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09.12.2011

NYSORA - The New York School of Regional Anesthesia - Ankle Block

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Co pyright NYSORA 1996, 2008 NYSORA.com Loading Image Ankle Block A kle Bl ck TABLE OF

Ankle Block

A kle Bl ck

A kle Bl ck

TABLE OF CONTENTS (click here o e pand)

OverviewBl ck TABLE OF CONTENTS ( click here o e pand ) General Considerations Regional Anesthesia

General ConsiderationsTABLE OF CONTENTS ( click here o e pand ) Overview Regional Anesthesia Anatomy Distribution of

Regional Anesthesia Anatomyclick here o e pand ) Overview General Considerations Distribution of Anesthesia Patient Positioning Equipment

Distribution of AnesthesiaOverview General Considerations Regional Anesthesia Anatomy Patient Positioning Equipment Landmarks Technique Choice of

Patient PositioningRegional Anesthesia Anatomy Distribution of Anesthesia Equipment Landmarks Technique Choice of Local Anesthetic

EquipmentAnatomy Distribution of Anesthesia Patient Positioning Landmarks Technique Choice of Local Anesthetic Block

LandmarksDistribution of Anesthesia Patient Positioning Equipment Technique Choice of Local Anesthetic Block Dynamics and

Techniqueof Anesthesia Patient Positioning Equipment Landmarks Choice of Local Anesthetic Block Dynamics and Perioperative

Choice of Local AnestheticAnesthesia Patient Positioning Equipment Landmarks Technique Block Dynamics and Perioperative Management Complications

Block Dynamics and Perioperative ManagementEquipment Landmarks Technique Choice of Local Anesthetic Complications and How to Avoid Them An ankle block

Complications and How to Avoid ThemLocal Anesthetic Block Dynamics and Perioperative Management An ankle block is essentiall a block of four

An ankle block is essentiall a block of four branches of the sciatic nerve (deep and superficial peroneal, tibial and sural nerves) and one cutaneous branch of the femoral nerve (saphenous nerve).

Overview

branch of the femoral nerve (saphenous nerve). Overview Indica ion : Surgery on foot and toes

Indica ion : Surgery on foot and toes Ne e :

T o deep ne e : Posterior tibial, deep peroneal Th ee pe ficial ne e : superficial peroneal, sural, saphenous Never use an epinephrine-containing local anesthetic

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09.12.2011

NYSORA - The New York School of Regional Anesthesia - Ankle Block

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09.12.2011

NYSORA - The New York School of Regional Anesthesia - Ankle Block

b e i m cle . Af e pie cing he deep fa cia co e ing he m cle , he ne e e en all eme ge f om he an e ola e al compa men of he

lo e pa of he leg and face f om benea h he fa cia 5-10 cm abo e he la e al malleol . A hi poin , he ne e di ide in o e minal c aneo b anche : he medial and la e al do al c aneo ne e .

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09.12.2011

NYSORA - The New York School of Regional Anesthesia - Ankle Block

- The New York School of Regional Anesthesia - Ankle Block Pa ie i i i
- The New York School of Regional Anesthesia - Ankle Block Pa ie i i i

Pa ie i i i g

The patient is in the supine position with the foot resting on a foot stand. TIPS

Position the foot on a footrest so that an access to all nerves to be blocked is maintained.supine position with the foot resting on a foot stand. TIPS Walk from one side of

Walk from one side of the foot to the other while performing the block procedure instead of bending and leaning to reach the opposite side.so that an access to all nerves to be blocked is maintained. E i e A

instead of bending and leaning to reach the opposite side. E i e A standard regional

E i e

A standard regional anesthesia tray is prepared with the following equipment:

Sterile towels and 4"x4" gauze packsanesthesia tray is prepared with the following equipment: Three 10-mL syringes with local anesthetic Sterile gloves,

Three 10-mL syringes with local anestheticequipment: Sterile towels and 4"x4" gauze packs Sterile gloves, marking pen, and surface electrode One 1

Sterile gloves, marking pen, and surface electrodegauze packs Three 10-mL syringes with local anesthetic One 1 " 25-gauge needle La d a

One 1 " 25-gauge needle " 25-gauge needle

pen, and surface electrode One 1 " 25-gauge needle La d a k The deep peroneal

La d a k

electrode One 1 " 25-gauge needle La d a k The deep peroneal nerve is located

The deep peroneal nerve is located immediately lateral to the tendon of the extensor hallucis longus muscle (between extensor hallucis longus and extensor digitorum longus). The pulse of the anterior tibial artery (dorsalis pedis) can be felt at this location; the nerve is immediately lateral to the artery. TIP: This landmark is easily palpated and can be accentuated by asking the patient to dorsiflex the foot or toes. The posterior tibial nerve is located just behind and distal to the medial malleolus. The pulse of the posterior tibial artery can be felt at this location; the nerve is just posterior to the artery. The superficial peroneal, sural, and saphenous nerves are located in the subcutaneous tissue alongside a circular line that stretches from the lateral aspect of the Achilles tendon across the lateral malleolus, anterior aspect of the foot, and medial malleolus to the medial aspect of the Achilles tendon. TIP: These nerves branch out and anastomose extensively and do not have a single, consistently positioned nerve trunk that can be anesthetized by a single, precise injection, as is often depicted in various regional anesthesiology books.

Tech i e

09.12.2011

NYSORA - The New York School of Regional Anesthesia - Ankle Block

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09.12.2011

NYSORA - The New York School of Regional Anesthesia - Ankle Block

- The New York School of Regional Anesthesia - Ankle Block TIP Similar to the technique
- The New York School of Regional Anesthesia - Ankle Block TIP Similar to the technique

TIP Similar to the technique used for deep peroneal nerve, a "fan" technique should be used to increase the success rate. The needle is pulled back to the skin and two additional boluses of 2 mL of local anesthetic are injected after lateral and medial needle reinsertions.

Block of the Superficial Peroneal, Sural and Saphenous Nerves These three nerves are superficial cutaneous extensions of the sciatic and femoral nerve. Since they are positioned superficial to the deep fascia, a simple injection of local anesthetic in the

territory in which they descend to the distal foot is adequate to achieve their blockade. Blockade of all three nerves is accomplished using a simple circumferential injection of local anesthetic subcutaneously. The sural nerve is a sensory nerve formed by the union of the medial sural nerve - a branch of the tibial nerve - and lateral sural nerve a branch of the common peroneal nerve. The sural nerve courses between the heads of the gastrocnemius muscle and after piercing the fascia covering the muscles, emerges on the lateral aspect of the Achilles tendon, 10 to 15 cm above the lateral mallelus. After giving lateral calcaneal branches to the heel, the sural nerve descends 1-1.5 cm behind the lateral malleolus, anterolateral to the short saphenous vein and on the surface of the fascia covering the muscles and tendons. At this level the nerve supplies the lateral malleolus, Achilles tendon and the ankle joint. The sural nerve continues on the lateral

aspect of the foot supplying the skin, subcutanous tissue, fourth interosseous space and sensory innervation of the fifth toe. To block the saphenous nerve, a 25-gauge 1 " needle is

inserted at the level of the medial malleous and a "ring" of local anesthetic is raised from the point of needle entry to the Achille's tendon and anteriorly to the tibial ridge. This can be usually accomplished through one or two needle insertions. Five mL of local anesthetic suffices. TIP

Remember the subcutaneous position of the superficial nerves and think of their blockade like a "field block". A distinct subcutaneous "wheal" should be with injection into a proper plane to block the superficial nerves.

into a proper plane to block the superficial nerves. Superficial peroneal nerve is blocked b subcutaneous

Superficial peroneal nerve is blocked b subcutaneous infiltration of local anesthetic over the lateral aspect of the foot.

of local anesthetic over the lateral aspect of the foot. Saphenous nerve is blocked b subcutaneous
of local anesthetic over the lateral aspect of the foot. Saphenous nerve is blocked b subcutaneous

Saphenous nerve is blocked b subcutaneous infiltration of local anesthetic over the medial as pect of the foot.

09.12.2011

NYSORA - The New York School of Regional Anesthesia - Ankle Block

Choice of local anesthetic

The choice of the type and concentration of local anesthetic for an ankle block is based on the desired duration of the blockade. Because it is almost always beneficial that the analgesia after an ankle block lasts some time after surgery, a long-acting local anesthetic is most commonly used. The following table provides onset times and duration for some commonly used local anesthetics mixtures.

Onset (min)Anesthesia (hrs)Analgesia (hrs)

1.5% Mepivacaine (+ HCO3)

15-20

2-3

3-5

2% Lidocaine (+ HCO3)

10-20

2-5

3-8

0.5% Ropivacaine

15-30

4-8

5-12

0.75% Ropivacaine

10-15

5-10

6-24

0.5 Bupivacaine (or I-bupivacaine)15-30

5-15

6-30

Block D namics and Perioperative Management

Although the ankle block is considered a "superficial block" procedure, it is one of the most uncomfortable block procedures for the patients. The reason is that an ankle block involves five separate needle insertions; subcutaneous injections to block the cutaneous nerves result in pressure distension of the skin and nerve endings. Additionally, the foot is supplied by an abundance of nerve endings and it is exquisitely sensitive to needle injections. For that reason, this block requires significant sedation/analgesia to make it acceptable to patient. We routinely use combination of midazolam (2-4 mg IV) and a narcotic (500-750 mg alfentanyl) to ensure the patient's comfort during the procedure. A typical onset time for this block is 10-25 minutes, depending primarily on the concentration of the local anesthetic used. Sensory anesthesia of the skin with this block develops faster than the motor block. Placement of an Esmarch or a tourniquet at the level of the ankle is well tolerated and typically does not require additional blockade.

Complications and How to Avoid Them

Complications after an ankle block are typically limited to residual paresthesias due to an inadvertent intraneuronal injection. Systemic toxicity is rare because of the distal location of the blockade. Infection Rare with the use of an aseptic technique

Infection Rare with the use of an aseptic technique Avoid multiple needle insertions Hematoma Most

Avoid multiple needle insertionsInfection Rare with the use of an aseptic technique Hematoma Most superficial blocks can be acomplished

Hematoma

Most superficial blocks can be acomplished through one or two needle insertionsHematoma

Use 25-gauge needle and avoid puncturing superficial veins.can be acomplished through one or two needle insertions Vascular Avoid puncturing the greater saphenous vein

Vascular

Avoid puncturing the greater saphenous vein at the medial malleolusVascular

puncture

Intermittent aspiration should be performed to avoid an intravascular injectionpuncture

Nerve injur

Do not inject when the patient complains of pain or high pressures are met on injectionNerve injur

Do not re-inject deep tibial and peroneal nervescomplains of pain or high pressures are met on injection Other Instruct the patient on the

Other Instruct the patient on the care of the insensate extremity

Instruct the patient on the care of the insensate extremity Bibliograph Delgado-Martinez AD, Marchal-Escalona JM:

Bibliograph

Delgado-Martinez AD, Marchal-Escalona JM: Supramalleolar ankle block anesthesia and ankle tourniquet for foot surgery. Foot Ankle Int 2001; 22:836-8patient on the care of the insensate extremity Bibliograph Hadzic A,Vloka JD, Kuroda MM: The use

Hadzic A,Vloka JD, Kuroda MM: The use of peripheral nerve blocks in anesthesia practice. A national survey. Reg Anesth Pain Med 1998; 23:241-6tourniquet for foot surgery. Foot Ankle Int 2001; 22:836-8 Mineo R, Sharrock NE: Venous levels of

Mineo R, Sharrock NE: Venous levels of lidocaine and bupivacaine after midtarsal ankle block. Reg Anesth 1992; 17:47-9A national survey. Reg Anesth Pain Med 1998; 23:241-6 Myerson MS, Ruland CM, Allon SM: Regional

Myerson MS, Ruland CM, Allon SM: Regional anesthesia for foot and ankle surgery. Foot Ankle 1992; 13:282-8after midtarsal ankle block. Reg Anesth 1992; 17:47-9 Needoff M, Radford P, Costigan P: Local anesthesia

Needoff M, Radford P, Costigan P: Local anesthesia for postoperative pain relief after foot surgery:for foot and ankle surgery. Foot Ankle 1992; 13:282-8 a prospective clinical trial. Foot Ankle Int

a prospective clinical trial. Foot Ankle Int 1999; 16:11-3

Noorpuri BS, Shahane SA, Getty CJ: Acute compartment syndrome following revisional arthroplasty of the forefoot: the dangers of ankle-block. Foot Ankle Int 2000; 21:680-2a prospective clinical trial. Foot Ankle Int 1999; 16:11-3 Reilley TE, Gerhardt MA: Anesthesia for foot

Reilley TE, Gerhardt MA: Anesthesia for foot and ankle surgery: Clin Podiatr Med Surg 2002;the dangers of ankle-block. Foot Ankle Int 2000; 21:680-2 19:125-47 Schurman DJ: Ankle-block anesthesia for foot

19:125-47

Schurman DJ: Ankle-block anesthesia for foot surgery. Anesthesiology 1976; 44:348-52and ankle surgery: Clin Podiatr Med Surg 2002; 19:125-47 Sharrock NE, Waller JF, Fierro LE: Midtarsal

Sharrock NE, Waller JF, Fierro LE: Midtarsal block for surgery of the forefoot. Br J Anaesth 1986;anesthesia for foot surgery. Anesthesiology 1976; 44:348-52 58:37-40 Back to Peripheral Nerve Blocks

58:37-40

Back to Peripheral Nerve Blocks