Deep Peroneal Nerve Block


Article Author:
Timothy Fletcher


Article Editor:
Brandon Barth


Editors In Chief:
Jeanie Skibiski
Kathrin Allen
Brian Cornelius


Managing Editors:
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Scott Dulebohn
Sobhan Daneshfar
William Gossman
Pritesh Sheth
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Richard Ciresi
Hajira Basit
Phillip Hynes


Updated:
1/16/2019 10:04:45 AM

Introduction

The deep peroneal nerve is one of 5 nerves that are often blocked or anesthetized to perform ankle surgery. It can be performed as a regional block and is a great alternative to achieve regional anesthesia for surgery in patients at high risk during general anesthesia. It has minimal risks, reduces complications of wound healing when compared to infiltration anesthesia, and provides better postoperative comfort for the patient.[1] With the rise of ultrasound-guided nerve blockade, there have been reports of longer-lasting and more effective anesthesia.[2] The deep peroneal nerve can also be blocked at the region of innervation for painful injuries such as burns or lacerations. Utilizing this safe and effective technique will aid with analgesia and minimize discomfort while repairing and managing the injury.

Anatomy

The deep peroneal nerve innervates muscles of the anterior leg compartment and the dorsum of the foot. It is also responsible for the sensation of the first interdigital cleft of the foot, or the space between the first and second digits. The nerve is derived from the common peroneal nerve, which originates as the dorsal branches of L4 and L5. In the lower leg, it descends, along with the anterior tibial artery, just anterior to the interosseous membrane. The nerve provides motor innervation to the muscles of the anterior compartment. It tracks along the lateral aspect of the anterior tibial artery and crosses the anterior aspect of the ankle between the extensor hallucis longus and extensor digitorum longus muscles. Approximately 1.3 cm above the ankle joint, the nerve divides into its 2 terminal branches, the lateral and medial branch. The lateral branch passes deep to the extensor digitorum brevis and extensor hallucis brevis muscles and provides their motor innervations. It also provides sensory innervation to the ankle and sinus tarsi. The medial branch courses medially along the dorsum of the foot lateral to the dorsalis pedis artery. The extensor hallucis brevis tendon crosses over the nerve, and the nerve terminates in the first interdigital cleft of the foot where it provides sensory innervation.[3][4][5][6][7]

Indications

Indications for a deep peroneal nerve block include:

  • Regional anesthesia for the ankle or foot during surgery
  • Analgesia for burns to the foot
  • Laceration repair of the first interdigital cleft[8]

Contraindications

Contraindications to a deep peroneal nerve block include:

  • Local anesthetic allergy/anaphylaxis
  • Patients receiving high levels of local anesthetic and are at risk for local anesthetic systemic toxicity (LAST)
  • Overlying cellulitis or abscess at the injection site
  • Patient refusal
  • Patients at risk for compartment syndrome at the site of injection (must speak with consultant first)[9]
  • Caution advised in patients who are anticoagulated but can still be performed due to foot and ankle being compressible sites

Equipment

Equipment for procedure includes:

  • Chlorhexidine gluconate or povidone iodine
  • Local anesthetic: The type and quantity vary depending on the intended duration of the block. Five milliliters of lidocaine 2% for a short-medium duration block (1 to 2 hours), 5 mL of bupivacaine 0.5%, or ropivacaine 0.5% (2 to 4 hours)
  • Ultrasound machine with high frequency (greater than 8 MHz) linear probe
  • Sterile gel and ultrasound probe cover
  • Short bevel block needle
  • 10 or 20 mL syringe[10][11]

Personnel

The practitioner trained in ultrasound-guided regional anesthesia techniques and support staff to administer rescue medications in the event of an adverse reaction.

Preparation

Obtain informed consent from the patient including risks, benefits, and alternative therapies to the procedure. Verify patient identity with name, date, and MRN and then verify site at which you will be administering the nerve block. Position the patient so that the dorsal surface of their foot and anterior leg are easily accessible. This is best achieved by having the patient lay down in bed with their knees bent and the plantar surfaces of their feet firmly against the bed. Perform a detailed neurovascular exam to the extremity to be blocked. Aseptic technique is used with application of chlorhexidine gluconate 2% or povidone-iodine solution to the skin of the injection site. Apply a sterile ultrasound probe cover and sterile gel to the high-frequency linear probe. Draw up the anesthetic solution in a sterile syringe and have patient's vitals closely monitored.

Technique

The nerve block is performed in the following steps:

  1. Place the ultrasound probe on the ventral fold of the ankle in a transverse orientation of the leg about 1 to 2 cm proximal to the level of the medial and lateral malleoli
  2. Identify the anterior tibial artery and track along both distally and proximally to ensure this is the correct vessel
  3. The deep peroneal nerve will be the white honeycomb-like structure lying lateral next to the anterior tibial artery
  4. Insert your needle in-plane and parallel to the probe surface
  5. Advance your needle until it is just superficial to the deep peroneal nerve, making sure you always visualize your needle tip as you advance
  6. Aspirate needle to ensure you are not in a vessel
  7. Inject 1 to 2 mL of local anesthetic while visualizing the spread of the fluid around the nerve
  8. Repeat steps 1 to 7 with slight adjustments to the needle to coat the entire nerve until you achieve a satisfactory level of anesthesia[6][4][11]

Complications

Complications include:

  • Bleeding
  • Infection
  • Local anesthetic systemic toxicity (LAST syndrome)
  • Allergic reaction to the local anesthetic 
  • Vascular puncture
  • Intramuscular hematoma
  • Intravascular injection
  • Nerve damage[12]

Clinical Significance

Blocking the deep peroneal nerve will provide anesthesia to the interdigital cleft between the first and second toes of the foot. While it does not provide a large amount of sensory innervation, it is still important for patients who are undergoing foot or ankle procedures. The increased prevalence of ultrasound has also allowed easy visualization of the nerve and increased success rate of onset to ankle block. While blocking the deep peroneal nerve and the other nerves of the ankle during surgery, it has shown this nerve block can improve outcomes in the patient's pain postoperatively. This nerve block can also be performed successfully using the extensor hallucis brevis musculotendinous junction as an anatomical landmark.[1][13][14]

Enhancing Healthcare Team Outcomes

A majority of the time the deep peroneal nerve block is used when performing ankle or foot surgery. As with any surgery, the process is a well-coordinated effort of many staff, in this case specifically the surgeon, anesthesiologist, and nursing staff. For these surgeries, either the surgeon or anesthesiologist places the block and nursing is available with medication for adverse reaction. In a large randomized trial, they found with well-organized care between specialties that there was a low risk of neurologic or nerve block site complications for post-operative complications.[15] (Level 1) It is also important to work closely with pharmacy and nursing during these situations to monitor for local anesthetic systemic toxicity or LAST syndrome. With pharmacy and nursing, they have access and could administer intralipid 20% (1.5 mL/kg bolus, 0.25mg/kg per hour drip) in the case of cardiac arrest due to LAST. These procedures require cohesive team approaches and all members of the team are integral to a successful procedure.


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Deep Peroneal Nerve Block - Questions

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For a block of the deep peroneal nerve in the foot, the nerve is usually identified by its location between the extensor digitorum longus and which one of the following?



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What should be done to check if a deep peroneal nerve block in the foot is working?



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A laborer is injured with a sharp instrument at work. He now has a 2-inch laceration over the dorsum of his right foot in the saddle area between the big toe and second digit. It is decided that the emergency room physician will block the deep peroneal nerve. To block this nerve one must infiltrate the local anesthetic between what two structures?



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A teenager undergoing ankle surgery is having a deep peroneal nerve block placed. The surgeon injects the lidocaine and achieves adequate anesthesia in the first interdigital web space of the foot. A few minutes later the patient begins to experience dizziness, drowsiness, and a metallic taste. The patient then enters cardiac arrest. What medication should be administered immediately?



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Ultrasound is used to performing a deep peroneal nerve block. Where should the probe be placed and what structures will help with identification?



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Deep Peroneal Nerve Block - References

References

Suriyuth J,Kittikun Viwatpinyo,Phornphutkul C,Mahakkanukrauh P, Anatomical relationship between the deep peroneal nerve and the anterolateral surface of the tibia in Thai cadavers. Journal of the Medical Association of Thailand = Chotmaihet thangphaet. 2015 Feb     [PubMed]
Piln� J,Kubes J, [Forefoot surgery under regional anesthesia]. Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca. 2005     [PubMed]
Walter WR,Burke CJ,Adler RS, Ultrasound-guided therapeutic injections for neural pathology about the foot and ankle: a 4 year retrospective review. Skeletal radiology. 2017 Jun     [PubMed]
Hromádka R,Barták V,Popelka S,Jahoda D,Pokorný D,Sosna A, [Regional anaesthesia of the foot achieved from two cutaneous points of injection: an anatomical study]. Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca. 2009 Apr     [PubMed]
Hromádka R,Barták V,Popelka S,Pokorný D,Jahoda D,Sosna A, Ankle block implemented through two skin punctures. Foot     [PubMed]
De Maeseneer M,Madani H,Lenchik L,Kalume Brigido M,Shahabpour M,Marcelis S,de Mey J,Scafoglieri A, Normal Anatomy and Compression Areas of Nerves of the Foot and Ankle: US and MR Imaging with Anatomic Correlation. Radiographics : a review publication of the Radiological Society of North America, Inc. 2015 Sep-Oct     [PubMed]
Tzika M,Paraskevas GK,Kitsoulis P, The accessory deep peroneal nerve: a review of the literature. Foot (Edinburgh, Scotland). 2012 Sep     [PubMed]
Myerson MS,Ruland CM,Allon SM, Regional anesthesia for foot and ankle surgery. Foot     [PubMed]
Soberón JR Jr,Sisco-Wise LE,Dunbar RM, Compartment syndrome in a patient treated with perineural liposomal bupivacaine (Exparel). Journal of clinical anesthesia. 2016 Jun     [PubMed]
Pester JM,Dulebohn SC, Nerve Block, Ulnar null. 2018 Jan     [PubMed]
D'Souza RS,Johnson RL, Nerve Block, Sural null. 2018 Jan     [PubMed]
Greensmith JE,Murray WB, Complications of regional anesthesia. Current opinion in anaesthesiology. 2006 Oct     [PubMed]
Loveday DT,Nogaro MC,Calder JD,Carmichael J, Is there an anatomical marker for the deep peroneal nerve in midfoot surgical approaches? Clinical anatomy (New York, N.Y.). 2013 Apr     [PubMed]
Antonakakis JG,Scalzo DC,Jorgenson AS,Figg KK,Ting P,Zuo Z,Sites BD, Ultrasound does not improve the success rate of a deep peroneal nerve block at the ankle. Regional anesthesia and pain medicine. 2010 Mar-Apr     [PubMed]
Kahn RL,Ellis SJ,Cheng J,Curren J,Fields KG,Roberts MM,YaDeau JT, The Incidence of Complications Is Low Following Foot and Ankle Surgery for Which Peripheral Nerve Blocks Are Used for Postoperative Pain Management. HSS journal : the musculoskeletal journal of Hospital for Special Surgery. 2018 Jul     [PubMed]

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