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Lower Extremity Blocks Flashcards

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1
Q

Lumbar plexus block can be performed with which two techniques?

A

Psoas compartment or inguinal perivsscular

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2
Q

What areas does a lumbar plexus block cover?

A

Femoral
Lateral femoral cutaneous
Obturator

(FLO)

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3
Q

What surgeries are appropriate for a lumbar plexus block?

A

Surgery on hip, knee, and anterior thigh

Complete anesthesia of the knee requires addition of sciatic nerve block

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4
Q

Which lumbar plexus block is more appropriate for analgesia vs surgical anesthesia?

A

Inguinal perivascular

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5
Q

Which block is called a 3 & 1 block?

A

The inguinal perivascular (femoral, lateral femoral cutaneous, and obturator)

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6
Q

Which landmarks are identified in an inguinal perivascular block?

A

Femoral artery and inguinal ligament

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7
Q

Correct needle placement during inguinal perivascular block found by dividing the inguinal ligament into thirds is where?

A

2cm distal to junction of middle and outer thirds

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8
Q

Two pops during inguinal perivascular block indicate puncture of what structures?

A

Fascia lata (superficial) and fascia iliaca (deep)

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9
Q

Alternative landmark for needle placement during inguinal perivascular block?

A

1cm lateral to femoral artery and 1cm inferior to inguinal ligament.

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10
Q

Peripheral nerve stimulation of correct needle placement of inguinal perivascular block results in twitch in which muscle?

A

Quadriceps extension/twitch

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11
Q

Correct needle measurements for inguinal perivascular block

A

4cm 22g

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12
Q

Correct amount of local for inguinal perivascular block?

A

30-40 mL

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13
Q

Major 3 nerves of the lumbar plexus

A

Lateral femoral cutaneous (superior L2 and L3)
Femoral (inferior L2, L3, and superior L4)
Obturator (L2, L3, and L4 roots)

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14
Q

Lumbar plexus involves which spinal nerves?

A

L1-L4 with some T12

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15
Q

Which nerve gives rise to the saphenous nerve?

A

Femoral

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16
Q

What lies between the quadratis lumbarum and behind the psoas major?

A

Lumbar plexus

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17
Q

What is the correct position for psoas compartment block?

A

Lateral decubitus with operative side up and knees flexed.

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18
Q

Psoas compartment block is also known as…

A

Posterior LP block

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19
Q

Correct needle selection for psoas compartment block?

A

4 inch needle

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20
Q

What is the correct dose of LA for a psoas compartment block?

A

20-30 mL

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21
Q

Which block is associated with the highest complication rate?

A

Psoas compartment block

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22
Q

What are the common complications of psoas block?

A

Hematoma
LAST
intrathecal/epidural injection
renal capsule puncture

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23
Q

What is the correct needle placement for psoas compartment block?

A

5cm lateral and 3cm caudal to L4; advance until appropriate motor response of quadriceps muscle is elicited.

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24
Q

Where is L5 typically encountered when performing a psoas compartment block?

A

Around 5-10 cm; walk off superior edge and reposition more cephelad, advance to 8-12cm

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25
Name the two ways a femoral nerve block can be performed.
Ultrasound and nerve stimulator
26
Femoral knee blocks are used for which procedures?
Knee and anterior thigh
27
Does the femoral block provide surgical or analgesic control of post op pain?
Post op pain control
28
Femoral nerve block provides anesthesia to what areas?
Entire anterior thigh and most of the femur and knee
29
Femoral block provides anesthesia to anterior thigh, most of the femur and knee with what dose of local?
30-40mL
30
What landmark is used for femoral nerve block?
Femoral artery in inguinal crease
31
Nerve stimulation of the femoral artery can achieved by placing ____ inch needle in a ______ direction at ___ degree angle until ____ muscle twitch is elicited.
2 inch needle, cephelad direction, at a 45 degree angle until quadriceps muscle twitch is elicited.
32
Ultrasound for femoral nerve block is placed where?
Parallel in inguinal crease
33
Femoral nerve will have what appearance under US
Honeycomb
34
Name landmarks of inguinal fold from lateral to medial
Nerve, artery, vein, empty space, lymphatics (NAVEL)
35
Saphenous nerve blocks are primarily used in conjunction with which block?
Sciatic
36
Sciatic + saphenous nerve blocks are used to provide anesthesia to what area?
Entire area below the knee
37
Saphenous block can be used alone to cover what area?
Medial lower leg
38
Saphenous nerve block can be performed how many different ways?
3 (trans sartorial, proximal saphenous, distal saphenous techniques)
39
Describe trans sartorial technique to saphenous nerve block
Needle inserted medial to lateral at junction of sartorius, versus medialis, and adductor muscles slightly above the knee 10-20 mL of local given (30 in Madisonville to cover medial thigh, knee and lower extremity)
40
Which plexus provides most innervation to lower leg?
Sacral plexus with exception of saphenous (femoral/lumbar plexus via femoral nerve)
41
Trans sartorial is also often referred to as what?
Adductor canal
42
What is the benefit of using adductor canal (trans sartorial) block vs femoral, thus decreasing risk of post operative complications?
Less motor block, can ambulate sooner
43
Describe proximal saphenous technique
Needle inserted 2cm distal to tibial tuberosity and directed medially with deposit of 5-10 mL local (lower leg)
44
How much local is used in a proximal saphenous block?
5-10 mL
45
Distal saphenous block provides anesthesia to what area?
Foot
46
Describe distal saphephenous technique
Medial malleolus is identified and 5mL infiltrated in a line running anteriorly around the ankle
47
How much local is required for distal saphenous block?
5mL
48
Which block is referred to as the "sav-y" block?
Adductor canal: sartorius, adductor longus, vastus medialis (Nerve is where the sartorius and vastus medialis)
49
Which block provides anesthesia to the lateral thigh?
Lateral femoral cutaneous
50
When is it appropriate to use a lateral cutaneous block?
To supplement femoral or limited anesthesia for the lateral thigh
51
What position is the patient placed in for lateral femoral cutaneous?
Supine or lateral
52
What is correct needle placement for lateral femoral cutaneous block?
2cm medial and 2cm distal to anterior superior iliac spine
53
What needle is appropriate for lateral femoral cutaneous blocks?
22g
54
What is the best needle direction for lateral femoral cutaneous blocks?
Laterally to observe pop as it goes through the fascia lata
55
How much local is required for a lateral femoral nerve blocks?
10-15mL
56
Sciatic nerve blocks provide anesthesia to what areas?
Knee, hip, thigh, lower leg, and foot; most often performed with femoral or saphenous nerve blocks or lumbar plexus for complete lower extremity anesthesia
57
What are the landmarks required for obturator nerve blocks?
Pubic tubercle (Needle placed 1.5cm inferior and 1.5cm lateral to the tubercle, once bone is contacted needle is redirected laterally and caudally and advanced 2-4cm until motor response is elicited)
58
How much local is required for an obturator nerve block?
15-20 mL
59
Obturator nerve block provides anesthesia to what area?
Knee; most often performed with femoral or sciatic nerve blocks.
60
Sciatic nerve block is indicated for what procedures?
Hip, Knee, thigh, lower legs, and foot depending on the level where nerve is blocked.
61
What position is required to posterior (Labat) approach of sciatic block?
Lateral with affected side bent at the knee and pelvis rolled forward (Sims position)
62
What landmarks are identified for posterior sciatic nerve blocks?
Trochanter, posterior superior iliac spine,and sacral hiatus identified.
63
Where are the lines drawn for posterior sciatic nerve blocks?
Trochanter to posterior superior iliac spine drawn caudally; then caudally from midpoint; then line from trochanter to sacral hiatus
64
What is correct needle placement for posterior sciatic nerve block?
Right side of "A"
65
How much local is required for posterior sciatic block?
25mL
66
Where is the correct needle placement for anterior approach sciatic nerve block?
Inserted through anterior thigh medial to lesser trochanter
67
What direction may make anterior sciatic block easier?
External rotation of leg to identify nerve under US
68
Where is the probe placed for anterior approach to sciatic nerve block?
Transverse to medial thigh at level of lesser trochanter
69
How is nerve identified under ultrasound for anterior sciatic block?
Hyperechoic
70
How many mLs of local is required for anterior sciatic nerve block?
25mL
71
Subgluteal approach to sciatic nerve blocks require patient to be in what position?
Sims (lateral affected side slightly bent at the knee and pelvis rolled forward)
72
What landmarks are utilized for subgluteal approach to sciatic nerve block?
Greater trochanter and ischial tuberosity
73
How is the correct needle placement identified for subgluteal approach to sciatic nerve block?
Line drawn from greater trochanter to ischial tuberosity; second line caudally down 4cm from midpoint of first line
74
When can you assume you have correct needle placement for a subgluteal sciatic block?
Plantar flexion or inversion
75
How much local is required for a subgluteal sciatic block?
25 mL
76
Popliteal nerve blocks are still what kind of block?
Sciatic
77
What surgeries are indications for popliteal nerve blocks?
Knee, tibia, ankle or foot
78
What does the sciatic nerve divide into?
Tibial and common peroneal
79
Where does the sciatic nerve divide?
Within or proximal to popliteal fossa
80
The upper fossa is bound laterally where?
Biceps femoris tendon
81
Upper fossa is bound medially by?
Semitendinosus and semimembranosus tendons
82
What position is a patient placed in for a posterior approach of popliteal nerve blocks?
Prone and flex knee against resistance to identify fossa and where biceps femoris and semimembranous/semitendinosus join.
83
Where is needle inserted during posterior approach to popliteal nerve blocks
1cm caudal to apex of fossa
84
When will you know you have correct needle placement during posterior approach popliteal block?
Plantar flexion or inversion
85
How much local is required for posterior approach popliteal block?
30-40 mL
86
What position is the patient placed in for lateral approach popliteal block?
Supine knee extended and intertendinous grove palpated
87
Where is needle inserted for lateral popliteal nerve block?
10cm proximal to the superior notch of the patella
88
What direction is the needle advanced in a lateral popliteal block?
30 degrees posteriorly until motor response
89
What size needle is appropriate for lateral approach popliteal block?
10cm
90
What position is a patient placed in for ultrasound guided popliteal blocks?
Supine, prone, or lateral
91
Where is ultrasound probe placed for popliteal block?
Transverse at the crease of knee and popliteal artery identified and nerve can be traced up to where it divides
92
Where is nerve typically found for us guided | Popliteal block?
Lateral
93
What can you have patient do to better local popliteal nerve with US?
Plantar Flex
94
All nerves used in ankle block is ____ with the exception of the saphenous?
Sacral plexus
95
What nerves are blocked for ankle block?
``` Deep peroneal Superficial peroneal Posterior tibial Saphenous Sural ```
96
Bottom of the foot is what nerve?
Tibial *medial and lateral *
97
How much local is given at each location for an ankle block?
5mL
98
Deep peroneal is located where?
Groove lateral to extensor hallucis longus muscle and injected lateral to dorsalis pedis at level of bone
99
Superficial peroneal is located where?
30 degrees lateral at depth of tibia
100
Saphenous nerve is where?
30 degrees medial at depth of medial malleolus of tibia
101
Posterior tibial is located where?
Medial to Achilles tendon, and posterior to medial malleolus posterior to posterial tibial pulse
102
Sural nerve is where?
Lateral to Achilles tendon and posterior to lateral malleolus

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