Nerve block landmarks
- Below inguinal ligament
- 1 cm lateral to femoral artery
- At level of femoral crease
Classic posterior approach
Line drawn between greater trochanter and PSIS
Needle insertion 4 cm distal to midpoint of these landmarks
Line drawn between ischial tuberosity and PSIS
Needle insertion 6 cm caudal to PSIS on line drawn
Line drawn between greater trochanter and ischial tuberosity
Needle insertion 4cm caudal to midpoint of these landmarks
Mark popliteal fossa crease
Mark tendons of biceps femoris(lateral)
Mark tendons of semitendinosus/semimembranosus(medial)
Needle insertion 7-8cm superior to popliteal crease at midpoint between tendons
Mark the vastus lateralis/biceps femoris/popliteal crease
Needle insertion 7-8cm above the popliteal crease in the groove between the vastus lateralis and biceps femoris
- Tibial tuberosity: Field block from medial surface of tuberosity to the dorsomedial aspect of upper calf
- Medial malleolus: Field block
- Mark level of iliac crest
- Mark midline (spinous process)
- Needle insertion 4 cm lateral to midline at level of iliac crest
Lateral Femoral cutaneous
- Needle insertion 2 cm medial and 2 cm caudal to ASIS
- Deep peroneal: Lateral to Extensor hallucis longus tendon
- Posterior tibial: Posterior to posterior tibial artery
- Sural: Posterior to lateral malleolus
- Superficial peroneal: Lateral to ext. digitorum longus
- Saphenous: Anterior to medial malleolus
- Mark the sternal and clavicular heads of the SCM muscle
- Mark the cricoid cartilage
- Mark the clavicle
- Needle insertion should be in the interscalene groove which is posterior to the clavicular head of the SCM and between the anterior and middle scalene muscles.
- Usually ultrasound guided with visualization of neural tissue and of pleura (PTX is feared complication). The ultrasound probe is placed in the supraclavicular fossa (superior to the clavicle). The brachial plexus lies lateral to the subclavian artery at this level.
Mark the coracoid process
Needle insertion 2cm inferior and 2cm medial to the coracoid process.
Palpate axillary artery
Insert needle until aspiration of arterial blood
Penetrate further until blood return stops (you have now passed through the axillary artery) Then inject. This will cover the radial nerve as it is directly posterior to the axillary artery. This is the most important branch to cover for this block. Withdraw needle and again pass through the axillary artery. Once you exit the artery and are anterior to it, inject again to cover the median and ulnar nerves.
The axillary artery and surrounding nerves are visualized. The local anesthetic can be injected near the neural tissue without penetration of the artery.
- Typically combined with axillary approach to ensure lateral forearm anesthesia
- Local anesthetic can be injected into the belly of the coracobrachialis muscle which sits just posterior to the biceps.