09.12.2011 NYSORA - The New York School of Regional Anesthesia - Ankle Block Copyright NYSORA Loading Image... 1996, 2008 NYSORA.com Ankle Block 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). 01/03/2009 04:33:00 A kle Bl ck TABLE OF CONTENTS (click here o e pand) Overview General C onsiderations Regional Anesthesia Anatomy Distribution of Anesthesia Patient Positioning Equipment Landmarks Technique C hoice of Local Anesthetic Block Dynamics and Perioperative Management C omplications and How to Avoid Them Overview 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 Local ane he ic: 6 mL per nerve nysora.com/peripheral_nerve_blocks/ /3035-ankle_block.html?print 1/7 2/7 nysora. S .The New York School of Regional Anesthesia . . . . I " .2011 NYSORA . I ( ) . C T (L4-5 : . . . T . A " . A ( .html?print . T . (F 2) A . . Regional anesthesia anatom W ). . .A . .I .09.Ankle Block Local anesthetic: 6 L Comple it level: B General considerations A ) ( ). T . T . . ( . T T ) . .J . ( . T . . ). ( S1-2) ) . . D T . . . . : . ( - .12. .I . A .com/peripheral_nerve_blocks/ /3035-ankle_block. . and en o inne a ion of he fif h oe. 10 o 15 cm abo e he la e al mallel . The ne e n di all in he hick ne o a c la fa cia and eme ge a he infe io hi d of he leg. f om benea h he ole and ga ocnemi m cle on he medial bo de of he Achille endon. TIP: All pe ficial (c aneo ) ne e of he foo ho ld be ho gh of a a ne onal ne o k. i h deep pe oneal ne e in he fi eb pace and al ne e on he la e al a pec of he foo . and Achille endon. pe ficial pe oneal). Tibial ne e The ibial ne e (medial popli eal o po e io ibial ne e) epa a e f om he common popli eal ne e a a io di ance f om he popli eal fo a c ea e and join he ibial a e behind he knee join . m cle .com/peripheral_nerve_blocks/ /3035-ankle_block. al. The po e io ibial ne e p o ide c aneo .12. Achille endon. The mo e p o imal b anche of he ibial and pe oneal ne e p o ide inne a ion o he deep c e of he ankle join ( ee "Ana om "). The e b anche ca en o inne a ion o he do m of he foo and comm nica e i h he apheno ne e mediall . 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 . and bone of he ole.Ankle Block b e i m cle . bone . The al ne e co e be een he head of he ga ocnemi m cle and af e pie cing he fa cia co e ing he m cle . he ne e pplie he la e al malleol . medial malleol . and he ankle join . a he han ingle ing of ne e i h a ell-defined and con i en ana omic po i ion. The o deep ne e ( ibial. bc aneo i e. S al ne e The al ne e i a en o ne e fo med b he nion of he medial al ne e . A he le el of he medial malleol . i ho ld be no ed ha an ankle block doe no e l in ane he ia of he ankle i elf. Ho e e . eme ge on he la e al a pec of he Achille endon. The p o imal e en ion of he blockade i o he le el a hich he block a e pe fo med. an e ola e al o he ho apheno ein and on he face of he fa cia co e ing he m cle and endon . and c aneo co e age of he ole and eb be een he fi and econd oe . inne a pec of he heel. Af e pie cing he deep fa cia co e ing he m cle . nysora.and la e al al ne e. I al o ca ie he b anche o he kin. he al ne e de cend 1-1. I co e i in he bc aneo i e of he kin on medial a pec of he ankle and foo . J benea h he malleol .The New York School of Regional Anesthesia . A hi poin . and a c la b anche o he ankle join .09. Af e gi ing la e al calcaneal b anche o he heel. he ibial ne e i co e ed b he pe ficial and deep fa ciae of he leg. 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 .a b anch of he ibial ne e . a ic la . fo h in e o eo pace. he ne e di ide in o la e al and medial plan a ne e .5 cm behind he la e al malleol . The al ne e con in e on he la e al a pec of he foo ppl ing inne a ion o he kin. deep pe oneal) confe ane he ia o he deep c e . bc ano i e. and mid a be een he po e io a pec of he medial malleol and po e io a pec of he Achille endon. I i po i ioned la e all and po e io l o he po e io ibial a e . Di ib ion of ane he ia An ankle block e l in ane he ia of he foo .2011 NYSORA .html?print 3/7 . a b anch of he common pe oneal ne e. C aneo inne a ion of he foo i p o ided b h ee pe ficial ne e ( apheno . A hi le el. Sapheno ne e The apheno ne e i a e minal c aneo b anch (b anche ) of he femo al ne e. The pulse of the anterior tibial artery (dorsalis pedis) can be felt at this location. the nerve is immediately lateral to the artery. precise injection. The superficial peroneal.Ankle Block Pa ie ii i g The patient is in the supine position with the foot resting on a foot stand.com/peripheral_nerve_blocks/ /3035-ankle_block.12. the nerve is just posterior to the artery.09. 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. The pulse of the posterior tibial artery can be felt at this location.2011 NYSORA . TIP: This landmark is easily palpated and can be accentuated by asking the patient to dorsiflex the foot or toes. and surface electrode One 1 " 25-gauge needle La d a k 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). and medial malleolus to the medial aspect of the Achilles tendon. Tech i e The anesthesiologist needs to change his or her position from lateral to nysora. TIPS Position the foot on a footrest so that an access to all nerves to be blocked is maintained. consistently positioned nerve trunk that can be anesthetized by a single. sural. The posterior tibial nerve is located just behind and distal to the medial malleolus. as is often depicted in various regional anesthesiology books. marking pen. E i e A standard regional anesthesia tray is prepared with the following equipment: Sterile towels and 4"x4" gauze packs Three 10-mL syringes with local anesthetic Sterile gloves. TIP: These nerves branch out and anastomose extensively and do not have a single.html?print 4/7 . 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.The New York School of Regional Anesthesia . anterior aspect of the foot. I .09. P P S T B . .2011 NYSORA . 2 . .T .12. A . . A . L M (30 . .A . A .The New York School of Regional Anesthesia .A .html?print 5/7 . . 1-2 " " . . . W . IP D . nysora. I B D T .Ankle Block T .com/peripheral_nerve_blocks/ /3035-ankle_block.D / ). T 1-2 2-3 L . 1-2 2-3 L . . " 30 " . and lateral sural nerve a branch of the common peroneal nerve. a "fan" technique should be used to increase the success rate. infiltration of local anesthetic over To block the saphenous nerve. subcutanous tissue. This can be usually accomplished through one or two needle insertions.12. Choice of local ane he ic 6/7 nysora. The sural nerve is a sensory nerve formed by the union of the medial sural nerve . Five mL of local anesthetic suffices. anterolateral to the short saphenous vein and on the surface of the fascia covering the muscles and tendons. After giving lateral calcaneal branches to the heel. Blockade of all three nerves is accomplished using a simple circumferential injection of local anesthetic subcutaneously.The New York School of Regional Anesthesia .5 cm behind the lateral malleolus. The sural nerve continues on the lateral Superficial peroneal nerve is aspect of the foot supplying the skin. a 25-gauge 1 " needle is the lateral aspect of the foot. At this level the nerve supplies the lateral malleolus.2011 NYSORA .html?print . a simple injection of local anesthetic in the territory in which they descend to the distal foot is adequate to achieve their blockade. Since they are positioned superficial to the deep fascia. Saphenous nerve is blocked b subcutaneous infiltration of local anesthetic over the medial as pect of the foot. 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. 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 anterio rly to the tibial ridge. A distinct subcutaneous "wheal" should be with injection into a proper plane to block the superficial nerves. The sural nerve courses between the heads of the gastrocnemius muscle and after piercing the fascia covering the muscles. Achilles tendon and the ankle joint.Ankle Block TIP Similar to the technique used for deep peroneal nerve.a branch of the tibial nerve .com/peripheral_nerve_blocks/ /3035-ankle_block. TIP Remember the subcutaneous position of the superficial nerves and think of their blockade like a "field block". Block of the Superficial Peroneal. fourth blocked b subcutaneous interosseous space and sensory innervation of the fifth toe. the sural nerve descends 1-1. 10 to 15 cm above the lateral mallelus. Sural and Saphenous Nerves These three nerves are superficial cutaneous extensions of the sciatic and femoral nerve.09. emerges on the lateral aspect of the Achilles tendon. The reason is that an ankle block involves five separate needle insertions. Foot Ankle Int 2000. 17:47-9 Myerson MS. depending primarily on the concentration of the local anesthetic used. 19:125-47 Schurman DJ: Ankle-block anesthesia for foot surgery. 44:348-52 Sharrock NE. Anesthesiology 1976.2011 Choice of local anesthetic NYSORA . 58:37-40 Back to Peripheral Nerve Blocks nysora.5% Ropivacaine 15-30 4-8 5-12 0. the foot is supplied by an abundance of nerve endings and it is exquisitely sensitive to needle injections.Ankle Block The choice of the type and concentration of local anesthetic for an ankle block is based on the desired duration of the blockade. Allon SM: Regional anesthesia for foot and ankle surgery.Vloka JD. Radford P. Ruland C M.html?print 7/7 . Block D namics and Perioperative Management Complications and How to Avoid Them C omplications after an ankle block are typically limited to residual paresthesias due to an inadvertent intraneuronal injection. Foot Ankle Int 2001. Marchal-Escalona JM: Supramalleolar ankle block anesthesia and ankle tourniquet for foot surgery. Waller JF. Reg Anesth Pain Med 1998. Vascular Avoid puncturing the greater saphenous vein at the medial malleolus puncture Intermittent aspiration should be performed to avoid an intravascular injection Do not inject when the patient complains of pain or high pressures are met on Nerve injur injection Do not re-inject deep tibial and peroneal nerves Other Instruct the patient on the care of the insensate extremity Bibliograph Delgado-Martinez AD. 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. Sensory anesthesia of the skin with this block develops faster than the motor block.5 Bupivacaine (or I-bupivacaine)15-30 5-15 6-30 Although the ankle block is considered a "superficial block" procedure. Reg Anesth 1992. 13:282-8 Needoff M. A national survey. Systemic toxicity is rare because of the distal location of the blockade. C ostigan P: Local anesthesia for postoperative pain relief after foot surgery: a prospective clinical trial.com/peripheral_nerve_blocks/ /3035-ankle_block.75% Ropivacaine 10-15 5-10 6-24 0. Additionally. a long-acting local anesthetic is most commonly used. Shahane SA. it is one of the most uncomfortable block procedures for the patients. 22:836-8 Hadzic A. subcutaneous injections to block the cutaneous nerves result in pressure distension of the skin and nerve endings. Br J Anaesth 1986. The following table provides onset times and duration for some commonly used local anesthetics mixtures. Sharrock NE: Venous levels of lidocaine and bupivacaine after midtarsal ankle block. this block requires significant sedation/analgesia to make it acceptable to patient. Gerhardt MA: Anesthesia for foot and ankle surgery: C lin Podiatr Med Surg 2002. For that reason. 16:11-3 Noorpuri BS.The New York School of Regional Anesthesia . Infection Rare with the use of an aseptic technique Avoid multiple needle insertions Hematoma Most superficial blocks can be acomplished through one or two needle insertions Use 25-gauge needle and avoid puncturing superficial veins. Because it is almost always beneficial that the analgesia after an ankle block lasts some time after surgery. 21:680-2 Reilley TE.12. A typical onset time for this block is 10-25 minutes. Onset (min)Anesthesia (hrs)Analgesia (hrs) 1. Getty C J: Acute compartment syndrome following revisional arthroplasty of the forefoot: the dangers of ankle-block. 23:241-6 Mineo R. Kuroda MM: The use of peripheral nerve blocks in anesthesia practice.09.5% Mepivacaine (+ HC O3) 15-20 2-3 3-5 2% Lidocaine (+ HC O3) 10-20 2-5 3-8 0. Foot Ankle Int 1999. Fierro LE: Midtarsal block for surgery of the forefoot. Placement of an Esmarch or a tourniquet at the level of the ankle is well tolerated and typically does not require additional blockade. Foot Ankle 1992.
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