Figure 148-1. Distribution of Blockade
Neurovascular supply cutaneous innervation of the right foot, showing the plantar (A) and dorsal (B) surfaces. Lateral and medial plantar Nn. are terminal branches of the tibial nerve. Reproduced from Morton D, ed. Gross Anatomy: The Big Picture. Figure 38-3, p. 447. McGraw-Hill. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.
- Any surgery on the foot (but consider tourniquet use; ideally no thigh tourniquet; Esmarch band above the ankle OK if not too >1 hour)
- Not effective for ankle surgery (e.g., popliteal + saphenous block should be used, although this would not cover a thigh tourniquet; in that case, use sciatic + femoral, or a spinal if blocks are only for postoperative pain)
- Infection/rash on injection site
- Severe peripheral vascular disease with risk of local necrosis
- Three of the five blocks are subcutaneous infiltrations, and two are in close proximity to blood vessels, with a risk of local anesthetic toxicity; prefer ropivacaine to bupivacaine; avoid bilateral blocks because of the increased total dose
Technique using landmarks:
- Blocks done just proximal to the level of the malleoli, above the ankle joint (Figure 148-2):
- Deep peroneal nerve block (Figure 148-3):
- Located next to the DP pulse and/or the extensor hallucis longus tendon; insert needle straight down to the bone, pull back 3–4 mm, aspirate, and infiltrate with 5–7 mL of LA
- Superficial peroneal nerve block (Figure 148-3):
- Create a skin wheal from the needle insertion point for the deep peroneal block to the lateral malleolus (5–7 mL)
- Saphenous nerve block (Figure 148-3):
- Create a skin wheal from the needle insertion point for the deep peroneal block to the medial malleolus (5–7 mL)
- Posterior tibial nerve block (Figure 148-4):
- Locate PT pulse in the posterior aspect of the medial malleolus; if not felt, aim for the area of the tendon “pulley” behind the malleolus. Insert needle in a posterior to anterior fashion, contact bone, pull back 2–3 mm, and infiltrate with 7–10 mL
- Sural nerve block (Figure 148-4):
- Create a skin wheal from the Achilles tendon to the lateral malleolus (5–7 mL)
Figure 148-2. Schematic Position of the Nerves to Be Blocked at the Level of the Right Ankle
T, tibia; F, fibula; EHL, extensor hallucis longus tendon; ATA/DPN, anterior tibial artery/deep peroneal nerve; SPN, superficial peroneal nerve; PB, peroneus brevis ...
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