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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
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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
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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.
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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.
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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.
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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.
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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.
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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
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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.
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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
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DEEP PERONEALDEEP PERONEAL
DORSAL CUTANEOUSDORSAL CUTANEOUS
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SAPHAENOUSSAPHAENOUS
SURALSURAL
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COMPLETE AND TOTAL ANESTHESIA COMPLETE AND TOTAL ANESTHESIA OF THE ENTIRE FOOT ANDOF THE ENTIRE FOOT AND
DISTAL ANKLEDISTAL ANKLE
Digital AnestheticDigital AnestheticBlockBlock
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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
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ALIEN EXCISIONS !ALIEN EXCISIONS !
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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
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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
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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.)
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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
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Neuroanatomy of the Neuroanatomy of the Foot and AnkleFoot and Ankle
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“Mr. Osborne, may I be excused?My brain is full.”
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Lateral plantar nerve
Medial plantarMedial plantar nerve
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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
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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
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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
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“Mr. Osborne, may I be excused?My brain is full.”
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Superficial Peroneal Nerve
Deep Peroneal Nerve
Saphenous Nerve
Sural Nerve
p
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Posterior tibial artery
Posterior tibial nerve
Flexor digitorum longus
Medial calcaneal nerveTibialis posterior
Lateral plantar nerve
Medial plantar nerveFlexor hallucis longus
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Posterior Tibial NervePosterior Tibial Nerve
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Deep Peroneal NerveDeep Peroneal Nerve
Dorsal Cutaneous NervesDorsal Cutaneous Nerves
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Sural NerveSural Nerve