Footnote Needle is inserted between the biceps femoris (lateral) and semitendinosis and semimembranosus muscles (medially)

Question 29

Popliteal Approach Steps (Lateral)

Answer 29

* pt is supine * needle is inserted ≈ 8cm cephalad of the popliteal crease * LA injected around the sciatic nerve sheath ## Footnote Needle is inserted between the biceps femoris (inferior) and vastus lateralis (superior)