Nerve block landmarks

Lower Extremity

Femoral

• Below inguinal ligament
• 1 cm lateral to femoral artery
• At level of femoral crease

Sciatic

• Classic posterior approach
• Line drawn between greater trochanter and PSIS
• Needle insertion 4 cm distal to midpoint of these landmarks
• Parasacral approach
• Line drawn between ischial tuberosity and PSIS
• Needle insertion 6 cm caudal to PSIS on line drawn
• Subgluteal approach
• Line drawn between greater trochanter and ischial tuberosity
• Needle insertion 4cm caudal to midpoint of these landmarks
• Popliteal
• Posterior approach
• 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
• Lateral approach
• 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

Saphenous

• Tibial tuberosity: Field block from medial surface of tuberosity to the dorsomedial aspect of upper calf
• Medial malleolus: Field block

Lumbar plexus

• 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

Ankle

• 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

Upper Extremity

Interscalene

• 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.

Supraclavicular

• 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.

Infraclavicular

• Coracoid Approach
• Mark the coracoid process
• Needle insertion 2cm inferior and 2cm medial to the coracoid process.

Axillary

• Transarterial Approach
• 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.
• Ultrasound Approach
• The axillary artery and surrounding nerves are visualized. The local anesthetic can be injected near the neural tissue without penetration of the artery.

Musculocutaneous

• 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.