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Anesthesia Foundations II Exam 2 > Peripheral Lower Extremity (week 9) > Flashcards

Peripheral Lower Extremity (week 9) Flashcards

1
Q

The lower extremity is innervated by two separate and distinct plexi - what are they?

A
  • Lumbar plexus
  • Sacral plexus

Nagelhout, pg. 1150

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2
Q

The lumbar plexus is formed from the ventral rami of what spinal nerves?

A
  • L1-L4
  • occasional contribution from T12

Nagelhout, pg. 1150

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3
Q

The lumbar plexus provides sensory and motor innervation to which areas?

A
  • lower anterior abdominopelvic wall & part of the genitalia
  • anterior and medial aspects of the thigh & knee
  • medial aspect of the lower extremity distal to the knee (sensory only)

Nagelhout, pg. 1150

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4
Q

The _____________ is formed by the union of a branch of L4 and L5 - it combines with S1-S4

A
  • lumbosacral trunk

Nagelhout, pg. 1150

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5
Q

What are the three terminal branches of the lumbar plexus? Describe which is most medial and most lateral

A
  • Obturator (most medial)
  • Femoral
  • Lateral femoral cutaneous (most lateral)

Nagelhout, pg. 1150-1151

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6
Q

The _________ is the largest of the three terminal branches of the lumbar plexus

A
  • femoral nerve

Nagelhout, pg. 1151

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7
Q

The femoral nerve is formed from contributions of the ___________ spinal nerves - it forms/appears at the middle to lower third of the ___________ muscle

A
  • L2-L4
  • psoas major

Nagelhout, pg. 1151

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8
Q

The femoral nerve remains within the groove of the psoas major and iliac muscles as it courses __________ to the inguinal ligament and ___________ to the femoral artery

A
  • deep/below
  • lateral

Nagelhout, pg. 1151

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9
Q

What is the landmark for the bifurcation of the femoral nerve into it’s anterior and posterior branches?

A
  • As it passes under the inguinal ligament

Nagelhout, pg. 1151

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10
Q

The anterior branch of the femoral nerve provides innervation to ______________

A
  • anterior surface of the thigh
  • sartorius muscle

Nagelhout, pg. 1151

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11
Q

The ____________ also arises from the anterior branch of the femoral nerve

A
  • saphenous nerve

Nagelhout, pg. 1151

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12
Q

The femoral nerve and vessels course distally along the proximal thigh in the femoral triangle - this is a space that is created by what structures?

A
  • Sartorius muscle (laterally)
  • Adductor longus muscle (medially)
  • Inguinal Ligament (proximally)

remember the acronym SAIL

Nagelhout, pg. 1151

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13
Q

Inside the femoral triangle, the femoral nerve lies anterior to the iliopsoas muscle and beneath the ___________ and ______________

A
  • fascia lata
  • fasica iliaca

Nagelhout, pg. 1151

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14
Q

The apex of the femoral triangle is the origin of what other anatomical structure important to lower extremity nerve blocks?

A
  • Adductor canal
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15
Q

Which nerve is formed from the L2 & L3 roots and passes under the lateral border of the inguinal ligament providing sensory innervation to the lateral aspect of the thigh?

A
  • Lateral femoral cutaneous

Nagelhout, pg. 1151

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16
Q

The ___________ nerve emerges from the lateral border of the psoas major muscle at its midpoint

A
  • lateral femoral cutaneous

Nagelhout, pg. 1151

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17
Q

Which nerve arises from L2-L4 and is primarily a motor nerve to the adductor muscles in the medial thigh?

A
  • Obturator

Nagelhout, pg. 1151

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18
Q

Due to its proximity to the external iliac artery, this nerve can be injured in patients undergoing extensive pelvic surgery

A
  • What is the obturator nerve, Trebek

Nagelhout, pg. 1151

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19
Q

The obturator nerve provides mixed sensory fibers to which areas of the leg?

A
  • articular branches of the hip (according to apex)
  • medial aspect of femur
  • skin & soft tissue along the medial aspect of the thigh proximal to the knee

Nagelhout, pg. 1151

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20
Q

The obturator nerve emerges from the medial border of the psoas major muscle at the level of the _____________

A
  • sacroiliac joint

Nagelhout, pg. 1151

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21
Q

The sciatic nerve is formed by the _________ nerve roots, and is the continuation of the __________ plexus

A
  • L4-S3
  • sacral

Nagelhout, pg. 1151

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22
Q

The sciatic nerve descends between the major trochanter and the ____________

A
  • ischial tuberosity

Nagelhout, pg. 1151

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23
Q

____________ to the popliteal fossa, the sciatic nerve bifurcates into the ___________ nerve (medially), and the ____________ nerve (laterally)

A
  • Proximal
  • tibial
  • common peroneal

Nagelhout, pg. 1151

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24
Q

What are the names of the 2 terminal branches of the common peroneal nerve? Describe their anatomic relationship to each other

A
  • deep peroneal - medial foot
  • superficial peroneal - lateral foot

Nagelhout, pg. 1151-1152 - Fig 50.12

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25
Q

List the five terminal nerves that innervate the foot

A
  • saphenous
  • superficial peroneal
  • deep peroneal
  • sural
  • posterior tibial

Nagelhout, pg. 1151

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26
Q

Which terminal nerve provides the greatest amount of innervation to the foot?

A
  • posterior tibial
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27
Q

Specify which nerve(s) innervate the following anatomic locations - include what nerve(s) they are branches of:

Sole of the foot

  • ________
  • _________

Heel

  • __________
A

Sole of the foot

  • medial plantar nerve - posterior tibial nerve
  • lateral plantar nerve - posterior tibial nerve

Heel

  • calcaneal nerve - posterior tibial nerve

Nagelhout, pg. 1151

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28
Q

The deep peroneal nerve lies __________ to the anterior tibial artery and provides motor innervation to _____________ and sensory innervation to ____________

A
  • lateral
  • short extensors of the toes
  • Cleft between 1st and 2nd toes (lateral aspect of the great toe and medial aspect of the second)

Nagelhout, pg. 1151

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29
Q

The superficial peroneal nerve provides sensation to the ___________

A
  • dorsum of the foot & toes

Nagelhout, pg. 1151

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30
Q

The sural nerve is formed by a union of branches from both the __________ nerve and __________ nerve

A
  • tibial
  • common peroneal

Nagelhout, pg. 1151

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31
Q

The sural nerve provides sensation to the:
1. _____________
2. _____________
3. _____________

A
  1. posterior heel
  2. lateral portion of the foot
  3. part of the Achilles tendon above the ankle

Nagelhout, pg. 1151

32
Q

The saphenous nerve courses along the _____________ aspect of the lower leg in the subcutaneous tissue - it provides __________ innervation to the medial aspect of the lower extremity below the knee, ankle, and medial aspect of the forefoot

A
  • medial
  • sensory

Nagelhout, pg. 1151

33
Q

Identify the 5 terminal nerves of the foot on this cross section

A

Miller’s, pg 1472 - Fig 46.32

34
Q

Identify the nerves providing sensory innervation to the leg

A

Apex Unit 8, Lower Extremity Blocks

35
Q

The femoral nerve block is commonly used for surgical procedures of the _______________, and analgesia following ______________ fracture

A
  • femur
  • patella
  • quadriceps surgery
  • hip

Nagelhout, pg. 1151

36
Q

When combined with ________________ the femoral nerve block provides complete coverage of the lower extremity

A
  • sciatic nerve block

Nagelhout, pg. 1151

37
Q

When performing the landmark technique for femoral nerve block, the injection site is approximately 1 cm __________ to the artery and 1 cm ____________ to the inguinal ligament

A
  • lateral
  • inferior

Nagelhout, pg. 1167

38
Q

When performing an ultrasound guided femoral nerve block the patient is placed in ____________ position with slight ______________ of the lower extremity

A
  • supine
  • external rotation

Nagelhout, pg. 1167

39
Q

True or false:

Identification of the bifurcation of the femoral artery into the superficial femoral and profunda femoris arteries is a sign that the transducer is in the right place to perform an ultrasound guided femoral nerve block

A
  • False - the transducer should be slid cephelad until the common femoral artery is identified

Nagelhout, pg. 1167

40
Q

When performing a femoral nerve block, the needle tip must pierce what two structures prior to ensure an efficacious block?

A
  • fascia lata
  • fasica iliaca

Nagelhout, pg. 1167

41
Q

Femoral nerve block

The ___________ division of the femoral nerve innervates the quadriceps muscles - the needle should be directed __________ there

A
  • posterior
  • towards

anterior division innervates anterior surface of thigh and sartorius m.

Nagelhout, pg. 1167

42
Q

Studies demonstrate that local anesthetic volumes greater than ____________ are not associated with improved femoral nerve block rates

A
  • 20 mL

Nagelhout, pg. 1167

43
Q

Because of the associated ______________ it has been speculated that femoral nerve block contributes to the rate of falls following lower extremity total joint surgery

A
  • quadriceps weakness

Nagelhout says BS, Apex say true

Nagelhout, pg. 1167

44
Q

Which nerve is the target of the adductor canal block?

A
  • saphenous nerve in the proximal to midthigh

Nagelhout, pg. 1167

45
Q

What is an advantage of the adductor canal block over femoral nerve block for surgeries of the lower extremity?

A
  • It spares quadriceps strength

Nagelhout, pg. 1167

46
Q

List several indications for an adductor canal block

A

surgeries of anteromedial knee:

  • ACL/MCL repears
  • patella fractures

Nagelhout, pg. 1168

47
Q

Describe how a patient should be positioned for an adductor canal block

A
  • supine with slight external rotation of the leg

Nagelhout, pg. 1168

48
Q

While performing an adductor canal block, you know that the saphenous nerve lies close to the _____________ artery, and both of structures are inferior to the _____________ muscle

A
  • superior femoral
  • sartorius

Nagelhout, pg. 1168

49
Q

When performing an adductor canal block, what will increase the risk of quadriceps weakness?

A
  • proximal injections
  • large volumes of local anesthetic (20-30 mL)

Nagelhout, pg. 1168

50
Q

What nerves are targeted by the Lumbar Plexus/Psoas Compartment Block (aka 3-in-1 block)?

A

The 3 nerves of the lumbar plexus:

  • femoral
  • lateral femoral cutaneous
  • obturator (Torabi says obturator rarely ever gets well blocked)

Nagelhout, pg. 1168

51
Q

The lumbar plexus block is not commonly performed today because it is an advanced technique with several risks - what is the most common complication of this block?

A
  • epidural spread (most common)

as well as:

  • spinal anesthesia
  • LAST
  • hypotension
  • renal hematoma

Nagelhout, pg. 1169

52
Q

The ___________ block is an anterior approach to the lumbar plexus that provides faster and more consistent blockade than the “three-in-one” block

A
  • fascia iliaca

Nagelhout, pg. 1169

53
Q

The fascia iliaca compartment block has been widely used for what types of surgeries?

A
  • hip
  • femoral shaft
  • knee

Apex adds quadriceps as well

Nagelhout, pg. 1169

54
Q

Which nerve of the lumbar plexus is NOT reliably blocked when performing a fascia iliaca block?

A
  • Obturator nerve

Nagelhout, pg. 1169

55
Q

When using a landmark technique for a fascia iliaca block, an initial loss of resistance is felt as the needle tip punctures the ____________, and a second loss of resistance as the ____________ is pierced

A
  • fascia lata (superficial)
  • fascia iliaca (deep)

Nagelhout, pg. 1169

56
Q

The fascia iliaca block is a large volume (30-40 mL) fascial plane block - because of these large volumes, what complication(s) might occur?

A
  • quadriceps weakness (due to spread in fascial plane to femoral nerve)
  • LAST

Nagelhout, pg. 1169

57
Q

What structures form the “bowtie sign” when performing a fascia iliaca block?

A
  • sartorius muscle and internal oblique muscle

Nagelhout, pg. 1169

58
Q

The ______________ block is a single injection technique targeting the articular branches of the femoral nerve

A
  • pericapsular nerve group (PENG) block

Nagelhout, pg. 1169

59
Q

The pericapsular nerve group (PENG) block is utilized for analgesia following _____________ and ______________

A
  • hip fracture
  • arthroplasty

Nagelhout, pg. 1169

60
Q

True or false:

The pericapsular nerve block provides superior analgesia for hip fracture/arthoplasty, but still carries the disadvantage of quadriceps weakness via femoral nerve spread

A
  • FALSE - the PENG block SPARES the femoral nerve and its associated quadriceps innervation

Nagelhout, pg. 1169

61
Q

Because the PENG block is _______________, it does not require large volumes of local anesthetics

A
  • an analgesic block (no motor loss)

Nagelhout, pg. 1170

62
Q

Because the ___________ is within close proximity to the obturator nerve, it is at risk for injury during PENG block if the needle is placed too medially

A
  • ureter

Nagelhout, pg. 1170

63
Q

During a pericapsular nerve group (PENG) block, the local anesthetic is deposited between the _________ muscle and the ____________

A
  • psoas muscle (with prominent tendon)
  • iliopubic eminence

Nagelhout, pg. 1170

64
Q

The ___________ approach is a higher approach to the sciatic nerve that can be used for surgery above and at the knee

A
  • subgluteal

Nagelhout, pg. 1170

65
Q

The subgluteal approach to the sciatic nerve is often done with nerve stimulation - what motor response would you expect to elicit when the needle is close to the desired location?

A
  • plantar flexion (posterior tibial distribution)
  • dorsal flexion (peroneal distribution)

Nagelhout, pg. 1171

66
Q

The popliteal block targets the _____________ nerve and is indicated for surgical procedures of the _____________

A
  • sciatic
  • lower extremity distal to the knee (ankle, achilles tendon, foot)

Nagelhout, pg. 1171

67
Q

The popliteal fossa is define by three anatomic structures - what are they?

A
  • popliteal crease (inferior)
  • medial border of femoris biceps muscle (lateral)
  • tendon of the semitendinosus muscle (medial)

Nagelhout, pg. 1171 - Fig 50.42

68
Q

When using nerve stimulation to guide needle placement during a popliteal block, what motor response do you expect to be elicited when the needle is properly placed?

A
  • plantar flexion (posterior tibial distribution)
  • dorsal flexion (peroneal distribution)

Nagelhout, pg. 1171

69
Q

The optimal location for local anesthetic placement during a popliteal block is at what point along the sciatic nerve?

A
  • Where it begins to divide into the tibial and common peroneal nerves

Nagelhout, pg. 1172

70
Q

All of the terminal nerves of the ankle/foot travel near vascular structures, except for the _____________ nerve

A
  • superficial peroneal

Nagelhout, pg. 1172

71
Q

When performing ankle blocks for the 5 terminal nerves, approximately _________ mL of local anesthetic is needed for each nerve

A
  • 3-5 mL

Nagelhout, pg. 1172-1174

72
Q

What are the only 2 nerves of the ankle that do not exist within the subcutaneous tissue?

A
  • Deep peroneal nerve
  • Posterior tibial nerve

They are the “deep” nerves of the ankle/foot

Nagelhout, pg. 1172

73
Q

The nerves such as the deep peroneal lie within tight spaces between ligaments, tendons, and bone - this increases the risk for what complication?

A
  • Ischemia due to increased pressure from injection of local anesthetic

Nagelhout, pg. 1174

74
Q

What is the landmark approach to the Popliteal nerve block?

A
  • Line across the popliteal crease from SemiT to BicepsF
  • Line extended 8-10 cm cephalad perpendicularly to the crease
  • Insert needle 1 cm lateral to this (Towards the BicepsF)

Nagelhout 7th ed., Ch 50., pg. 1171

75
Q

What landmarks are you looking for with a PENG block?

A
  • Place transducer parallel to inguinal ligament @ level of Anterior superior iliac spine (ASIS)
  • Slide caudally until you view the AIIS and iliopubic eminence (IPE)
  • Look for the IPE, AIIS & femoral n., a. & v.

Nagelhout 7th ed., Ch 50., pg. 1169-1170

Anesthesia Foundations II Exam 2 (6 decks)

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