1Kaan Yücel M.D., Ph.D.

NERVE BLOCKS

21.March.2012 Thursday

NERVE BLOCKSUPPER EXTREMITY

Injection of an anesthetic solution into or immediately surrounding the axillary sheath interrupts conduction of impulses of peripheral nerves.

The distal part of the sheath is closed with finger pressure, and a syringe needle is inserted into the proximal part of the sheath.

Sensation blocked in all deep structures of the upper limb and the skin distal to the middle of the arm.

Brachial Plexus Block

Brachial plexus can be anesthetized using a number of approaches:

Interscalene blockSupraclavicular blockInfraclavicular blockAxillary block

Interval between the scalene muscles

Roots of the upper part of the brachial plexus can be blocked.

Interscalene BlockPROCEDURE

Between scalenus anterior & scalenus medius directed caudally behind subclavian artery toward upper surface of 1st rib

brachial plexus compactupper middle lower trunks

Supraclavicular Block

PROCEDURE

- Identify the middle of the clavicle

- Insert the needle 1 in. (2.5 cm) inferior to it

Anatomy of complicationsVessel puncture Hematoma formation

Infraclavicular BlockPROCEDUR

E

• Palpate axillary artery within the axillary sheath high up in the axilla• Abduct the arm to an angle greater than 90°• Compress the artery there• Insert the need prox. to the point of compressionDisadvantage: Leaking of anesthetic into musculocutanoues nerve Anatomy of complicationsVessel puncture Hematoma formation

Axillary Block

PROCEDURE

Musculocutaneous Nerve Block

PROCEDURESIndicationsRepair of lacerations on the lateral border of the forearm

Brachial plexus approachMusculocutaneous + Rest of the brachial plexusSufficiently high in the axillary sheath

Lateral cutaneous nerve of the forearm approachBetween biceps & brachialis just above lateral epicondyle Lateral to biceps tendon on a line between

two epicondyles of the humerus

Area of anesthesia Lateral half of the palmPalmar aspect of lateral 3 ½ fingers including nail beds on the dorsum

Median Nerve Block

Median Nerve Block

PROCEDURES

-Elbow joint extended, palpate brachial artery @cubital fossa on medial side of biceps brachii tendon

-Insert needle on medial side of brachial artery

-Here median nerve lies on medial side of tendons of flexor carpi radialis & to the lateral side of the flexor digitorum superficialis

Block @ elbow

Block @ wrist

IndicationsRepair of lacerations of the hand & fingers

Where it enters the forearm between olecranon process & medial

epicondyle

Just lateral to flexor carpi ulnaris tendon @ level of distal transverse crease of the

wrist Ulnar artery lateral side of the ulnar nerve

Ulnar Nerve Block

PROCEDURES

Block @ elbow

Block @ wrist

At the level of the proximal transverse flexor crease on the lateral side of the radial artery

Radial Nerve BlockIndicationsRepair of lacerations of the hand

PROCEDURES

Block @ elbow

Block @ wrist

Halfway between biceps brachii tendon &tip of lateral epicondyle

Area of anesthesia Skin of the fingers

Each finger supplied by four digital nerves at 2 o’clock, 5 o’clock, 7 o’clock, and 10 o’clock positions.

IndicationsRepair of lacerations involving individual fingers; removal of nails

Digital Nerve Blocks

Palmar digital nerves (ulnar & median nerves)Palmar surface :Medial 1 ½ fingers including their nail bedsPalmar surface : Lateral 3 ½ fingers

Dorsal digital nerves (ulnar & radial nerves)Dorsal surface of the proximal parts of medial 1 ½ fingers Dorsal surface of the proximal parts of lateral 3 ½ fingers

Digital Nerve Blocks

Between the metacarpal bones, stopping just short of the palmar skin

The anesthetic solution will block the common palmar and dorsal digital nerves

PROCEDURESDigital Nerve BlocksWeb space method

At the web space, digital nerves are about to enter the fingers.

A block on both sides of the fingers

Dorsal metacarpal method

NERVE BLOCKSLOWER EXTREMITY

Distal nerve blocks of the lower limb

Area of anesthesia Front & medial side of the thigh, extending down the medial side of the knee & leg

Medial border of the foot as far as ball of the big toe

Below the midpoint of the inguinal ligament and lateral to the femoral artery

Femoral Nerve Block

PROCEDURE

PROCEDURE

Lateral Cutaneous Nerve of the Thigh BlockArea of anesthesia Anterolateral surface of thigh down to the lateral side of the knee

Just inferior to the inguinal ligament about 0.5 in. (1.3 cm) medial to ASIAS

Sciatic Nerve Block Anterior approach

An advanced block technique

For surgery on the leg below the knee, particularly on the ankle and foot

Complete anesthesia of the leg below the knee with the exception of the medial strip of skin, innervated by the saphenous nerve

LandmarksFemoral creaseFemoral artery pulseNeedle insertion point marked 4-5 cm distally on the line passing through the pulse of the femoral artery and perpendicular to the femoral crease.

Sciatic Nerve Block Posterior approach

Wide clinical applicability for surgery and pain management of the lower extremity

One of the most commonly used techniques in aneshetsia practice

Anesthesia of the skin of the posterior aspect of the thigh, hamstrings and biceps muscles, part of hip and knee joint, and entire leg below the knee, with the exception of the skin of the medial aspect of the lower leg

Indications: Surgery on the knee, tibia, ankle, and foot

Landmarks: Greater trochanter, superior posterior iliac spine, midline between the two

Popliteal Nerve Block Block of the sciatic nerve

in the popliteal fossa with the patient in the prone position.

Ideal for surgeriesof the lower leg, particularly the foot and ankle.

Popliteal fossa creaseTendon of biceps femoris (laterally)Tendons of semitendinosus and semimembranosus muscles (medially)The needle insertion point is marked at 7 cm. above the popliteal fossa crease at the midpoint between the tendons.

Below the head of the fibula

Common Peroneal Nerve BlockArea of anesthesia

Anterior & lateral sides of the leg

Dorsum of the foot & toes

including the medial side of the big toe

PROCEDURE

Superficial Peroneal Nerve BlockArea of anesthesia

Lower anterior & lateral sides of leg Dorsum of foot & toes except Cleft between 1st & 2nd toes deep peroneal nerve Lateral side of little toe sural nerve

PROCEDURELower part of the leg by along a transverse line connecting medial & lateral malleoli

- Palpate the dorsalis pedis artery midway between medial & lateral malleoli

- Foot dorsiflexed, observe extensor digitorum longus & extensor hallucis longus

- The nerve on the lateral side of the artery between these tendons

- Insert the needle over the nerve

Deep Peroneal Nerve BlockArea of anesthesia Cleft between big & second toes

PROCEDURE

Behind medial malleolus

Tibial Nerve BlockArea of anesthesia

Sole of the foot

PROCEDURE

Pulsations of posterior tibial artery midway between medial malleolus & the heel

The nerve lies immediately posterior to the artery, and the anesthetic needle can be inserted at this location.

Area of anesthesia Lateral border of foot & lateral side of little toe

Midway between lateral malleolus &Achilles tendon

Sural Nerve Block

PROCEDURE

Medial side of knee either over medial femoral condyle or lower down over condyle of the tibia

Avoid great saphenous vein

Alternative @ ankle where it passes anterior to medial malleolus

Saphenous Nerve BlockArea of anesthesia

Medial side of the leg Medial border of the foot down

as far as the ball of big toe

PROCEDURE

Area of anesthesia Skin of the toes Each toe is supplied by four digital nerves @ 2 o’clock, 5 o’clock, 7 o’clock, & 10 o’clock positions.

Around the base of each toe

Toe Nerve Blocks

Plantar digital nerves Medial & lateral plantar nervesDorsal digital nerves Superficial peroneal nerve Except : Cleft between big toe&second toe Deep peroneal nerve Lateral side of little toe Sural nerve

PROCEDURE