including ankle,wrist,digital block.

1. Peripheral Nerve block
I. Ankle
II. Wrist
II. Digital

2. Ankle block

3. Ankle block- Essential
• Indications:- Podiatric surgery - Foot and toe debridement or amputation.
• Two deep nerves: Posterior tibial, Deep peroneal
• Three Superficial nerves: Superficial peroneal, Sural, Saphenous
• Local anesthetic: 5-6 mL per nerve
• two deep nerves are anesthetized by injecting local anesthetic under the
fascia,
• whereas the three superficial nerves are anesthetized by a simple
subcutaneous injection of local anesthetic.

4. The ankle block involves blockade of 5 nerves
• Posterior tibial nerve
• Sural nerve
• Superficial peroneal nerve
• Deep peroneal nerve
• Saphenous nerve
Terminal branch of
sciatic nerve
Terminal branch
of femoral nerve

5. medial
lateral

6. FOOT INNERVATION

7. Posterior tibial nerve- provides
sensation to the heel, medial, and
lateral sole of the foot.

8. Posterior tibial nerve- provides
sensation to the heel, medial, and
lateral sole of the foot.

9. Posterior tibial nerve- provides
sensation to the heel, medial, and
lateral sole of the foot.

10. provides sensation to the medial foot

11. Provides sensation to the
lateral foot

12. Provides sensation to the 1st dorsal
webspace

13. provides
sensation to the
dorsum of the foot
excluding first web
space

14. -provides sensation to the anteromedial foot.
provides sensation to the lateral
foot

16. Equipment
• Alcohol wipes
• Sterile gloves
• Sterile towels
• 2-3 10 cc syringes with local
anesthetic
• 25 gauge needle 1.5 inch needle

17. Choice of Local Anesthetic
• Depends on the length of time you wish block to last
• Longer acting local anesthetics may take longer for onset
• May wish to mix a local anesthetic that has faster onset with
a longer acting local anesthetic
• Sodium bicarbonate may help speed onset

18. Local Anesthetic Choices

21. Blockade of the Deep Peroneal Nerve, Superficial
Peroneal Nerve, and Saphenous Nerve can be
blocked in one needle stick.

22. Deep Peroneal Nerve can be located at the level of the medial
malleolus just lateral to the extensor hallucis longus
Location of deep
peroneal nerve
Medial
Malleolus
Extensor
Hallucis
Longus
Lateral
Malleolus
Extensor
Digitorum
Longus

23. Deep Peroneal Nerve Block
• Identify the extensor hallucis longus tendon
and the extensor digitorum longus muscle
• Palpate the dorsalis pedis artery
• The finger of the palpating hand is positioned
in the groove just lateral to the extensor
hallucis longus.
• The needle is inserted under the skin and
advanced until stopped by the bone.
• At this point, the needle is withdrawn back 1-2
mm and 2-3 mL of local anesthetic is injected.
• A “fan” technique is recommended to increase
the success rate.

24. Superficial peroneal nerve
block
• Bring the needle back and
direct it superficially in a lateral
fashion towards the lateral
malleolus depositing 3-5 ml of
local anesthetic subcutaneously

25. Saphenous Nerve
Block
• At the site of the deep
peroneal nerve blockade
bring your needle back and
redirect in a medial
direction towards the
medial malleolus
depositing 3-5 ml of local
anesthetic subutaneously

26. A. Deep Peroneal Nerve- advance
needle perpendicular and deep to
the retinaculum.
B. Superificial Peroneal Nerve- direct
needle superficially towards the
lateral malleolus.
C. Saphenous Nerve- direct needle
superficially towards the medial
malleolus.

27. Posterior Tibial nerve

29. A) Landmark for posterior tibial nerve
block is found by palpating the pulse of
the tibial artery posterior to the medial
malleolus.
B) Posterior tibial nerve block is accomplished by
inserting the needle posterior to the pulse of the
tibial artery. The needle is advanced until contact
with the bone is established. At this point the
needle is withdrawn 2-3 mm, and 5 mL of local
anesthetic is injected.

30. Sural Nerve
Block
• Sural nerve block is
accomplished by injecting
local anesthetic in a
fanwise fashion
subcutaneously and below
the fascia posterior to the
lateral malleolus.
• 5ml of local anesthetic is
deposited in a circular
fashion to raise a skin
“wheal.”

31. Summary of five nerve block

32. Wrist block

33. Essentials
• Indications: surgery on the hand and fingers
• Nerves: 1. Radial,
2. Ulnar,
3. Median

34. Functional Anatomy-ulnar
nerve
• The ulnar nerve provides sensory
innervation to the skin of the little
finger and the (ulnar aspect) half
of the ring finger, and to the
corresponding area of the palm.
The same area is covered on the
corresponding dorsal side of the
hand.

35. Functional Anatomy-median nerve
• Sensory supply:
-palmar aspect of thumb, index,
middle and radial border of the
ring finger,
-dorsal surface of the distal
phalanges of index and middle,
radial border of the ring finger.

36. Functional Anatomy- Radial nerve
• The radial nerve lies on the
anterior aspect of the radial
side of the forearm.
• supply sensation to the dorsum
of the thumb and the dorsum
of the hand (the thumb, index,
middle and one-half ring finger
as far as the distal
interphalangeal joint).

37. Epinephrine Is Safe in the Finger
• It was once widely believed that injected epinephrine frequently caused finger
ischemia and necrosis.
• That belief was widespread before 1948 when procaine was the only
injectable local anesthetic.
• Before expiration dates were mandated by the FDA in 1972, procaine (pH 3.6)
that had become increasingly acidic during storage was used in surgical
procedures
• 2 Batches of procaine with a pH of 1 were used for injections as late as 1948
• More finger necrosis occurred with procaine without epinephrine than
occurred with procaine combined with epinephrine, but epinephrine was
blamed because of its vasoconstrictive effect.
Wide-awake Hand and Wrist Surgery: A New Horizon in Outpatient Surgery © 2015 AAOS Instructional Course Lectures, Volume 64
http://handsurgery.org/multimedia/files/preCourse/AAOS%20paperchapter%20with%20Jupiter%20and%20Amadio.pdf

38. Epinephrine Is Safe in the Finger
• Level I evidence has shown that phentolamine, an alpha blocker that became
available in 1957, reliably reverses epinephrine vasoconstriction in the human
finger.
• However, its use is seldom required in clinical practice.
• The literature has reports from large studies that clinical epinephrine has been used
without inducing infarction.
• In addition, no cases of digital infarction have been reported with high-dose
(1:1000) accidental epinephrine finger injections,
• so it is unlikely that epinephrine would infarct fingers at a concentration of
1:100,000.
• More cases of digital infarction have been reported with improperly used digital
tourniquets than with lidocaine and epinephrine use, although both are rare

41. Maneuvers to Facilitate Landmark
Identification-radial block
• Palpation of the
radial styloid. The
superficial radial
nerve is blocked by
an injection just
proximal to the
styloid.

42. Maneuvers to Facilitate Landmark Identification-
median nerve
Outlining palmaris longus tendon.A maneuver to accentuate the tendons of the flexors of the
wrist.
(A) Shown are palmaris longus (white arrow) and flexor carpi
radialis (red arrow) tendons.

43. Maneuvers to Facilitate Landmark
Identification- median nerve
The palmaris longus tendon can
be accentuated by asking the
patient to oppose the thumb and
fifth finger while flexing the wrist.

44. Maneuvers to Facilitate Landmark
Identification- ulnar nerve
Outlining flexor carpi
ulnaris tendon.

45. Block of the Ulnar Nerve
• The needle is inserted just medial to and
underneath the flexor carpi ulnaris
tendon to inject local anesthetic in the
immediate proximity of the ulnar artery.
• The needle is advanced 5 to 10 mm to
just past the tendon of the flexor carpi
ulnaris .
• After negative aspiration, 3 to 5 mL of
local anesthetic solution is injected.
• A subcutaneous injection of 2 to 3 mL of
local anesthesia just above the tendon
of the flexor carpi ulnaris is advisable for
blocking the cutaneous branches of the
ulnar nerve, which often extend to the
hypothenar area.

46. Block of the Median Nerve
• The median nerve is blocked by
inserting the needle between the
tendons of the palmaris longus and
flexor carpi radialis .
• The needle is inserted until it pierces
the deep fascia, and 3 to 5 mL of local
anesthetic is injected.
• Although piercing of the deep fascia
has been described to result in a
fascial “click,” it is more reliable to
simply insert the needle until it
contacts the bone.
• The needle is withdrawn 2 to 3 mm,
and the local anesthetic is injected.

47. Block of the Median Nerve
• A “fan” technique is recommended to increase the success rate
of the median nerve block. After the initial injection, the needle
is withdrawn back to skin level, redirected 30° laterally, and
advanced again to contact the bone.
• After pulling back the needle 1 to 2 mm from the bone, an
additional 2 mL of local anesthetic is injected.
• A similar procedure is repeated with medial redirection of the
needle.
• Paresthesia in the median nerve distribution warrants a 1- to 2-
mm withdrawal of the needle, followed by a slow measured
injection of the local anesthetic.
• If paresthesia worsens or persists, the needle should be
removed and reinserted.

48. Block of the Radial Nerve
• The superficial branches of the radial nerve
are blocked by a subcutaneous injection of
local anesthetic in a circular fashion.
• The injection is made proximal to the radial
styloid head (circle)
• The radial nerve block is essentially a “field
block” and requires more extensive
infiltration because of its less predictable
anatomic location and division into multiple
smaller cutaneous branches.
• 5ml of local anesthetic should be injected
subcutaneously just proximal to the radial
styloid, aiming medially.
• Then the infiltration is extended laterally,
using an additional 5 mL of local anesthetic

51. Digital nerve block-

52. Regional Anesthesia Anatomy
• These nerve blocks are used for minor
operation on the fingers .
• Each digits has 2 dorsal and 2 palmar
branches of the digital nerve.
• Never administer more than 4ml of
total volume per digit.
• A total of 2-3ml local anesthethic is
injected on each side.

53. Patient Positioning
The hand is pronated
and rested on a flat
surface or supported
by an attendant

54. Block of Volar and Dorsal Digital
Nerves at the Base of the Finger
• Needle is inserted at a point on the dorsolateral aspect of
the base of the finger and a small skin wheel is raised.
• The needle is then directed anteriorly toward the base of
the phalanx.
• The needle is advanced until the it contacts the phalanx,
• One mL of solution is injected as the needle is withdrawn 1
to 2 mm from the bone contact.
• An additional 1 mL is injected continuously as the needle is
withdrawn back to the skin.
• The same procedure is repeated on each side of the base of
the finger to achieve anesthesia of the entire finger.

55. Web-space block
• Place hand palm down on sterile field
• Hold syringe perpendicular to digit
• Insert needle~1 inch into dorsal web space
close to the mcpj
• Aspirate and inject slowly into dorsal aspect
digital nerves
• Advance needle to volar aspect of web
space
• Aspirate and inject 1-2ml local anesthethic.
• Repeat on lateral aspect of the digit.

57. Complications and How to Avoid Them
Infection This should be very rare with use of an aseptic technique.
Hematoma • Avoid multiple needle insertions.
• Use 25-gauge needle (or smaller) and avoid puncturing superficial veins.
Vascular
Puncture
• Avoid puncturing the greater saphenous vein at the medial malleolus
• Intermittent aspiration should be performed to avoid intravascular injection
Gangrene of the
digit(s)
• The mechanical pressure effects of injecting solution into a potentially confined space should
always be borne in mind, particularly in blocks at the base of the digit
• Limit the injection volume to 2mL on each side
• In patients with small vessel disease, perhaps an alternative method should be sought in
addition to avoidance of digital tourniquet
Nerve Injury • Residual paresthesias are likely due to an inadvertent intraneuronal injection
• Systemic toxicity is rare because of the distal location of the blockade
• Do not inject when the patient complains of pain or when high pressures on injection are met
Other • Instruct the patient to the care of the insensate finger

58. Local Anaesthetic Systemic Toxicity (LAST)
• Recognition
• Immediate Management
• Treatment
• Follow-up

59. • Major Signs/Symptoms
Tonic-clonic seizures
Global CNS depression
Decreased level of consciousness
Apnea
• Neurologic symptoms typically precede
cardiovascular symptoms in lidocaine toxicity
LAST -CNS Signs + Symptoms
• Minor sign and symptoms:
 Tongue and perioral numbness
 Paresthesias
 Restlessness
 Tinnitus
 Muscle fasciculations + tremors

60. LAST-Cardiovascular Symptoms
• Early Signs: Hypertension and tachycardia
• Late Signs
• Peripheral vasodilation + profound hypotension
• Sinus bradycardia, AV blocs
• Conduction defects (Prolonged PR, Prolonged QRS)
• Ventricular dysrhythmias
• Cardiac arrest
• Cardiovascular symptoms typically present first in bupivacaine
toxicity

61. AAGBI: Association of anesthethics of great Britain and Ireland

65. Intralipid 20%

68. Reference
• https://www.nysora.com/digital-nerve-block
• http://handsurgery.org/multimedia/files/preCourse/AAOS%20paperchapte
r%20with%20Jupiter%20and%20Amadio.pdf
• https://www.aagbi.org/sites/default/files/275%20Wrist%20Block%20-
%20Landmark%20Technique.pdf
• https://www.nysora.com/ankle-block
• http://www.luigivicari.it/med/wp-content/uploads/2012/11/w-urmey-
ankle-block.pdf
• https://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf
• http://rebelem.com/local-anesthetic-systemic-toxicity-last/
• https://emedicine.medscape.com/article/80887-technique#showall