Lower Extremity blocks
Lumbar Plexus
• The lumbar plexus consists of five nerves on
each side, the first of which emerges between
the first and second lumbar vertebra and the
last one between the last lumbar vertebra and
the base of the sacrum.
• The major branches of the lumbar plexus are
the genitofemoral, lateral femoral cutaneous,
femoral, and obturator nerves.
• The femoral nerve is formed by the posterior
divisions of L2-4 and descends from the
plexus lateral to the psoas muscle.
Genitofemoral nerve block
• The genitofemoral nerve is mainly a sensory nerve,
and it is formed from the first and second lumbar
nerves
• The nerve descends on the surface of the psoas major
muscle behind the ureter, and divides into the genital
and femoral branches at a variable distance above the
inguinal ligament.
• The genital branch enters the inguinal canal through
the deep inguinal ring and passes through the inguinal
canal (man) or round ligament of the uterus (woman).
• The femoral branch accompanies the external iliac
artery and below the inguinal ligament remains
enveloped by the femoral vascular sheath lateral to
the femoral artery.
1. Pubic Tubercle
2. Inguinal Ligament
3. Anterior Superior Iliac
Spine
4. Obturator Nerve
5. Accessory Obturator
Nerve
6. Superior Ramus of the
Pubic Bone
7. Genitofemoral Nerve
8. Femoral Nerve
9. Sciatic Nerve
Technique
• Patient in supine position.
• The main anatomical landmarks are identified: the
pubic tubercle, inguinal ligament, inguinal crease and
femoral artery.
• The femoral branch of the genitofemoral nerve is
blocked by inserting the 25G/5-cm needle at the
lateral border of the femoral artery at the inguinal
crease.
• A fanlike infiltration of the subcutaneous tissue is
made in a medial, caudal and cephalad direction with
10-15 ml of local anesthetic solution.
• The genital branch of the genitofemoral nerve is
blocked by infiltration of 10 ml of local anesthetic
just lateral to the pubic tubercle, below the inguinal
ligament.
Anatomic landmarks
Landmarks for the posterior approach to sciatic
blockade are easily identified in most patients.
Proper palpation technique is of utmost
importance because the adipose tissue over the
gluteal area may obscure these bony
prominences.
The landmarks are outlined by a marking pen:
• Greater trochanter
• Posterior-superior iliac spine
• Needle insertion point 4-cm distal to the
midpoint between landmarks 1 and 2
Popliteal Block
• Indications: Ankle and foot surgery
• Landmarks: Popliteal fossa crease,
tendons of the semitendinosus and
semimembranosus muscles
Popliteal Block
Popliteal Block
Popliteal Block
Popliteal Block
Popliteal Block
Popliteal Block
Popliteal Block
Popliteal Block
Popliteal Block
Popliteal Block: Lateral Approach
Popliteal Block: Lateral Approach
Popliteal Block: Lateral Approach
Popliteal Block: Lateral Approach
Popliteal Block: Lateral Approach
Popliteal Block: Lateral Approach
Popliteal Block: Lateral Approach
Popliteal Block: Lateral Approach
Popliteal Block: Lateral Approach
Popliteal Block: Lateral Approach
Popliteal Block: Lateral Approach
Saphenous Nerve Block
Saphenous Nerve Block
Saphenous Nerve Block
Ankle Block
• Indications: Surgery on foot and toes
• Nerves:
• Two deep nerves: Posterior tibial, deep
peroneal
• Three superficial nerves: superficial
peroneal, sural, saphenous
Ankle Block
Ankle Block
Ankle Block
Ankle Block
Ankle Block
Ankle Block
Ankle Block
Ankle Block
Ankle Block
Ankle Block
Ankle Block
Ankle Block
Ankle Block
Ankle Block
Ankle Block
Ankle Block