ANKLE BLOCKANKLE BLOCKANKLE BLOCK ANKLE BLOCK ANESTHESIAANESTHESIA

GREGORY CLARK D.P.M.GREGORY CLARK D.P.M.

HEAD, SECTION OF PODIATRYHEAD, SECTION OF PODIATRYSCRIPPS CLINIC SCRIPPS CLINIC

LA JOLLA, CALIFORNIALA JOLLA, CALIFORNIA

A METHOD BY WHICH ONE MAY PROVIDE ANA METHOD BY WHICH ONE MAY PROVIDE ANA METHOD BY WHICH ONE MAY PROVIDE ANA METHOD BY WHICH ONE MAY PROVIDE ANANESTHETIC BLOCK TO THE FOOT OR ANKLE ANESTHETIC BLOCK TO THE FOOT OR ANKLE WITH A MINIMUM OF PATIENT DISCOMFORTWITH A MINIMUM OF PATIENT DISCOMFORT

NEUROANATOMY OF THE NEUROANATOMY OF THE ANKLE BLOCKANKLE BLOCK

POSTERIOR TIBIALPOSTERIOR TIBIALDEEP PERONEALDEEP PERONEALSUPERFICIAL DORSAL CUTANEOUSSUPERFICIAL DORSAL CUTANEOUSSURALSURALSAPHAENOUSSAPHAENOUS

Posterior Tibial NervePosterior Tibial Nerve

• Located Deep to Flexor Retinaculum on medial aspect of ankle.

• Posterior to Posterior Tibial Artery.

• “Tom, Dick, and Very Nervous Harry”

• Branches include Medial Calcaneal, Lateral Plantar, and Medial Plantar Nerves

• Innervates plantar aspect of the foot including toes.

Posterior tibial artery

Posterior tibial nerve

Flexor digitorum longus

Medial calcaneal nerveTibialis posterior

Lateral plantar nerve

Medial plantar nerveFlexor hallucis longus

Deep Peroneal NerveDeep Peroneal Nerve

• Located on dorsum of foot between theExtensor Hallucis Longus tendon and theExtensor Hallucis Longus tendon and theExtensor Digitorum Longus tendon at the levelof the cuneiforms.

• Closely associated with the Dorsalis Pedis Artery.

• Innervates the first interdigital web space.

Dorsalis pedis artery

Deep Peroneal Nerve

Extensor hallucis brevis

Extensor digitorum brevis

Dorsal Cutaneous NervesDorsal Cutaneous Nerves

• Medial and Intermediate Dorsal Cutaneous Nerves.

• Extremely superficial nerves within thesubcutaneous tissues on dorsum of foot.

• Innervate dorsum of foot to toes.

Superficial peroneal nerve

Deep peroneal

Medial dorsal cutaneous nerve

Intermediate dorsal cutaneous

pnerve

cutaneous nerve

Lateral dorsal cutaneous nerve(branch of sural nerve)

Sural NerveSural Nerve

• Located on lateral-posterior aspect ofankle posterior to the peroneal tendons.

• Innervates the lateral aspect of the foot to the fifth digitfoot to the fifth digit.

Sural nerve (cut)

Sural nerve

Saphaenous NerveSaphaenous Nerve

• Associated with Greater Marginal Vein on gantero-medial aspect of ankle and foot.

• Innervates dorso-medial aspect of foot tofirst MP joint.

Saphenous nerve

Infrapatellar branch ofsaphenous nerve

Medial crural cutaneous branches ofsaphenous nerve

Local Anesthetic Block Local Anesthetic Block of the Foot and Ankleof the Foot and Ankle

Supplies RequiredSupplies Required

• Local anesthetic of choice. (Xylocaine or Marcaine with or without epinepherineMarcaine with or without epinepherine

• Generally 10cc. To 15cc. of solution will suffice.

• Small-bore 1 1/4-inch needle.

T i l th ti ki f i t• Topical anesthetic or skin refrigerant.

Steps of BlockSteps of Block

• Position patient supine and comfortable.

• Provide blocks to nerves:• Posterior Tibial: 5cc.• Deep Peroneal: 1-2cc.• Dorsal Cutaneous: 3cc.• Sural: 3cc.• Saphenous: 1-2cc.

• WAIT for blocks to take effect.

POSTERIOR TIBIALPOSTERIOR TIBIAL

DEEP PERONEALDEEP PERONEAL

DORSAL CUTANEOUSDORSAL CUTANEOUS

SAPHAENOUSSAPHAENOUS

SURALSURAL

COMPLETE AND TOTAL ANESTHESIA COMPLETE AND TOTAL ANESTHESIA OF THE ENTIRE FOOT ANDOF THE ENTIRE FOOT AND

DISTAL ANKLEDISTAL ANKLE

Digital AnestheticDigital AnestheticBlockBlock

Many Surgical Many Surgical y gy gProcedures of the Foot Procedures of the Foot

Can Be Performed Can Be Performed Under Local AnesthesiaUnder Local Anesthesia

ALIEN EXCISIONS !ALIEN EXCISIONS !

SUMMARY:SUMMARY:FOOT AND ANKLE BLOCKSFOOT AND ANKLE BLOCKS

Blocks provide excellent anesthesia of foot Blocks provide excellent anesthesia of foot and ankle for most ALL proceduresand ankle for most ALL proceduresand ankle for most ALL proceduresand ankle for most ALL proceduresEasy and quick to administerEasy and quick to administerMinimal discomfort to patientsMinimal discomfort to patientsIncrease patient confidenceIncrease patient confidenceExcellent practice builderExcellent practice builder

THANKTHANK--YOUYOU

Small (Short) Saphenous vein

Saral nerve

Superficial peroneal nerve (Musculo-cutaneous a)

Fibular malleolus

Dorsal venous arch

Perferating or Anastomotic veins

Common dorsal digital veins

Lateral cutaneous nerveof thigh, ant. branch

Ilio-inguinal nerve

Cutaneous branchof obturator nerve

Femoral brs. Of genito-femoral nerve(Lumbo-inguinal n.)Genital br. Of genito-femoral nerve(Ext. spermatic n.)

Lateral cutaneous branchof subcostal nerve (T.12)Lateral cutaneous nerveof thigh, post. branch

Intermediatecutaneous n. of thigh

Infrapatellar branchof saphenous nerve

Saphenous nerve

Medial cutaneous nerveof thigh, ant. branch

Cutaneous branchsf (l t l lit l )of (lateral popliteal n.)

common peroneal nerve

(Musculo-cutaneous n.)Superficial peroneal nervebecoming dorsal digitalnerves

Dorsal lateral cutaneousnerve of foot

Deep peroneal nerve(Anterior tibial n.)

Superficial Peroneal Nerve

Deep Peroneal Nerve

Saphenous Nerve

Sural Nerve

p

Nerve Anesthetized in Ankle BlockNerve Anesthetized in Ankle Block

• Posterior tibial

• Deep Peroneal

• Sural

• Dorsal Cutaneous

• Saphaenous

Neuroanatomy of the Neuroanatomy of the Foot and AnkleFoot and Ankle

“Mr. Osborne, may I be excused?My brain is full.”

Lateral plantar nerve

Medial plantarMedial plantar nerve

Lateral cutaneous nerveof thigh, ant. branch

Ilio-inguinal nerve

Cutaneous branchof obturator nerve

Femoral brs. Of genito-femoral nerve(Lumbo-inguinal n.)Genital br. Of genito-femoral nerve(Ext. spermatic n.)

Lateral cutaneous branchof subcostal nerve (T.12)Lateral cutaneous nerveof thigh, post. branch

Intermediatecutaneous n. of thigh

Infrapatellar branchof saphenous nerve

Saphenous nerve

Medial cutaneous nerveof thigh, ant. branch

Cutaneous branchsf (l t l lit l )of (lateral popliteal n.)

common peroneal nerve

(Musculo-cutaneous n.)Superficial peroneal nervebecoming dorsal digitalnerves

Dorsal lateral cutaneousnerve of foot

Deep peroneal nerve(Anterior tibial n.)

Superficial Peroneal Nerve

Deep Peroneal Nerve

Saphenous Nerve

Sural Nerve

p

Small (Short) Saphenous vein

Sural nerve

Superficial peroneal nerve (Musculo-cutaneous a)

Fibular malleolus

Dorsal venous arch

Perferating or Anastomotic veins

Common dorsal digital veins

Posterior tibial artery

Posterior tibial nerve

Flexor digitorum longus

Medial calcaneal nerveTibialis posterior

Lateral plantar nerve

Medial plantar nerveFlexor hallucis longus

Dorsalis pedis artery

Deep fibular (peroneal) nerve

Extensor hallucis brevis

Extensor digitorum brevis

“Mr. Osborne, may I be excused?My brain is full.”

Superficial Peroneal Nerve

Deep Peroneal Nerve

Saphenous Nerve

Sural Nerve

p

Posterior tibial artery

Posterior tibial nerve

Flexor digitorum longus

Medial calcaneal nerveTibialis posterior

Lateral plantar nerve

Medial plantar nerveFlexor hallucis longus

Posterior Tibial NervePosterior Tibial Nerve

Deep Peroneal NerveDeep Peroneal Nerve

Dorsal Cutaneous NervesDorsal Cutaneous Nerves

Sural NerveSural Nerve