j/j04 p183-192 cme - podiatry management · welcome to podiatry management’s cme instructional...

Popliteal and

Saphenous NerveBlocks

This is analternative to

general or spinalanesthesia for

surgery of the leg,ankle and foot.

JUNE/JULY 2004 • PODIATRY MANAGEMENTwww.podiatrym.com 183

Common types of local anestheticblocks performed by foot and anklesurgeons include local infiltration,digital blocks, ray blocks and ankleblocks. Consideration can be givento regional anesthesia at a level

proximal to the ankle as an alterna-tive to general or spinal anesthesia.Use of a saphenous nerve block(SNB) at the proximal leg segmentcombined with the terminal sciatic

Continued on page 184

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Following this article, an answer sheet and full set of instructions are provided (p. 190).—Editor

Objectives1) Explain the details of the

popliteal and saphenous nerveblocks, including techniques, indica-tions and potential complications.

2) Explain the value of this type ofregional anesthetic block, whengeneral, spinal anesthesia and ankleblock anesthesia is contraindicated.

3) Show the wide range of surgi-cal procedures that can be doneusing these techniques.

4) Demonstrate the possibilities ofincorporating these techniques intoresidency training programs wherelower-extremity surgery is done.

5) Show the value of these blocksas an adjunct to post-operative anal-gesia.

6) Suggest the potential value ofthese techniques in developing re-gions around the world where gen-eral and spinal anesthesia are notreadily available.

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Local anesthesia has long beenused for lower extremity sur-gery with immense success.

Popliteal and

Saphenous NerveBlocks

C L I N I C A L P O D I A T R YC L I N I C A L P O D I A T R Y

This is analternative to

general or spinalanesthesia for

surgery of the leg,ankle and foot.

By Cornelius M. Donohue III, DPM, LarryR. Goss, DPM, and Larry B. Dyal, DPM, MS

pared to general anesthesia, theycarry fewer inherent risks, especiallyfor the compromised or chronically illpatient. Many patients who requiresurgical intervention are diabetic, hy-pertensive and have cardiac disease. Asignificant number of these patientsare not good candidates for generalanesthesia. In addition, comparedwith general anesthesia, the neuroen-docrine response with regional anes-thesia is significantly inhibited due tothe blockade of spinothalamic tractafferent impulses and their stimula-tion of hypothalamic-pituitary-adrenal pathways.1 Intra-operativeand post-operative hemodynamic dis-

turbances are mini-mized as a result ofthis blockade. Thevalue of inhibitingthe neuroendocineresponse can be espe-cially appreciated inthe diabetic patient,where the secretionof cortisol and othersteroids is mini-mized. Both generaland spinal anesthesiaincrease the risk ofpost-operative com-plications, includingnausea and vomitingand prolonged recov-ery.2, 3

When comparedto spinal anesthesia,this procedure yieldsno risk of postduralpuncture headache,and unlike spinalanesthesia, the anes-thetic effect is unilat-eral. Compared tomore proximal ap-proaches to the sciat-ic nerve block, thepopliteal block sparesthe hamstring mus-cles and promotesimmediate post-oper-ative ambulation. Inaddition, a poplitealblock can provideprolonged post-oper-ative analgesia andcan be performed inpatients being treatedwith anticoagulanttherapy.4, 5, 6 Many au-thors have advocatedthis procedure in the

past with good results; however, it isstill not routinely used in the UnitedStates and other countries, both de-veloped and developing.7, 8, 9 In fact, in1980, Rorie, et al. reported an 88.2%overall satisfaction rate in a study of119 patients.10 Infrequent use of thisblock method may be related to lackof resident training, concerns over op-erating room efficiency and an unpre-dictable success rate of the block.11, 12, 13

Anatomical ConsiderationsFormed from spinal roots L4-S2

and occasionally S3, the sciaticnerve consists of two distinct divi-sions, the tibial nerve (TN) andcommon peroneal nerve (CPN)(Figure 1).4 They share a commonepineural sheath from their originto the popliteal fossa.14 In thepopliteal fossa, the sciatic nerve istermed the popliteal nerve. At avariable distance above thepopliteal fossa crease, the poplitealnerve divides into two separatenerves, the TN and CPN. Therefore,a popliteal nerve block is essentiallythe terminal block of the sciaticnerve at the level of the knee.15

The TN is the larger of the twobranches and runs parallel andslightly lateral to the midline. Infe-riorly, it passes between the headsof the gastrocnemius muscle.15 TheCPN follows the tendon of the bi-ceps femoris muscle laterally andtravels around the fibular head as itleaves the popliteal fossa. Bothnerves innervate the entire legbelow the knee except for the an-teromedial aspects of the leg andfoot, which are innervated by thesaphenous nerve (L2-L4).16

General PrinciplesSuggested anatomic landmarks

for determining needle insertionContinued on page 185

184 www.podiatrym.comPODIATRY MANAGEMENT • JUNE/JULY 2004

Nerve Blocks...

nerve block or popliteal fossanerve block (PFNB) results in

complete anesthesia below the kneefor soft tissue and osseous proce-dures. Advocacy for more frequentuse of this method of anesthesia, aswell as anatomical considerations,alternative techniques and surgicalapplications are reviewed.

Incorporation of a terminal sciaticor popliteal fossa nerve block (PFNB)and a saphenous nerve block (SNB)has certain advantages over generaland spinal anesthesia for surgery ofthe leg, ankle and foot. When com-

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Figure 2

Figure 3

Figure 1


approach.28 Confirmed by MRI, theyfound an accuracy of 75% comparedto 25% with the classical approach.Hadzic, et al. found that the muscleboundaries of the popliteal triangle areoften difficult to appreciate with anyreproducible accuracy. Subsequently,placement of the needle is often madetoo far lateral for contact with the sci-atic nerve using the classical approach.Subsequent medial redirection of theneedle for sciatic nerve contact maycarry an increased risk of puncturingthe popliteal vessels, especially whenneedles longer than 40 mm are used(Figure 4).17, 20 In addition, needles in-serted using the classical approach are

more prone to transect the body of thebiceps femoris muscle, which can re-sult in increased pain during the proce-dure.29 Landmarks for the intertendi-nous approach utilize the semimem-branosus and biceps femoris tendonsonly, without the additional variablesof the semimembranosus and bicepsfemoris muscles as landmarks (Figure3). The needle is inserted at a midpointbetween the semimembranosus andbiceps femoris tendons 5-6 cm. proxi-mal to the popliteal crease. In 1988,Hadzic et al compared a lateral ap-proach to the classical posterior ap-proach, and found no significant dif-ferences in anesthesia results.30

points for the tibial and commonperoneal blocks have been catego-rized into two approaches: the classi-cal and intertendinous methods.17

Both of these approaches can be per-formed with or without a peripheralnerve stimulator (Figure 2). The valueof a peripheral nerve stimulator isthat it takes advantage of the clinicalmotor activity of the tibial and com-mon peroneal nerves in locating anappropriate injection point for thelocal anesthesia.9, 18, 19, 20, 21, 22, 23 Thistechnique removes some of theguesswork from positioning the nee-dle, because when the peripheralnerve stimulator is not used, the onlyclinical symptom assisting the clini-cian is the elicitation of paresthesias.

Precise placement of the needleduring the popliteal block is impor-tant because of a potential differen-tial blockade of the tibial and com-mon peroneal nerves. Vloka, et al.found that this may be due to a com-mon epineural sheath.14 Additionally,the peripheral nerve stimulator is avaluable tool in the obese patient orwhere there is acute or chronic defor-mity of the popliteal region.

Classical or AnatomicalApproach

Landmarks for the classical ap-proach are formed in the posterior as-pect of the knee (popliteal fossa), withthe borders forming a triangle. Medialand lateral borders are formed by thesemimembranosus and biceps femoristendons and muscle bellies, respec-tively. Identification of the poplitealcease is marked and a bisection of thetriangle is drawn (Figure 3). In theclassical approach, the needle is in-serted 5-6 cm. proximal to thepopliteal crease and 1 cmlateral to the bisection.

IntertendinousApproach

In 2002, Hadzic, et al.suggested needle place-ment should be directlybetween the semimem-branosus and bicepsfemoris tendons.17, 24, 25, 26, 27

In 1997, Vloka, et al.demonstrated that theclassical approach is sig-nificantly less effectivethan the intertendinous

Nerve Blocks... The need to positionthe patient in the prone posi-tion is the main disadvantage ofeither of the posterior approachtechniques to the sciatic nerve blockin the popliteal fossa, and may pro-hibit its use in certain circumstances.Conditions such as advanced preg-nancy, morbid obesity, spine andhemodynamic instability, and me-chanical ventilation are examples thatmay prevent the use of the prone po-sition.31 However, the lateral approachto the sciatic nerve can result in reli-able anesthesia, comparable to that ofthe posterior approach. Execution ofthe block using the lateral approach isrelatively straightforward when thedescribed technique is followed, al-though it may take more attempts atnerve localization. In addition to uti-lizing the lateral approach in patientswho cannot assume the prone posi-tion, this technique provides the op-tion of performing supplementaryblocks (i.e., saphenous or femoralnerve blocks) and surgery without theneed for patient repositioning.24, 29, 30

Block TechniqueTechniques described here are

the intertendinous popliteal ap-proach with and without a periph-eral nerve stimulator, a lateralpopliteal approach with and with-out a peripheral nerve stimulatorand the saphenous nerve block,which is used in conjunction witheither technique.

Intertendinous Popliteal Technique(Figures 3, 5, 6 and 7)

1. The block is performed withthe patient in the prone position.

2. Landmarks are identified andmarked as previously described.

3. Proper needle placement ismarked by extending a 5-6 cm. vertical line cephal-ad from the midpoint ofthe popliteal crease linebetween the semi-mem-branosus and bicepsfemoris tendons intersec-tion with that line.

4. A needle is intro-duced at an angle of ap-proximately 45-60 de-grees cephalad.

5. Insert the needleto 3-5 cm. depth.

6. Paresthesias will beContinued on page 186

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As with any anesthesia procedure,these approaches do

carry potentialcomplications.

Figure 4

13. Again, common peronealdistribution paresthesias or an ever-sion of the foot will be elicited de-pending on the technique.

14. Perform the same local anes-thetic injection sequence as de-scribed previously for the tibialnerve to anesthetize the commonperoneal nerve.

Lateral Popliteal Technique

1. The block is performed withthe patient in the supine position.

2. Identification of the bicepsfemoris tendon and the poplitealcrease are marked.

3. A needle with or without anerve stimulator is inserted 5 cm.proximal to the popliteal creaseand along the anterior border ofthe biceps femoris tendon in aslight cephalad direction.

4. Utilizing this approach, theneedle will encounter the commonperoneal nerve first, eliciting pares-thesias or an eversion motor re-sponse.

5. Perform the same local anes-thetic injection sequence as de-scribed previously for the common

peroneal nerve in-jection with theintertendinous ap-proach.

6. Continueinserting the nee-dle or needle withstimulator untiltibial nerve distri-bution paresthe-sias or plantarflex-ion motor re-sponse is elicited.

7. Performthe same localanesthetic injec-tion sequence asdescribed previ-ously for the tib-ial nerve injec-tion with the in-tertendinous approach.

SaphenousNerve Block Technique (Figure 8)16, 32

The final stepin both tech-niques includesanesthetizing the

saphenous nerve.1. Palpate the tuberosity of the

tibia and from this point, draw aline distal and medial at a 45 °angle to the intersection of the an-terior and medial border of the gas-trocnemius muscle.

2. Along this line, inject 10 cc.of local anesthetic into the subcuta-neous tissues.

3. The saphenous nerve lies ap-proximately midway between theselandmarks, passing beneath themidpoint of this line.

As with any anesthesia proce-dure, these approaches do carry po-tential complications. Besides thegeneral risks of local anestheticagents such as toxic and allergic re-actions, one major complicationwould be puncture or rupture ofthe popliteal artery or vein.33 An-other potential complication, how-ever uncommon, would be the riskof puncturing and /or transectingthe sciatic nerve, which could causeshort or long-term paresthesias orpermanent autonomic, sensory ormotor deficits throughout thelower extremity.34, 35 Signs andsymptoms of infection andhematoma must also be monitored.

DiscussionIn addressing the historical lack

of training in this technique, it issuggested that anesthesia depart-ments institute clinical instructionfor all appropriate staff, includinganesthesia, podiatric, orthopedic,plastic, vascular and general sur-gery. Operating room efficiency canbe facilitated with appropriate plan-ning and staff training. Experiencehas demonstrated that this blockcan be integrated well into anesthe-sia operating room procedures.19

Use of this relatively safe and suc-cessful anesthetic technique withand without a peripheral nerve



Nerve Blocks...

elicited when the needle is inthe proximity of nerves.7. If a peripheral nerve stimula-

tor is used, the needle with stimula-tor should be inserted in the samemanner as described above and thenerve stimulator set at 1.5 mA.

8. A motor response will benoted when the tibial nerve is stim-ulated with resultant plantarflexionof the foot clinically observable.

9. Continue to lower the am-peres to 0.5 mA; if motor responseis still visible, acceptable proximityto the nerve has been achieved.

10. When paresthesias or amotor response are elicited, (de-pending on the technique) inject 1cc of 1.0 % lidocaine and the pares-thesias or motor response shouldcease.

11. When the paresthesias ormotor response ceases, infiltrate 9cc of 1.0% lidocaine plain or 0.5%bupivacaine, or a mixture of bothto anesthetize the tibial nerve.

12. The needle with or withouta nerve stimulator is then redirect-ed slightly laterally.

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A peripheral nervestimulator is

unquestionably areliable tool in a

teaching environment.

Figure 6

Figure 5


guidelines for “blind” unassistednerve block administration.

The terminal sciatic and saphe-nous nerve blocks have many ap-plications in lower extremity sur-gery distal to the knee (Figure 9).This technique, supplemented withintravenous monitored anesthesiacare, has applications not only forincision and drainage and debride-ment, but also in reconstruction of

the foot, ankle and legthreatened by trauma, infec-tion, ischemia, arthritis, pri-mary ulcerative disease, neo-plasia, neuropathy and con-genital and neuromusculardeformity.3, 4, 9, 19, 36 Forefoot,midfoot, rearfoot, ankle andbelow-knee amputations canbe performed safely and effi-ciently using these blocks. Inaddition, this technique canbe used to provide anesthesiafor application of externalfixators to the foot and leg

for procedures in-volving recon-struction of thediabetic Charcotfoot and anklewith or withoutadditional com-ponents of footand ankle inter-nal fixation suchas screws, plates,pins and staples.8

Injection of alocal anestheticagent at the footand ankle levelinvolved with

cellulitis is usually avoided to pre-vent seeding of deeper tissues withinfection. Saphenous and distal sci-atic nerve blocks have significantvalue in cases such as this becausethe regional anesthesia can be ad-ministered at a level more proximalto that of the active infection.

Post-operative pain manage-ment is an inherent benefit of thistechnique, particularly when longacting anesthetic agents are used.37

The value of prolonged analgesia inthe chronically ill post-operativepatient in preventing complica-tions is obvious, particularly in pa-tients suffering from hypertension,diabetes and cardiac disease.6, 7

Ease of administering theseanesthetic blocks suggests that

stimulator, can result in a high suc-cess rate for administering regionalanesthesia at this level.

A peripheral nerve stimulator isunquestionably a reliable tool in ateaching environment.22 Addition-ally, the nerve stimulator can pro-duce motor activity in patients whomay have diminished or absent

elicited paresthesias due to diabeticor other forms of peripheral neu-ropathy or central nervous systemdisease. Even with the nerve stimu-lator, motor neuropathy or signifi-cant muscle atrophy can eliminateany visible motor activity used as aguide to anesthetic needle place-ment. Because of the occasional ab-sent elicitable paresthesias andmotor activity, the authors encour-age more empiric research to deter-mine reliable modifications of thistechnique which will define rela-tive 3-dimensional nerve-depth

Nerve Blocks... there is significant valuein encouraging its use indeveloping regions of theworld. In many rural, medicallyunderserved areas around theworld, early intervention in lowerextremity wounds caused by infec-tion, trauma, ischemia, neuropathyand primary ulcerative disease canmean the difference between recon-struction and restored function andthe alternative, amputation or evendeath from sepsis.

Where general and spinal anes-thesia are not available, the combi-nation of saphenous and poplitealblocks could be used routinely inmodestly equipped medical facili-ties for incision and drainage, de-bridement and reconstruction ofthe distal lower extremity. WithW.H.O. statistics predicting 300million cases of Type II diabetes bythe year 2012, the widespread useof these techniques could potential-ly translate into prevention ofcountless lower extremity amputa-tions around the world annually.The role of telemedicine for bothlive and archived instruction in thistechnique can assist in widespreadtraining on a global scale. Wheretelemedicine is not available, thistechnique could be disseminated byCD teaching material with still andvideo components.

In our experience, with over 40of these blocks, over the past 2years, no patient has had toprogress to general anesthesia fol-lowing this type of local anestheticblock. When considering the risksof spinal and general anesthesia, es-pecially for the chronically ill, thisprocedure is a viable alternative.The authors advocate more fre-quent utilization of this block tech-nique when anesthesia is neededdistal to the knee.

SummaryThe purpose of this article is to

advocate more universal clinical useof the terminal sciatic and saphe-nous nerve blocks, particularly inchronically ill patients. Applicationsof this block for surgical proceduresbelow the knee as an alternative togeneral and spinal anesthesia are re-viewed. Techniques with and with-out the assistance of a peripheralnerve stimulator are described. Ad-


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Figure 8

Figure 9

Figure 7

14 Vloka JD, Hadzic A, Lesser JB, Kitain E,Geatz H, April EW, Thys DM. A CommonEpineural Sheath for the Nerves in thePopliteal Fossa and Its Possible Implicationsfor Sciatic Nerve Block. Anesth Analg 84:387-90, 1997.

15 Sunderland S.:The sciatic nerve and itstibial and common peroneal divisions.Anatomical features. Nerves and Nerve In-juries. Edinburgh and London: E. & S. Liv-ingstone LTD., 1012-95, 1968.

16 Van der Wal M, Lang SA, Yip, RW:Transsartorial approach for saphenous nerveblock. Can J Anaesth 40:543, 1993.

17 Hadzic A, Vloka JD, Singson R, SantosAC, Thys DM.: A comparison of intertendi-nous and classical approaches to poplitealnerve block using magnetic resonance imag-ing simulation. Anesth Analg 94:1321-4,2002.

18 Benzon, HT, Kim C, Benzon HP, Sil-verstein ME, Jericho B, Prillaman K, Bue-naventura R. Correlation between evokedmotor response of the sciatic nerve andsensory blockade. Anesthesiolog 87:547-552, 1997.

19 Lee TH, Wapner KL, Hecht PJ, HuntPJ: Regional anesthesia in foot and ankle sur-gery. Orthopedics 19:578, 1996.

20 Hadzic A, Vloka JD. Peripheral NerveStimulator for Unassisted Nerve Blockade.Anesthesiology 84(6):1528-1529, 1996.

21 Gouverneur JM.: Sciatic nerve blockin the popliteal fossa with atraumaticneedles and nerve stimulation. ActaAnaesth Belgica 4:391-9, 1985.

22 Singelyn FJ, Gouverneur JM, Gri-bomont BF. Popliteal sciatic nerve blockaided by a nerve stimulator: a reliable tech-nique for foot and ankle surgery. Reg Anesth16:278-81, 1991.

23 Smith BE, Allison A: The use of a lowpower nerve stimulator during sciatic nerveblock. Anaesthesia 42:297, 1987.

24 Vloka JD, Hadzic A, Koorn R, ThysDM.: Supine approach to the sciaticnerve in the popliteal fossa. Can JAnaesth 43(9):964-967, 1996.

Beck GP: Anterior approach to sciaticnerve block. Anesthesiology 24:222-224,1963.

26 Kilpatrick AWA, Coventy DM, ToddJG.: A comparison of two approaches to sci-atic nerve block. Anaesthesia 47:155-7. 1992.

27 Singelyn FJ, Aye F, Governeur JM:Continuous popliteal sciatic nerve block: anoriginal technique to provide postoperativeanalgesia after foot surgery. Anesth Analg84:384, 1997.

28 Vloka JD, Hadzic A, Singson R, KoornR, Thys DM. The popliteal nerve block revis-ited: Results of an MRI study. Anesth Analg84:344, 1997.

29 Zetlaoui PJ, Bouaziz H: Lateral ap-proach to the sciatic nerve in the poplitealfossa. Anesth Analg 87:79, 1998.

30 Hadzic A, Vloka JD. A Comparison ofthe Posterior versus Lateral Approaches tothe Block of the Sciatic Nerve in the Popliteal

Fossa. Anesthesiology 88(6):1480-1486,1988.

31 Vloka JD, Hadzic A, Kitain E, Lesser JB,Kuroda MM, April EW, Thys DM. Anatomicconsiderations for sciatic nerve block in thepopliteal fossa through the lateral approach.Reg Anesth 21:414-418, 1996.

32 Bouaziz H, Benhamou D, Narchi P: Anew approach for the saphenous nerveblock. Reg Anesth 21:490, 1996.

33 Selander D. Paresthesias or no pares-thesias? Nerve complications after neuralblockades. Acta Anaesth Belg 39:173-4, 1988.

34 Selander D, Dhuner K-G, LundborgG: Peripheral nerve injury due to injec-tion needles used for regional anesthesia:An experimental study of the acute ef-fects of needle point trauma. ActaAnaesth Scand 21:182-8, 1977.

35 Bonner SM, Pridie AK: Sciatic nervepalsy following juneventful sciatic nerveblock. Anaesth 52:1206, 1997.

36 Sarrafian SK, Ibrahim IN, Breihan JH:Ankle-foot peripheral nerve block for midand forefoot surgery. Foot Ankle 4:87, 1983

37 McLeod DH, Wong DHW, VaghadiaH, Claridge RJ. Lateral popliteal sciatic nerveblock compared with ankle block for analge-sia following foot surgery. Can J Anaesth42(9):765-9, 1995.


Nerve Blocks...

vocacy for more training ini-tiatives in hospital settings is

made as well as the technique’s im-plications for post-operative painmanagement. The impact of thistechnique in limb preservation on aglobal scale in underserved regionsof the world is discussed. The au-thors have had good results withthis form of anesthesia with mini-mal adverse effects. ■

References1 Adriani J. Labat’s Regional

Anesthesia.Techniques and Clinical Applica-tions., W.B. Saunders Company, Philadel-phia, pp 317-21, 1967.

2 Brown, DL: “Popliteal Block,” in Atlasof Regional Anesthesia, ed by DL Brown, ,WB Saunders, Philadelphia, p 109, 1992.

3 Beskin JL, Baxter, DE: Regional anes-thesia for ambulatory foot and ankle surgery.Orthopedics 10:109, 1987.

4 Hansen E, Eshelman MR, Cracchiolo IIIA. Popliteal fossa neural blockade as the soleanesthetic technique for outpatient foot andankle surgery. Foot Ankle 21:38-44, 2000.

5 Provenzano DA, Viscusi ER, Adams, SBJr, Kerner, M, Abidi NA. The safety and effica-cy of the popliteal fossa nerve block for footand ankle surgery. American OrthopaedicFoot and Ankle Society 31st Annual Meeting,San Francisco, CA, March 2001.

6 Rongstad KM, Mann RA, Prieskorn D,Nicholson S, Horton G. Popliteal sciaticnerve block for postoperative analgesia. FootAnkle 17:378-382, 1996.

7 McLeod DH, Wong DH, Claridge RJ,Merrick PM. Lateral popliteal sciatic nerveblock compared with subcutaneous infiltra-tion for analgesia following foot surgery. CanJ Anaesth 41:673-676, 1994.

8 Myerson, MS, Ruland, CM, Allon, SM:Regional anesthesia for foot and ankle sur-gery. Foot Ankle 13:284, 1992.

9 Nusbaum LM, Hamelberg W: Intra-venous regional anesthesia for surgery on thefoot and ankle. Anesthesiology 64:91, 1986

10 Rorie DK, Byer DE, Nelson DO, etal.: Assessment of block of the sciaticnerve in the popliteal fossa. Anesth Analg59:371-6, 1980.

11 Hadzic A, Vloka JD, Kuroda MM,Koorn R, Birnbach DJ. The practice of pe-ripheral nerve blocks in the United States:A national survey. Reg Anesth 23:241-246, 1998.

12 Hadzic A,Vloka JD, Kuroda MM,Koorn R, Birnbach DJ, Thys DM. The use ofperipheral nerve blockade in anesthesia prac-tice. A national survey. Anesth Analg,84:300, 1997.

13 Kopacz DJ, Bridenbaugh LD. Are anes-thesia residency programs failing regionalanesthesia? The past, present, and future. RegAnesth 18(2):84-7, 1993.

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Dr. Dyal is ChiefResident at thepodiatric surgi-cal residency atTENET Roxbor-ough Hospital,Phi ladelphia ,PA.

Dr. Goss is is Di-rector of Surgi-cal ResidencyProgram atTENET Roxbor-ough Hospitaland is AdjunctClinical Instruc-tor at the Tem-ple UniversitySchool of Podia-tric Medicine, Philadelphia, PA. He is aFellow of the American College of Footand Ankle Surgeons.

Dr. Donahue is As-sistant Professor,Department ofSurgery at theDrexel UniversityCollege of Medi-cine, Philadelphia,PA and a Fellow ofthe American Col-lege of Foot andAnkle Surgeons.


surgery of the leg, foot andankle is:A) Historically, they have notbeen incorporated into resi-dency training programs.B) There is a high incidenceof block failure.C) They are difficult tech-niques to teach.D) There is limited post-oper-ative analgesia with thesetechniques.

7) The__________ approach tothe tibial and common peronealnerve blocks has been shown tobe as effective as the posterior,intertendinous approach.

A) MedialB) AnteriorC) LateralD) Retrograde

8) Which technique reduces therisk of neurovascular damageduring the popliteal block?

A) Intertendinous approachB) Classical approachC) Scalene blockD) Ankle block

9) One of the advantages of thepopliteal and saphenous nerveblocks as well as all regionalanesthetic blocks is:

A) Elevation of the bloodpressure in hypotensive pa-tients.B) Increase of endogenousendorphins.C) Reduced neuroendocrineresponse in the chronically illpatient.D) Reduction of blood sugarlevels in the diabetic surgicalpatient.

10) Which of the following mightbe considered a contraindicationto a popliteal block?

A) DVTB) Foot infectionC) Charcot footD) Ankle fracture

1) The popliteal nerve is thename given to the distal aspectof :

A) The sciatic nerveB) The saphenous nerveC) The sural nerveD) The superficial femoralnerve

2) The popliteal block consists of2 components:

A) Saphenous and sural nerveblocks.B) Tibial and common per-oneal nerve blocks.C) Superfical femoral and tib-ial nerve blocksD) Pudental and commonperoneal nerve blocks

3) The following anesthetic pro-cedure does not selectively blockpain impulses to the spinothala-mic tract:

A) GeneralB) Tibial nerve blockC) Common peroneal nerveblockD) Saphenous nerve block

4) The following is not a compli-cation of a popliteal nerve block:

A) Puncture of the femoralarteryB) Puncture of poplitealarteryC) Puncture of popliteal veinD) Laceration of the tibialnerve

5) A _________is used to locatethe tibial and common peronealnerves prior to injection of localanesthesia in the popliteal fossa.

A) Sensory action potentialB) ElectromyographC) Nerve conduction velocityD) Peripheral nerve stimula-tor

6) One of the main reasons thatthe popliteal and saphenousnerve blocks are not routinelyused for

11) One of the side effects ofspinal anesthesia not caused bypopliteal and saphenous nerveblocks is:

A) Postdural headacheB) Spinothalamic tract block-adeC) Complete anesthesia distalto the kneeD) DVT

12) One of the many applica-tions of the popliteal and saphe-nous nerve blocks that has beentraditionally underutilized is:

A) Use of these blocks in de-veloping regions and coun-tries.B) Abcesses of the knee.C) Hospitals without anesthe-siologists.D) Distal bypass procedures.

13) The lateral approach to thepopliteal nerve block, with thepatient in the supine position,has the advantage of:

A) Improved quality of blockcompared to that in theprone position.B) Less risk of neurovasculardamage.C) Not having to turn andreposition the patient afterthe block before surgery.D) More proximal distribu-tion of the block compared tothat in the prone position.

14) The most valuable asset inusing a peripheral nerve stimula-tor when administering apopliteal block is:

A) Elicitation of motor activityof the common peroneal andtibial nerves.B) Elicitation of motor activityof the saphenous nerve.C) Elicitation of sensory ac-tion potentials of the tibialnerve.D) Elicitation of motor activi-ty of the sural nerve.

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E X A M I N A T I O N

See answer sheet on page 191.


190 PODIATRY MANAGEMENT • JUNE/JULY 2004

15) The popliteal nerve is located___________ tothe popliteal vessels.

A) MedialB) LateralC) AnteriorD) Posterior

16) The popliteal nerve is composed of:A) The sural and saphenous nerves.B) The superficial femoral and tibial nerves.C) The tibial and common peroneal nerves.D) The sural and the superficial peronealnerves.

17) When using the intertendionous or classicalapproach to the popliteal block, the needleshould make an angle of ______degrees with theskin of the popliteal region.

A) 10-20B) 45-60C) 80-90D) 0-10

18) One of the complications of the classical ap-proach to the popliteal block which is signifi-cantly reduced with the intertendinous ap-proach is:

A) DVTB) InfectionC) ParesthesiasD) Risk of puncture of the popliteal vessels

19) One important benefit of a popliteal-saphe-nous nerve block compared to general anesthe-sia is:

A) Accelerated wound healingB) Less time for patient in the operatingroomC) Post-operative analgesiaD) Better anesthesia

20) The sciatic nerve is formed from the spinalroots L4-S2 and occasionally S3 and consists oftwo

distinct divisions:A) The tibial nerve and the common per-oneal nerve.B) The superficial femoral nerve and thesaphenous nerve.C) The common peroneal nerve and thesural nerve.D) The sural nerve and the superficialfemoral nerve.

E X A M I N A T I O N

(cont’d)

See answer sheet on page 191.

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LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

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_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

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EXAM #6/04Popliteal and Saphenous Nerve Blocks

(Donohue, Goss and Dyal)

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

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j/j04 p183-192 cme - podiatry management · welcome to podiatry management’s cme instructional...

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