Clinical Leg

Question 1

Common fibular nerve (L4-S2) pathway

Answer 1

• From sciatic nerve
• Passes around fibular neck
• Enters lateral compartment by passing through posterior intermuscular septum
• Bifurcates into terminal branches

Question 2

Bifurcation of someone fibular nerve (L4-S2) terminal branches

Answer 2

• Deep fibular nerve

- Superficial fibular nerve

Question 3

Deep fibular nerve pathway

Answer 3

• Terminal branch of common fibular nerve
• passes through anterior intermuscular septum
• Enters anterior compartment

Question 4

Common fibular nerve (L4-S2) injury

Answer 4

• Susceptible to injury as it passes around fibula
• Prolonged compression
• Trauma

Question 5

Prolonged compression of common fibular may result from

Answer 5

• Tight casts

- Excessive sitting/sleeping position

Question 6

Injury to common fibular nerve (L4-S2) associated with

Answer 6

• Footdrop (increased tripping with gait)
• Weak dorsifelxion, to extension, and eversion
• Steppage gait
• Loss of sensation of distal anterolateral leg, dorsum of foot, 1st web space

Question 7

Transmalleolar angle

Answer 7

• Line between center of medial/lateral malleoli
• In relation to line passing through knee joint axis
• Measures tibial torsion

Question 8

Normal range of tibial torsion

Answer 8

• Childhood: -10-0 degrees

- Adults: 10-15 degrees external rotation

Question 9

Obtaining tibial torsion angle

Answer 9

• Measure transmalleolar angle

- Can also use thigh foot angle

Question 10

Measuring transmalleolar angle

Answer 10

• Patient prone
• Line through the longitudinal axis of the thigh
• Line perpendicular to the most prominent point of the malleloli

Question 11

Measuring thigh foot angle

Answer 11

• Patient prone

- Line bisecting foot and line bisecting thigh

Question 12

Kager angle

Answer 12

• Radiolucent triangle seen one lateral radiographs

- Kager fat pad (pre-calcaneal fat pad/pre-Achilles fat pad)

Question 13

Kager triangle may be obliterated by pathologies

Answer 13

• Achilles pathology (tearing, inflammation)
• Calcaneal fracture
• FHL tendon pathology
• Accessory soleus muscle

Question 14

Tarsal tunnel syndrome

Answer 14

• Compressive neuropathy of tibial nerve or it’s branches within the tarsal tunnel
• Porta pedis is also entrapment site

Question 15

Symptoms of tarsal tunnel syndrome

Answer 15

• Altered sensation of medial/plantar foot and medial ankle (tibial nerve distribution)
• Atrophy of intrinsic foot muscles (prolonged compression)
• Tinel sign

Question 16

Tinel sign

Answer 16

• Pain with tapping

- Percussing the nerve in tunnel

Question 17

Symptoms of tarsal tunnel syndrome may be reproduced by

Answer 17

• Sustained dorsiflexion of ankle and MTPJs

- Sustained plantarflexion and inversion

Question 18

Tarsal tunnel syndrome may be treated

Answer 18

• Surgically

- Conservatively

Question 19

Boundaries of tarsal tunnel

Answer 19

• Medial: flexor retinaculum (laciniate ligament) and abductor hallucis
• Lateral: calcaneus, posterior talotibial and calcaneotibial ligaments
• Distal margin: porta pedis

Question 20

Tarsal tunnel MEDIAL boundary

Answer 20

• Flexor retinaculum (laciniate ligament)

- Abductor hallucis

Question 21

Tarsal tunnel LATERAL boundary

Answer 21

• Calcaneus
• Posterior tibial and calcaneotibial ligaments
• Tibia, talus, calcaneus (body and sustentaculum tail)

Question 22

Tarsal tunnel DISTAL MARGIN

Answer 22

• Porta pedis

Question 23

Ankle nerve blocks used for

Answer 23

• Procedures fo the foot
• Pain relief
• When more local is not possible, etc.

Question 24

Ankle blocks avoid general anesthesia, avoiding

Answer 24

• Motor block of the leg muscles

- Sensory of the leg

Question 25

Ankle blocks avoid releasing

Answer 25

- Anesthesia into vessels and puncturing nerves | - Anesthesia is released around the nerve

Question 26

Most of the foot is innervated by nerves derived from

Answer 26

- Sciatic nerve (except 1) - 5 nerves located at ankle (sensory innervation foot) - (3 superficial, 2 deep)

Question 27

3 superficial ankle nerves

Answer 27

- Saphenous - Sural - Superficial fibular

Question 28

2 deep ankle nerves

Answer 28

- Posterior tibial | - Deep fibular

Question 29

Posterior tibial nerve is blocked via

Answer 29

- Medial calcaneal branches | - Medial/lateral plantar nerves

Question 30

Sural nerve blocks

Answer 30

- Lateral ankle - Lateral heel - Lateral foot - Lateral 5th digit

Question 31

Deep fibular nerve blocks

Answer 31

- 1st web space - Superficial fibular - Most of the dorsum of the foot and toes

Question 32

Saphenous nerve blocks

Answer 32

- Medial foot

Question 33

Subcutaneous nerve blocks at level of malleoli

Answer 33

- Saphenous - Superficial fibular - Sural - Where they are blocked depends on procedure

Question 34

Deep fibular nerve block landmarks

Answer 34

- EHL and TA tendons | - Medial malleolus

Question 35

Perimalleolar (deep fibular nerve block)

Answer 35

- Lateral to EHL | - Level of the superior aspect of medial malleolus

Question 36

Midtarsal (deep fibular nerve block)

Answer 36

- Lateral to EHL | - Medial to dorsalis pedis artery pulse

Question 37

Superficial fibular nerve block

Answer 37

- Subcutaneous between lateral malleolus and EHL tendon (landmarks) - Perimalleolar - Anesthesia is administered in the area between the 2 landmarks

Question 38

Perimalleolar (superficial fibular nerve block)

Answer 38

- Between superior aspect of lateral malleolus and EHL

Question 39

Sural nerve block

Answer 39

- Perimalleolar | - Anesthesia is administered between the 2 landmarks

Question 40

Perimalleolar (sural nerve block)

Answer 40

- Subcutaneous | - Between Achilles tendon and superior aspect of lateral malleolus

Question 41

Posterior tibial nerve block

Answer 41

- Perimalleolar - Posterior to posterior tibial pulse - (Midway between superior aspect of medial malleolus and Achilles tendon)

Question 42

Perimalleolar (posterior tibial nerve block)

Answer 42

- Deep to the deep fascia | - Posterior to medial malleolus

Question 43

Saphenous nerve block

Answer 43

- Perimalleolar | - Saphenous vein is nearby and can be punctured easily

Question 44

Perimalleolar (saphenous nerve block)

Answer 44

- Subcutaneous between TA tendon and medial malleolus

Question 45

Posterior tibial nerve blocks

Answer 45

- Plantar foot - Medial heel - Toe tips

Question 46

Deep fibular nerve block location

Answer 46

- Deeply located at ankle | - Deep to deep fascia

Question 47

Types of deep fibular nerve blocks

Answer 47

- Perimalleolar | - Midtarsal

Question 48

Deep nerve blocks at level of malleoli

Answer 48

- Deep fibular - Posterior tibial - Located deep to retinacula - More superficial distally - Where they are blocked depends on procedure