Nerve Blocks of the Lower Extremities

Procedures Consult Mobile
Quick ReviewFull DetailsChecklist
Help  |  Print
- Full procedure text, video and illustrations available with the full product
  • A nerve block is indicated when it will provide advantages over other techniques.
  • An ankle block is useful for lacerations of the sole of the foot, foreign body removal from the sole, severely swollen and contused feet, burns of the foot, incision and drainage, and extensive wound car.
  • Digital nerve blocks in the foot and toes are superior to local anesthesia for all but the most minor procedures.
  • Allergies to local anesthetics
  • Peripheral vascular, heart, and liver disease may increase the risk of severe complications.
  • For the majority of blocks, a 25-gauge needle is ideal.
  • 10-mL syringe for local anesthetic injection
  • Gauze sponges
  • Towels
  • Three-way stopcock and IV extension tubing set
  • 18-gauge needle for withdrawing anesthetic from the vial
  • Anesthetic
    • For most of the blocks described in this chapter, 0.25% bupivacaine is suggested as the anesthetic of choice, but equal volumes of 1% lidocaine with epinephrine can be substituted.
    • Higher concentrations of lidocaine (up to 2%) or bupivacaine (0.5%) are commonly used for large nerves.
  • The foot is supplied by the five nerve branches of the principal nerve trunks.
  • Anterior nerves
    • The superficial peroneal nerve (dorsal cutaneous or musculocutaneous nerve) supplies a large portion of the dorsal aspect of the foot and is located superficially between the lateral malleolus and extensor hallucis longus tendon.
    • The deep peroneal nerve.
    • The saphenous nerve runs superficially with the saphenous vein between the medial malleolus and tibialis anterior tendon and supplies the medial aspect of the foot near the arch.
  • Posterior nerves
    • The posterior tibial nerve runs with the posterior tibial artery. It branches into the medial and lateral plantar nerves, which supply sensation to most of the volar aspects of the foot and toes and supply motor innervation to the intrinsic muscles of the foot.
    • The sural nerve runs subcutaneously between the lateral malleolus and the Achilles tendon and supplies the lateral border, both volar and dorsal, of the foot.
  • Metatarsal and digital nerves
    • Each toe is supplied by two dorsal and two volar nerves.
    • In the toes, the nerves lie at the 2, 4, 8, and 10 o’clock positions in close relationship to the bone.
    • In the proximal foot, the nerves run with the tendons and the positions are not as predictable.

Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

  • Specific follow up is for the anesthetic procedure is not needed unless there is a complication.
  • With major nerve blocks, do not release the patient to go home until sensation and function have returned.
  • With minor blocks, the patient may be sent home but properly caution the patient about the risks.

Nerve Injury

  • Neuritis, an inflammation of the nerve, is the most common nerve injury.
  • Minimize direct nerve damage by choosing proper needle type, positioning, and manipulation.
  • Avoid intraneural injection, because it may rarely cause nerve ischemia and injury.

Intravascular Injection

  • Intravascular injection may rarely result in both systemic and limb toxicity.
  • Epinephrine, can cause a prolonged vasospasm and ischemia if it is injected into an artery.
    • Severe epinephrine-induced tissue blanching or vasospasm may be reversed with local or intravascular injection of phentolamine.


  • Hematoma formation may result from arterial puncture.
  • Apply direct pressure for 5 to 10 minutes.


  • Minimize the risk by following aseptic technique and using a low concentration of epinephrine.

Systemic Toxicity

  • Allergic reactions account for only 1% of untoward reactions.

Limb Injury

  • Patients may inadvertently injure the anesthetized limb, so patients with major blocks should not be released until sensation and function have returned.
About Procedures Consult | Help | Contact Us | Terms and Conditions | Privacy Policy
Copyright © 2019 Elsevier Inc. All rights reserved.