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APEX > Unit 8 - Lower Extremity Blocks > Flashcards

Unit 8 - Lower Extremity Blocks Flashcards

1
Q
A

A = lateral femoral cutaneous
B = obturator
C = saphenous
D = superficial peroneal

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2
Q

nerves anesthetized by a 3-in-1 femoral n. block

A

femoral n.
lateral femoral cutaneous n.
obturator n. (commonly missed)

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3
Q

which nerve innervates this osteotome

A

superficial peroneal n.

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4
Q

which nerve is anesthetized by injecting LA into the plane of the line between the Achilles tendon and lateral malleolus

A

sural n.

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5
Q

LA is injected around which nerves for a popliteal block

A

common peroneal n.
tibial n.

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6
Q

assessing which movement is the best way to assess femoral n. block

A

knee extension

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7
Q

the sural n. is formed by collateral branches of what 2 nerves

A

tibial n
common peroneal n

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8
Q

largest peripheral nerve in the body

A

sciatic nerve

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9
Q

6 terminal branches of the lumbar plexus

A

Iliohypogastric
Ilioinguinal
Genitofemoral
Lateral femoral cutaneous
Obturator
Femoral

I
Invariably
Get
Lazy
On
Fridays

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10
Q

2 plexuses that innervate lower extremities

A

sacral plexus
lumbar plexus

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11
Q

where does the lumbar plexus originate

A

from anterior rami of L1-L4 (+T12 contribution in ~50% of the population)

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12
Q

what does the lumbar plexus primarily innervate

A

front of leg

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13
Q

origin of sacral plexus

A

originates from anterior rami of L4-S4

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14
Q

primary innervation of sacral plexus

A

back of leg

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15
Q

where does the lumbar plexus form

A

within psoas muscle and passes in front of quadratus lumborum

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16
Q

which nerve roots give rise to lateral femoral cutaneous n.

A

L2-L3 (posterior divisions)

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17
Q

which nerve roots give rise to femoral n.

A

L2-L4 (posterior divisions)

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18
Q

which nerve roots give rise to obturator n.

A

L2-L4 (anterior divisions)

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19
Q

where does lateral femoral cutaneous n form

A

midpoint of psoas muscle

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20
Q

where does femoral n form

A

near middle and lower third of psoas

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21
Q

branch of femoral n. that gives rise to saphenous n

A

posterior branch

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22
Q

where does obturator n form

A

medial border of psoas at level of SI joint

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23
Q

nerve often injured in pts undergoing extensive pelvic surgery

A

obturator

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24
Q

where does sacral plexus form

A

anterior to psoas major

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25
Q

5 major branches of sacral plexus

A

Superior gluteal
Inferior gluteal
Posterior cutaneous
Pudendal
Sciatic

SIPPS

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26
Q

trunks that comprise sciatic n

A

tibial
common peroneal/fibular

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27
Q

where does sciatic n divide into tibial & common peroneal nerves

A

proximal popliteal fossa

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28
Q

where does tibial n arise from

A

anterior branches of L4-S3

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29
Q

where does common peroneal n arise from

A

posterior branches of L4-S3

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30
Q

3 terminal branches of common peroneal n.

A

Deep peroneal n.
Superficial peroneal n.
Sural n.

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31
Q

terminal nerves at ankle that originate from sciatic n.

A

Superficial peroneal
Deep peroneal
Sural
Posterior tibial

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32
Q

primary nerves of coccygeal plexus

A

pudendal
inferior anal
perineal

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33
Q

sensory innervation of L2 dermatome

A

upper medial thigh

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34
Q

sensory innervation of L3 dermatome

A

lower medial thigh

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35
Q

sensory innervation of L4 dermatome

A

lateral thigh + anterior knee

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36
Q

sensory innervation of L5 dermatome

A

lateral lower leg + top of foot

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37
Q

sensory innervation of S1 dermatome

A

posterior leg (more lateral)

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38
Q

sensory innervation of S2 dermatome

A

posterior leg (more medial)

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39
Q

peripheral nerves from lumbar plexus that are sensory only

A

lateral femoral cutaneous, saphenous, sural

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40
Q

sensory & motor innervation of femoral n.

A

sensory = anterior thigh, medial leg
motor = hip flexion/lateral rotation, knee extension + flexion

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41
Q

sensory & motor innervation of obturator nerve

A

sensory = hip joint, medial thigh
motor = hip ADDuction, flexion, & extension

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42
Q

sensory innervation of lateral femoral cutaneous n

A

lateral thigh to knee

no motor

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43
Q

sensory & motor innervation of pudendal n

A

sensory = perineum, anal canal, external sphincter
motor = anal sphincter tone

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44
Q

sensory innervation of posterior femoral cutaneous n

A

posterior hip to midcalf

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45
Q

sensory & motor innervation of superficial peroneal n

A

sensory = dorsal surface of foot
motor = ankle eversion

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46
Q

sensory innervation of deep peroneal n.

A

web space between big toe and 2nd toe

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47
Q

motor innervation of tibial n

A

Toe: ABduction + ADDuction + extension + flexion
Ankle: plantar flexion

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48
Q

motor innervatin of sciatic n

A

hip extension
knee flexion

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49
Q

peripheral nerve responsible for sensory innervation of dorsal surface of foot

A

superficial peroneal n

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50
Q

peripheral nerve responsible for hip flexion and knee extension

A

femoral n

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51
Q

peripheral n responsible for hip extension and knee flexion

A

sciatic n

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52
Q

peripheral n responsible for plantar flexion

A

tibial n

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53
Q

peripheral nerve responsible for dorsiflexion

A

peroneal n

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54
Q

peripheral nerve responsible for ankle eversion

A

superficial peroneal n

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55
Q

peripheral nerve responsible for ankle inversion

A

deep peroneal n

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56
Q

nerves that innervate the hip joint

A

femoral
obturator
sciatic

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57
Q

nerve that innervates the biceps femoris, semitendinosus, and semimembranosus

A

sciatic n

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58
Q

spinal nerve roots posterior femoral cutaneous n arises from

A

S1-S3

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59
Q

spinal nerve roots lateral femoral cutaneous n arises from

A

L2-L3

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60
Q

provides sensory and motor innervation to lower abd wall, anteromedial thigh, and knee

A

lumbar plexus

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61
Q

provides sensory and motor innervation to gluteal region, posterior thigh, lower leg, and foot

A

sacral plexus

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62
Q
A

A = lateral femoral cutaneous n
B = femoral n
C = posterior femoral cutaneous n
D = obturator n
E = saphenous n
F = common peroneal n
G = superficial peroneal n
H = deep peroneal n
I = sural n
J = medial calcaneal n
K = lateral plantar n
L = medial plantar n

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63
Q

how to assess motor function of femoral n

A

hip: flexion & rotation
knee: extension & flexion

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64
Q

how to assess function of obturator n

A

hip adduction, flexion, & extension

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65
Q

how to assess function of pudendal n

A

anal sphincter tone

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66
Q

how to assess function of sciatic n

A

hip extension
knee flexion

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67
Q

how to assess function of tibial n

A

toe abduction, flexion, & extension
ankle plantar flexion

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68
Q

how to assess function of superficial peroneal n

A

ankle eversion

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69
Q

how to assess function of deep peroneal n

A

ankle dorsiflesion + inversion

70
Q

objective of PENG block

A

inject LA deep into psoas tendon at level of iliopubic prominence

71
Q

PENG block indications

A

hip fracture, hip arthroplasty

72
Q

why are high conncentrations of LA not required for PENG block

A
73
Q

LA volume for PENG block

A

30-40 mL

74
Q

what is the iliopublic eminence

A

junction of ilium and pubis

75
Q

what does PENG block target

A

articulating branches from lumbar plexus that supply only sensory innervation to hip capsule

*Femoral nerve is spared

76
Q

why are high concentrations of LA not required for PENG block

A

analgesic block (not anesthetic)

77
Q

PENG block complications

A

few
direct injection in psoas = quad weakness
ureter injury

78
Q

3 nerves targeted by fascia iliaca block

A

femoral, obturator, lateral cutaneous

79
Q

advantages of fascia iliaca block over lumbar plexus block

A

faster and more consistent blockade of femoral & lateral cutaneous nerves

80
Q

increases risk of ureter injury with PENG block

A

Inserting needle above level of inguinal ligament & advancing too

81
Q

fascia iliaca block indications

A
  • Surgical procedures of femur, quadriceps, knee
  • Acute pain management for hip fractures
82
Q

lower extremity block only performed with US

A

PENG

83
Q

objective of fascia iliaca block

A

deposit LA below fascia iliaca that travels towards lumbar plexus

84
Q

transducer used for fascia iliaca block

A

high-frequency linear array transducer in a sagittal orientation

85
Q

total LA volume for fascia iliaca block

A

40 mL

86
Q

landmarks for fascia iliaca block

A

ASIS
pubic tubercle
sartorius
internal oblique

sartorius & IO form “bowtie”

87
Q

when is LOR felt with fascia iliaca block (landmark technique)

A

as needle passes through fascia lata
2nd loss of resistance as it pierces fascia iliaca

88
Q

what happens if you if needle inserted too superficially and medial to femoral nerve for fascia ilacia block

A

stimulation of sartorius mucle (inner thigh twitching)

If it happens, withdraw needle and advance slightly laterally until you obtain a ‘patellar snap’

89
Q

what happens if you if needle inserted too superficially and medial to femoral nerve for fascia ilacia block

A

stimulation of sartorius mucle (inner thigh twitching)

If it happens, withdraw needle and advance slightly laterally until you obtain a ‘patellar snap’

90
Q

fascia iliaca block complications

A

failed/incomplete block if LA injected above fascia
LAST
quad weakness

91
Q

where do L2-L4 roots merge to form femoral n

A

in psoas major

92
Q

borders of femoral triangle

A
  • Sartorius muscle
  • Adductor longus muscle
  • Inguinal Ligament

“SAIL”

93
Q

borders of femoral triangle

A
  • Sartorius muscle
  • Adductor longus muscle
  • Inguinal Ligament

“SAIL”

94
Q

anatomic structures inside the femoral triangle

A

femoral vein
femoral artery
femoral nerve

95
Q

where does femoral n divide into anterior and posterior branches

A

once under the inguinal ligament

96
Q

best assessment of femoral n block

A

assess knee extension

97
Q

what does the anterior branch of femoral n innervate

A

ventral surface of the thigh and sartorius muscle

98
Q

what does the posterior branch of femoral n innervate

A

quadriceps muscle, knee joint, and its medial ligament

99
Q

combination of what 2 blocks provides almost complete surgical coverage to lower extremity

A

femoral + sciatic blocks

100
Q

can femoral n block be used for surgical anesthesia?

A

nope, not alone

combine with sciatic block

101
Q

can femoral n block be used for surgical anesthesia?

A

nope, not alone

combine with sciatic block

102
Q

femoral n block indications

A
  • Surgical anesthesia & analgesia for procedures involving hip, femur, quadriceps, and knee
  • acute pain management for hip fractures
103
Q

position for femoral n block

A

supine position with slight external extremity rotation

104
Q

transducer used for femoral n block

A

high-frequency linear array transducer (10-12 MHz) in transverse orientation

105
Q

major anatomical landmarks for US-guided femoral n block

A

femoral artery
femoral vein
femoral n

106
Q

LA volume for femoral n block

A

20-30 mL

107
Q

regardless of technique, needle must penetrate ____ to ensure efficacious block

A

fascia lata & fascia iliaca

108
Q

indicates proper needle placement for nerve stim. guided femoral n block

A

quadriceps contraction

109
Q

3-in-1 block approach to femoral n is designed to block what 3 nerves

A

femoral n
lateral femoral cutaneous n
obturator n (often missed)

110
Q

why is femoral block assoc with falls

A

quadriceps weaness

111
Q

boundaries of femoral triangle

A
  1. Base of triangle = inguinal ligament
  2. Medial side of triangle = Medial aspect of sartorius
  3. Lateral side of triangle = medial aspect of adductor longus
112
Q

nerves in adductor canal

A
  • saphenous n. (terminal branch of femoral n.)
  • the nerve that innervates the vastus medialis (branch of posterior femoral n.)
113
Q

lateral wall of adductor canal

A

vastus medialis

114
Q

where does the femoral artery become popliteal artery

A

popliteal fossa

115
Q

indications for adductor canal block

A

ACL repair, MCL repair, patella fracture, vein stripping & harvesting, supplementation to sciatic nerve block for foot/ankle surgery

116
Q

transducer used for adductor canal block

A

high-frequency linear array transducer (10 - 12 MHz) in transverse orientation

May need a lower frequency for patients with increased body habitus

117
Q

transducer used for adductor canal block

A

high-frequency linear array transducer (10 - 12 MHz) in transverse orientation

May need a lower frequency for patients with increased body habitus

118
Q

how does saphenous n appear on US in adductor canal approach

A

hyperechoic - anterolateral to artery

119
Q

LA volume for adductor canal lbock

A

15-20 mL

120
Q

increases likelihood of quadriceps weakness with adductor canal block

A

proximal injections and local anesthetic volumes that exceed 20 mL

121
Q

where is the popliteal fossa formed

A

between muscles in posterior compartment of the lower extremity

122
Q

key anatomic landmarks for popliteal block

A
  • Popliteal artery & vein
  • Biceps femoris, semitendinosus, semimembranosus muscles
  • Bifurcation of sciatic n. into common tibial n. and common peroneal n.
123
Q

where does the sciatic n become superficial and divide into tibial & common peroneal n

A

approx 7-10 cm proximal to popliteal fossa

124
Q

how to identify the approximate location of the sciatic nerve

A

by finding the ‘triangle’ in the posterior knee created by the popliteal crease (the base) and the convergence of the biceps femoris and semitendinosus muscles (the apex)

125
Q

target of popliteal block

A

sciatic nerve branches in proximal popliteal fossa

126
Q

indications of popliteal n block

A
  • Provides pain control for below-the-knee surgical procedures (ankle surgery, Achilles repair, foot surgeries)
  • Helps manage acute pain
  • Combined with saphenous n. block, provides complete coverage of lower extremity and knee
127
Q

how does tibial n appear on US for popliteal block

A

hyperechoic structure dorsal and lateral to anechoic artery and vein in popliteal fossa

128
Q

what positions can patient be in for an US-guided popliteal block

A

prone, lateral, or supine

129
Q

total LA volume for popliteal block

A

25 mL

130
Q

optimal location for LA placement for popliteal block

A

point where sciatic n. divides into TN & CPN

Some use PNS with US

131
Q

main drawback of popliteal block

A

foot drop
numbness of sole

may contribute to patient falls

132
Q

main drawback of popliteal block

A

foot drop
numbness of sole

may contribute to patient falls

133
Q

5 nerves blocked for a total ankle block

A
  1. saphenous
  2. sural
  3. superficial peroneal
  4. deep peroneal
  5. posterior tibial
134
Q

nerves of ankle block that are sensory only in the ankle and foot

A

saphenous
sural
superficial peroneal

135
Q

mnemonic for nerves and actions at ankle/foot

A

TIPPED
Tibial: Inversion, Plantarflexion
Peroneal: Eversion, Dorsiflexion

136
Q

landmarks for ankle block -posterior tibial n

A

posterior tibial artery
achilles tendon
medial malleolus

137
Q

landmarks for ankle block - sural n

A

lesser saphenous vein
Achilles tendon
lateral malleolus

138
Q

landmarks for ankle block - deep peroneal n

A

medial malleolus
tendons of anterior tibial & long mucles of great toe

139
Q

landmarks for ankle block - superficial peroneal n

A

lateral malleolus

140
Q

landmarks for ankle block - saphenous n

A

greater saphenous vein, medial malleolus

141
Q

nerves of ankle block in close proximity to arteries

A

posterior tibial n. (posterior tibial a.)
deep peroneal n. (anterior tibial a.)

142
Q

sensory and motor functions of deep peroneal n.

A
  • Sensory innervation = Lateral side of the great toe (hallux),medial side of the 2nd digit
  • Motor innervation = eversion + dorsiflexion
143
Q

sensory and motor innervation of posterior tibial n.

A
  • Sensory innervation = Sole of the foot
  • Motor innervation = Inversion + plantar flexion
144
Q

transducer used for ankle blocks

A
  • high-frequency (10-12 MHzO) linear array
  • Use a small footprint transducer, such as a “hockey stick,” to reduce the incidence of air artifact due to the limited surface area of the ankle.
145
Q

equipment needed for ankle block with landmark technique

A

10 mL syringe with 1.5” 25g needle
nerve stimulation not necessary

146
Q

nerves of ankle block that can be blocked without removing the needle (one skin puncture)

A

deep peroneal, superficial peroneal, and saphenous nerves

147
Q

LA volume of ankle block

A

3-5 mL per nerve

148
Q

where must LA reach to anesthetize sural n

A

superior border of lateral malleolus (landmark technique)

149
Q

goal of LA distribution in US-guided sural n block

A

circumferential spread around lesser saphenous vein

150
Q

complication of nerve blocks

A

vascular injury (except superficial peroneal n)
nerve compression/ischemia

avoid excessive LA volumes, vasoconstrictors

150
Q

complication of nerve blocks

A

vascular injury (except superficial peroneal n)
nerve compression/ischemia

avoid excessive LA volumes, vasoconstrictors

151
Q

where is the lumbar plexus contained

A

within a sheath inside psoas compartment

152
Q

location of lumbar plexus within the psoas compartment

A
  • Lateral to the vertebral column
  • Anterior to the quadratus lumborum muscle
  • Posterior to the psoas muscle
153
Q

3 major nerves targeted by psoas compartment (lumbar plexus) block

A
  1. lateral femoral cutaneous n
  2. femoral n
  3. obturator n
154
Q

patient position for lumbar plexus block

A

lateral decubitus - block side up

155
Q

landmarks for lumbar plexus block

A

intercristal line/L4-L5 interspace
PSIS

156
Q

point of needle entry for lumbar plexus block

A

3 cm caudad from L4 and 5 cm lateral from the midline.

157
Q

mean skin to lumbar plexus depth

A

8 cm

158
Q

total LA volume for lumbar plexus block

A

20-30 mL

159
Q

complications of lumbar plexus block

A
  • sympathectomy of ipsilateral extremity
  • retroperitoneal hematoma
  • renal capsular injection
160
Q

what increases risk of bilateral extremity spread in lumbar plexus block

A

LA volumes > 20 mL

161
Q

contraindication to lumbar plexus block

A

coagulopathies

162
Q

nerve roots that contribute to sciatic nerve

A

L4-L5 and S1-S3

163
Q

where does the sciatic nerve divides into tibial and common peroneal nerves

A

As it passes between the major trochanter and the tuberosity of the ischium into the lower third of the thigh

164
Q

uses of sciatic n block by itself

A

useful for procedures on the back of the thigh, lower leg, ankle, and foot

165
Q

sciatic n. block approach often combined with femoral n block to provide complete coverage for TKA

A

posterior landmark approach (Labat approach)

166
Q

landmarks for sciatic n block

A

greater trochanter
PSIS
sacral hiatus

167
Q

what motor response is desired when using nerve stimulation for a sciatic n block

A

dorsiflesion or plantarflexion

For surgical anesthesia, plantar flexion (foot inversion) is preferred

168
Q

what motor response is desired when using nerve stimulation for a sciatic n block

A

dorsiflexion or plantarflexion

For surgical anesthesia, plantar flexion (foot inversion) is preferred

169
Q

at the level of the ankle, which nerve is not immediately adjacent to a vascular structure

A

superficial peroneal n.

APEX (54 decks)

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