Anterior Ankle Nerve Block

Aka: Anterior Ankle Nerve Block, Regional Anesthesia of the Anterior Ankle, Superficial Peroneal Nerve Block, Deep Peroneal Nerve Block, Saphenous Nerve Block

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II. Indications

  1. Anesthesia of the dorsum of the foot

III. Preparation

  1. Needle: 27 gauge 1.5 inch
  2. Skin Preparation (e.g. Hibiclens or Betadine)
    1. See Regional Anesthesia
  3. Anesthetic
    1. See Regional Anesthesia for Anesthetic options
    2. Local Anesthetic 2-5 ml (Ultrasound) or 5-10 ml (landmark)
  4. Bedside Ultrasound (high frequency linear probe) guidance is recommended

IV. Technique: Saphenous Nerve Block

  1. Indications
    1. Anesthesia of the medial ankle and medial foot
  2. Ultrasound guided (preferred)
    1. Images
      1. saphenousNerveBlockUltrasound.jpg
    2. Patient position
      1. Lateral decubitus position with the medial ankle upright (or patient supine)
    3. Ultrasound probe
      1. Linear probe positioned transverse proximal to the medial malleolus, at distal medial thigh
      2. Saphenous vein and nerve run between vastus medialis (lateral) and sartorius Muscle (medial)
    4. Injection
      1. Insert needle inline with probe from anterolateral to posteromedial
      2. Saphenous nerve is adjacent to greater saphenous vein (visualize the needle tip!)
  3. Landmark Based
    1. Images
      1. saphenousNerveBlockLandmark.jpg
    2. Patient position
      1. Supine position with knee flexed and foot rests on table
    3. Injection
      1. Inject superior (proximal) and anterior to medial malleolus
      2. Direct the needle at 45 degree angle posteromedially
      3. Inject 3 cc subcutaneously along the course (but not within) the greater saphenous vein
        1. Greater saphenous vein parallels the saphenous nerve

V. Technique: Deep Peroneal Nerve Block

  1. Indications
    1. Anesthesia of the first web space
  2. Landmarks
    1. Tibia (medial)
    2. Extensor Hallucis Longus Tendon
    3. Deep Peroneal Nerve
    4. Dorsalis Pedis Artery (midline ankle)
  3. Ultrasound guided (preferred)
    1. Images
      1. deepPeronealNerveBlockUltrasound.jpg
    2. Position
      1. Patient Supine
    3. Ultrasound Probe
      1. Linear probe transverse to anterior ankle
    4. Injection
      1. Inline injection of Anesthetic at the deep peroneal nerve
  4. Landmark Based
    1. Images
      1. deepPeronealNerveBlockLandmark.jpg
    2. Position
      1. Patient Supine
      2. Knee Flexed
      3. Foot resting against table
    3. Landmarks
      1. Identify extensor hallucis longus tendon with great toe dorsiflexion against resistance
      2. Injection site is at level between malleoli, lateral to extensor hallucis longus (and medial to tibialis anterior)
    4. Injection
      1. Insert needle toward tibia at site 0.5 cm lateral to extensor hallucis longus tendon
      2. After striking tibia with needle, withdraw a few mm and aspirate to confirm not within artery
      3. Inject 5 cc Anesthetic

VI. Technique: Superficial peroneal nerve

  1. Indications
    1. Anesthesia of most of dorsal foot (and anterolateral leg)
  2. Ultrasound-Guided (preferred)
    1. Images
      1. SuperficialPeronealNerveBlockUltrasound.jpg
    2. Position
      1. Lateral decubitus position with lateral ankle up
    3. Ultrasound Probe
      1. Linear probe transverse to lateral ankle at 3-4 cm superior (proximal) to the lateral malleolus
    4. Landmarks
      1. Posterior Ankle
        1. Peroneus Brevis Muscle (superficial)
        2. Fibula (deep)
      2. Mid-Ankle
        1. Superficial Peroneal Nerve
      3. Anterior Ankle
        1. Extensor Digitorum Muscle (superficial)
        2. Tibia (deep)
    5. Injection
      1. Inline injection of Anesthetic at the superficial peroneal nerve
  3. Landmark Based
    1. Images
      1. superficialPeronealNerveBlockLandmark.jpg
    2. Position
      1. Patient supine with knee flexed and foot resting on table
    3. Landmarks
      1. Anterior tibial border AND
      2. Superior to lateral malleolus
    4. Injection
      1. Inject superior to lateral malleolus at 10-15 degree angle towards anterolateral tibia
      2. Inject 5 cc along the course of the needle

VII. Precautions

  1. Avoid injecting directly into nerves
  2. Distal Paresthesias with needle with injection
    1. Indicates needle is in nerve
    2. Do not inject here!
    3. Remove needle and reposition

VIII. References

  1. Pfenninger (1994) Procedures, Mosby, p. 1036-54
  2. Salam (2004) Am Fam Physician 69(4):896 [PubMed]
  3. Yurgil (2020) Am Fam Physician 101(11):654-64 [PubMed]

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