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Ultrasound guided lower limb blocks

Dr Anthony Allan
Great Western Hospital
Overview of lower limb nerve blocks
Femoral
Saphenous
Sciatic
Subgluteal approach
Popliteal approach
Tibial
Anatomy/sonoanatomy
Block conduct
Tips and clips
Lower limb ultrasound
general points

Pattern recognition + practice

Proximal fat distribution and block conduct
variability in probe/needle choice
Femoral anatomy
Sonoanatomy of femoral nerve

Hyperechoeic honeycomb architecture

Suprainguinal - oval 67%, triangular 33%

Infrainguinal oval 95%, triangular 5%

Average 10 mm by 3 mm
Femoral nerve block

Patient Supine, leg laterally rotated

Probe High frequency placed transversely just
below inguinal ligament

Needle Dependant on approach/depth, 50-
100mm


US guided femoral block

Improves block onset time to 3:1 block
Improves quality of block

Ultrasound Nerve stimulator
Onset time 16+/- 14 min 27+/-16 min
3:1 Block 95% 85%
2:1 Block 0% 5%
No block 5% 10%
Tips

Variable distance from vessels

Splits into terminal branched 0-5cms below
inguinal ligament

If deep - IP approach - place nerve on opposite
side of screen to needle entry


Saphenous nerve
anatomy/sonoanatomy

Cutaneous branch of post div of femoral nerve
Leaves adductor canal to emerge between
sartorius and gracilis
Runs down medial aspect of leg with and
immediately posterior and slightly deep to great
saphenous vein
Seen as small speckled nerve bundle


Saphenous nerve anatomy

Saphenous nerve block
Patient Supine, knee slightly flexed, leg
externally rotated

Probe High frequency placed transversely over
medial aspect lower thigh

Needle 50mm
Tips

Can be v difficult to visualise

Perivascular inj around great saphenous vein at
level of tibial tuberosity


Sciatic nerve block subgluteal
approach
Subgluteal space potential space
Roof - Gluteus maximus then biceps
Floor - Gemellus superior, obturator internus,
gemellus inferior, quadratus femoris, adductor
magnus

Contains
Sciatic and Post cut nerve of thigh
Inferior gluteal A+V

Sonoanatomy

Flat/oval hyperechoeic band

Up to 1.5-3cms wide

May see post cut nerve of thigh
Sciatic nerve block subgluteal
approach

Patient - Lateral, hips and knees flexed

Probe low frequency, sector array placed
transversely at level of line dividing greater
trochanter + ischial tuberosity

Needle 100mm
Tips

Depth makes needle visualisation more difficult

? Better view distally below biceps (infragluteal)

Helpful to use in conjunction with NS
Sciatic nerve block popliteal
approach
Sciatic nerve block popliteal
approach
Sonoanatomy

1 large or 2 smaller nerve bundles under biceps

Tibial n larger, medially in front of pop v + a

Common peroneal n smaller, moves laterally
following medial border of biceps to neck of
fibula, possible to see sural com branch

Sciatic nerve block popliteal
approach

Patient position prone or supine with knee
flexed

Probe Mid/high frequency, transversely
proximal to popliteal crease angled slightly
caudad

Needle 50/100 approach/depth dependant,
Tips
Plantar/dorsiflexion of foot seesaw sign

Separate tibial and common peroneal injections when
nerve divides proximally
nerve v deep - allows more distal injection where nerve is
more superficial

If doing IP approach
consider true lateral approach
inject to deep surface first
Tibial nerve anatomy

Sonoanatomy
Structures visible from ant-posterior
Tibia
Tendon of tibialis posterior
Tendon of flexor dig longus
Post tibial a + vs
Flexor hal longus + soleus
Achilles tendon
Tibial nerve speckled appearance, may have
already divided
Tibial nerve block
Patient supine, legs crossed distally and ext
rotated

Probe high frequency placed transverse just
above medial malleolus

Needle 50mm
References
Marhofer P, Greher M, Kapral S. Ultrasound guidance in
regional anaesthesia. Br J Anaesth 2005; 94: 7-17
Marhofer P, Schrogendorfer K, Koinig H et al. Ultrasonographic
guidance improves sensory block and onset time of three in one
blocks. Anesth Analg 1997; 85: 854-7
Lundblad M, Kapral S, Marhofer P, Londqvist P. Ultrasound-
guided infrapateller nerve block in human volunteers: description
of a novel technique. Br J Anaesth 2006; 97: 710-14
Karmarker M, Kwok W, Ho A et al. Ultrasound-guided sciatic
nerve block: description of a new approach at the subgluteal
space. Br J Anaesth 2007; 98: 390-5

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