++++++
++
- 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)
++