1. NERVE BLOCKS
Kaan Yücel M.D., Ph.D.
21.March.2012 Thursday

2. NERVE BLOCKS
UPPER EXTREMITY

3. Brachial Plexus Block
Injection of an anesthetic solution into or immediately surrounding the axillary sheath interrupts conduction of impulses of peripheral nerves.
The distal part of the sheath is closed with finger pressure, and a syringe needle is inserted into the proximal part of the sheath.
Sensation blocked in all deep structures of the upper limb and the skin distal to the middle of the arm.

4. Brachial plexus can be anesthetized using a number of approaches:
Interscalene block
Supraclavicular block
Infraclavicular block
Axillary block

5. Interscalene Block
PROCEDURE
Interval between the scalene muscles
Roots of the upper part of the brachial plexus can be blocked.

6. upper middle lower trunks
Supraclavicular Block
PROCEDURE
Between
scalenus anterior & scalenus medius
directed caudally behind subclavian artery toward
upper surface of 1st rib
brachial plexus compact
upper middle lower trunks

7. Infraclavicular Block
PROCEDURE
Identify the middle of the clavicle
Insert the needle 1 in. (2.5 cm) inferior to it
Anatomy of complications
Vessel puncture
Hematoma formation

8. Axillary Block PROCEDURE
Palpate axillary artery within the axillary sheath high up in the axilla
Abduct the arm to an angle greater than 90°
Compress the artery there
Insert the need prox. to the point of compression
Disadvantage: Leaking of anesthetic into musculocutanoues nerve
Anatomy of complications
Vessel puncture
Hematoma formation

9. Musculocutaneous Nerve Block
PROCEDURES
Indications
Repair of lacerations on the lateral border of the forearm
Brachial plexus approach
Musculocutaneous + Rest of the brachial plexus
Sufficiently high in the axillary sheath
Lateral cutaneous nerve of the forearm approach
Between biceps & brachialis just above lateral epicondyle
Lateral to biceps tendon on a line between
two epicondyles of the humerus

10. Median Nerve Block Area of anesthesia Lateral half of the palm
Palmar aspect of lateral 3 ½ fingers
including nail beds on the dorsum

11. Median Nerve Block PROCEDURES Block @ elbow
Elbow joint extended, palpate
brachial fossa on medial side of biceps brachii tendon
-Insert needle on medial side of brachial artery
-Here median nerve lies on medial side of tendons of flexor carpi radialis & to the lateral side of the flexor digitorum superficialis
wrist

12. Ulnar Nerve Block PROCEDURES Indications
Repair of lacerations of the hand & fingers
Where it enters the forearm
between olecranon process & medial epicondyle
Just lateral to flexor carpi ulnaris tendon
@ level of distal transverse crease of the wrist
Ulnar artery lateral side of the ulnar nerve
elbow
wrist

13. Radial Nerve Block PROCEDURES Indications
Repair of lacerations of the hand
elbow
Halfway between biceps brachii tendon
&tip of lateral epicondyle
wrist
At the level of the proximal transverse flexor crease on the lateral side of the radial artery

14. Digital Nerve Blocks Area of anesthesia Skin of the fingers
Each finger
supplied by four digital nerves at
2 o’clock, 5 o’clock, 7 o’clock, and 10 o’clock positions.
Indications
Repair of lacerations involving individual fingers; removal of nails

15. Palmar digital nerves Dorsal digital nerves
Digital Nerve Blocks
Palmar digital nerves
(ulnar & median nerves)
Palmar surface :Medial 1 ½ fingers
including their nail beds
Palmar surface : Lateral 3 ½ fingers
Dorsal digital nerves
(ulnar & radial nerves)
Dorsal surface of the proximal parts of medial 1 ½ fingers
Dorsal surface of the proximal parts of lateral 3 ½ fingers

16. Dorsal metacarpal method
Digital Nerve Blocks
PROCEDURES
Web space method
At the web space, digital nerves are about to enter the fingers.
A block on both sides of the fingers
Dorsal metacarpal method
Between the metacarpal bones, stopping just short of the palmar skin
The anesthetic solution will block the common palmar and dorsal digital nerves

17. NERVE BLOCKS LOWER EXTREMITY
Distal nerve blocks of the lower limb

18. Femoral Nerve Block Area of anesthesia
Front & medial side of the thigh, extending down the medial side of the knee & leg
Medial border of the foot as far as ball of the big toe
Below the midpoint of the inguinal ligament and lateral to the femoral artery
PROCEDURE

19. Lateral Cutaneous Nerve of the Thigh Block
Area of anesthesia
Anterolateral surface of thigh
down to the lateral side of the knee
PROCEDURE
Just inferior to the inguinal ligament about 0.5 in. (1.3 cm) medial to ASIAS

20. Sciatic Nerve Block Anterior approach An advanced block technique
For surgery on the leg below the knee, particularly on the ankle and foot
Complete anesthesia of the leg below the knee with the exception of the medial strip of skin, innervated by the saphenous nerve
Landmarks
Femoral crease
Femoral artery pulse
Needle insertion point marked 4-5 cm distally on the line passing through the pulse of the femoral artery and perpendicular to the femoral crease.

21. Sciatic Nerve Block Posterior approach
Wide clinical applicability for surgery and pain management of the lower extremity
One of the most commonly used techniques in aneshetsia practice
Anesthesia of the skin of the posterior aspect of the thigh, hamstrings and biceps muscles, part of hip and knee joint, and entire leg below the knee, with the exception of the skin of the medial aspect of the lower leg
Indications: Surgery on the knee, tibia, ankle, and foot
Landmarks: Greater trochanter, superior posterior iliac spine, midline between the two

22. Popliteal Nerve Block
Block of the sciatic nerve in the popliteal fossa with the patient in the prone position.
Ideal for surgeriesof the lower leg, particularly the foot and ankle.
Popliteal fossa crease
Tendon of biceps femoris (laterally)
Tendons of semitendinosus and semimembranosus muscles (medially)
The needle insertion point is marked at 7 cm. above the popliteal fossa crease at the midpoint between the tendons.

23. Common Peroneal Nerve Block
Area of anesthesia
Anterior & lateral sides of the leg
Dorsum of the foot & toes
including the medial side of the big toe
PROCEDURE
Below the head of the fibula

24. Superficial Peroneal Nerve Block
Area of anesthesia
Lower anterior & lateral sides of leg
Dorsum of foot & toes
except
Cleft between 1st & 2nd toes
deep peroneal nerve
Lateral side of little toe
sural nerve
PROCEDURE
Lower part of the leg by along a transverse line connecting medial & lateral malleoli

25. Deep Peroneal Nerve Block
Area of anesthesia
Cleft between big & second toes
PROCEDURE
Palpate the dorsalis pedis artery midway between medial & lateral malleoli
Foot dorsiflexed, observe extensor digitorum longus & extensor hallucis longus
The nerve on the lateral side of the artery between these tendons
- Insert the needle over the nerve

26. Tibial Nerve Block Area of anesthesia Sole of the foot PROCEDURE
Behind medial malleolus
Pulsations of posterior tibial artery midway between medial malleolus
& the heel
The nerve lies immediately posterior to the artery, and the anesthetic needle can be inserted at this location.

27. Sural Nerve Block Area of anesthesia
Lateral border of foot & lateral side of little toe
Midway between
lateral malleolus &Achilles tendon
PROCEDURE

28. Saphenous Nerve Block Area of anesthesia Medial side of the leg
Medial border of the foot down
as far as the ball of big toe
PROCEDURE
Medial side of knee either
over medial femoral condyle or
lower down over condyle of the tibia
Avoid great saphenous vein
ankle where it passes anterior to medial malleolus

29. Toe Nerve Blocks Area of anesthesia Skin of the toes
Each toe is supplied by four digital 2 o’clock, 5 o’clock, 7 o’clock, & 10 o’clock positions.
Around the base of each toe
PROCEDURE
Plantar digital nerves Medial & lateral plantar nerves
Dorsal digital nerves Superficial peroneal nerve
Except : Cleft between big toe&second toe Deep peroneal nerve
Lateral side of little toe Sural nerve