WRIST BLOCK, ANKLE BLOCK HIMANSHU BAXY.pptx

Wrist block and Ankle block

1. WRIST BLOCK AND ANKLE BLOCK HIMANSHU BAXY, JR1, ANAESTHESIA MODERATOR – DR. SAMEER SIR

2. WRIST BLOCK Wrist block is the technique of blocking terminal branches of some or all of the six nerves that supply the wrist, hand and fingers. The combination of nerves that need to be blocked depends upon the exact location of surgery. This block can be used to provide regional anaesthesia for a patient undergoing surgery awake or as an analgesic technique to be used in combination with general anaesthesia or brachial plexus block

3. Indications Carpal tunnel and ulnar tunnel releases Tenosynovitis Dupuytren’s contracture Metacarpal or Phalangeal osteotomy Debridement

4. Contraindications Absolute contraindications - a) Patient refusal b) Allergy to Local anaesthetic c) Active infection at the site of block 2. Relative contraindications – Anti coagulants Bleeding diathesis

5. Nerves in the Distal Forearm The wrist, hand and fingers are supplied by six nerves: • the median nerve • the ulnar nerve • the dorsal branch of the ulnar nerve • the radial nerve • the posterior interosseous nerve • the anterior interosseous nerve All six originate from the brachial plexus and descend into the forearm to supply the distal structures.

6. FUNCTIONAL ANATOMY OF ULNAR NERVE The ulnar nerve provides sensory innervation to the skin of the little finger and the (ulnar aspect) half of the ring finger, and to the corresponding area of the palm. The same area is covered on the corresponding dorsal side of the hand.

7. FUNCTIONAL ANATOMY OF MEDIAN NERVE Sensory supply: -palmar aspect of thumb, index, middle and radial border of the ring finger, -dorsal surface of the distal phalanges of index and middle, radial border of the ring finger.

8. FUNCTIONAL ANATOMY OF RADIAL NERVE The radial nerve lies on the anterior aspect of the radial side of the forearm. supply sensation to the dorsum of the thumb and the dorsum of the hand (the thumb, index, middle and one-half ring finger as far as the distal interphalangeal joint).

9. TECHNIQUE Preparation and positioning - Fully prepare the equipment and patient, including obtaining informed consent. Also ensure that intravenous access, monitoring and full resuscitation facilities are available. The patient is in the supine position with the arm abducted. Prepare the skin with antiseptic solution.

10. The Radial nerve Landmarks The SRN runs along the medial aspect of the brachioradialis muscle. It then passes between the tendon of the brachioradialis and radius to pierce the fascia on the dorsal aspect. Just above the styloid process of the radius, it gives digital branches for the dorsal skin of the thumb, index finger and lateral half of the middle finger. Several of its branches pass superficially over the ‘anatomical snuff box’.

11. Radial Nerve block The superficial branches of the radial nerve are blocked by a subcutaneous injection of local anesthetic in a circular fashion. The injection is made proximal to the radial styloid head (circle) The radial nerve block is essentially a “field block” and requires more extensive infiltration because of its less predictable anatomic location and division into multiple smaller cutaneous branches. 5ml of local anesthetic should be injected subcutaneously just proximal to the radial styloid, aiming medially. Then the infiltration is extended laterally, using an additional 5 mL of local anesthetic

12. The median nerve Landmarks The median nerve is located between the tendons of the palmaris longus (PL) – present in approximately 85% of the population – and the flexor carpi radialis (FCR). The PL tendon is usually the more prominent of the two; the median nerve passes just deep and lateral to it.

13. Technique The median nerve is blocked by inserting the needle between the tendons of the palmaris longus and flexor carpi radialis . The needle is inserted until it pierces the deep fascia, and 3 to 5 mL of local anesthetic is injected. Although piercing of the deep fascia has been described to result in a fascial “click,” it is more reliable to simply insert the needle until it contacts the bone. The needle is withdrawn 2 to 3 mm, and the local anesthetic is injected.

14. A “fan” technique is recommended to increase the success rate of the median nerve block. After the initial injection, the needle is withdrawn back to skin level, redirected 30° laterally, and advanced again to contact the bone. After pulling back the needle 1 to 2 mm from the bone, an additional 2 mL of local anesthetic is injected. A similar procedure is repeated with medial redirection of the needle. Paresthesia in the median nerve distribution warrants a 1- to 2-mm withdrawal of the needle, followed by a slow measured injection of the local anesthetic. If paresthesia worsens or persists, the needle should be removed and reinserted.

15. The ulnar nerve Landmarks The ulnar nerve passes between the ulnar artery and tendon of the flexor carpi ulnaris (FCU). The tendon of the FCU is superficial to the ulnar nerve, which is the medial to the artery. The dorsal cutaneous branch of the ulnar nerve (which must be blocked if anaesthesia to the ulnar aspect of the back of the hand is required) curves around the ulnar aspect of the wrist, 1 cm distal to the ulnar styloid in the mid-axial plane to reach the skin of the back of the hand.

16. ULNAR NERVE BLOCK The ulnar nerve is anesthetised by inserting the needle under the tendon of the FCU muscle close to its distal attachment just above the styloid process of the ulna. The needle is advanced 5–10 mm to just past the tendon of the FCU and 3–5 mL of local anaesthetic solution is injected. If blood is aspirated prior to the injection, redirect the needle more superficially and medially as the ulnar artery has been pierced. As with the medial nerve injection, any lancinating symptoms into the fingers felt by the awake patient on needle insertion should prompt redirection.

17. ANKLE BLOCK Indications:- Podiatric surgery - Foot and toe debridement or amputation. Two deep nerves: Posterior tibial, Deep peroneal Three S uperficial nerves: S uperficial peroneal, S ural, S aphenous Local anesthetic: 5-6 mL per nerve two deep nerves are anesthetized by injecting local anesthetic under the fascia, whereas the three superficial nerves are anesthetized by a simple subcutaneous injection of local anesthetic.

18. The ankle block involves blockade of 5 nerves Posterior tibial nerve S ural nerve S uperficial peroneal nerve Deep peroneal nerve S aphenous nerve Terminal branch of sciatic nerve Terminal branch of femoral nerve

19. medial lateral

20. Blockade of the Deep Peroneal Nerve, Superficial Peroneal Nerve, and Saphenous Nerve can be blocked in one needle stick.

21. Deep Peroneal Nerve can be located at the level of the medial malleolus just lateral to the extensor hallucis longus Location of deep peroneal nerve Medial Malleolus Extensor Hallucis Longus Lateral Malleolus Extensor Digitorum Longus

22. Deep Peroneal Nerve Block Identify the extensor hallucis longus tendon and the extensor digitorum longus muscle Palpate the dorsalis pedis artery The finger of the palpating hand is positioned in the groove just lateral to the extensor hallucis longus. The needle is inserted under the skin and advanced until stopped by the bone. At this point, the needle is withdrawn back 1-2 mm and 2-3 mL of local anesthetic is injected.  A “fan” technique is recommended to increase the success rate.

23. Superficial peroneal nerve block Bring the needle back and direct it superficially in a lateral fashion towards the lateral malleolus depositing 3-5 ml of local anesthetic subcutaneously

24. Saphenous Nerve Block At the site of the deep peroneal nerve blockade bring your needle back and redirect in a medial direction towards the medial malleolus depositing 3-5 ml of local anesthetic subutaneously

25. Deep Peroneal Nerve- advance needle perpendicular and deep to the retinaculum. B. Superificial Peroneal Nerve- direct needle superficially towards the lateral malleolus. C. Saphenous Nerve- direct needle superficially towards the medial malleolus.

26. TIBIAL NERVE BLOCK A) Landmark for posterior tibial nerve block is found by palpating the pulse of the tibial artery posterior to the medial malleolus.  B) Posterior tibial nerve block is accomplished by inserting the needle posterior to the pulse of the tibial artery . The needle is advanced until contact with the bone is established. At this point the needle is withdrawn 2-3 mm, and 5 mL of local anesthetic is injected.

27. Sural Nerve Block Sural nerve block is accomplished by injecting local anesthetic in a fanwise fashion subcutaneously and below the fascia posterior to the lateral malleolus. 5ml of local anesthetic is deposited in a circular fashion to raise a skin “wheal.”

28. Summary of five nerve block

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