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Deep Peroneal Nerve Block

  • Author: Meda Raghavendra (Raghu), MD; Chief Editor: Alex Macario, MD, MBA  more...
 
Updated: Mar 21, 2016
 

Overview

Deep peroneal nerve block is one of the 2 deep nerve blocks at the level of the ankle. The deep peroneal nerve block is easy to perform and may constitute part of an ankle block.

The deep peroneal nerve block is useful for anesthesia and postoperative analgesia to surgeries of the first web space (eg, Morton neuroma). It can also be used to treat chronic pain conditions like anterior tarsal tunnel syndrome.

Anatomy

The common peroneal nerve (root values: L4, L5, S1, and S2) winds around the fibula through the fibular tunnel. The tunnel is bordered by the peroneus longus tendon and the fibula. Just distal to the fibular tunnel, the nerve divides into the superficial and deep peroneal nerves. The deep peroneal nerve (or the anterior tibial nerve) begins at the bifurcation of the common peroneal nerve, between the fibula and upper part of peroneus longus.[1, 2] In the distal one third of the ankle, the nerve is located between the tibialis anterior and extensor hallucis longus muscles and is superficial to the anterior tibial artery. At an average distance of 12.5 mm proximal to the ankle, the nerve crosses deep to the extensor hallucis longus tendon and courses between the extensor hallucis longus and extensor digitorum longus tendons.[3] The image below shows the nerve and adjacent structures.

Deep peroneal nerve and adjacent structures. Deep peroneal nerve and adjacent structures.

In the leg, the deep peroneal nerve supplies muscular branches to the tibialis anterior, extensor digitorum longus, peroneus tertius, and extensor hallucis longus. It also provides an articular branch to the ankle joint.

The deep peroneal branch continues into the foot along with the tibial artery and the vein. It passes beneath the dense superficial fascia of the ankle. Then it divides into lateral terminal and medial terminal branches.

The lateral terminal branch (external branch) passes across the tarsus anterolaterally, enlarges and supplies the extensor digitorum brevis. From the enlargement, 3 minute interosseous branches (dorsal interosseous nerves) are given off, which supply the tarsal joints and the metatarsophalangeal joints of the 2nd, 3rd, and 4th toes. The medial terminal branch (internal branch) accompanies and runs medial to the dorsalis pedis artery along the dorsum of the foot. At the first interosseous space, it divides into dorsal digital nerves, which provide sensory innervation to the first webspace and the adjacent dorsum of the foot.

Two cm distal to the intermalleolar line, the following structures (from medial to lateral) are related to the deep peroneal nerve:

  1. Tendon of tibialis anterior
  2. Tendon of extensor hallucis longus
  3. Dorsal pedis artery
  4. Deep peroneal nerve
  5. Tendon of extensor digitorum longus

Blocking the following five nerves (3 superficial and 2 deep) results in complete block of sensory perception beneath the ankle:

  1. Superficial peroneal nerve
  2. Saphenous nerve
  3. Sural nerve
  4. Deep peroneal nerve
  5. Posterior tibial nerve

All 5 nerves should be blocked if a tourniquet is used for foot surgery.[4]

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Indications

See the list below:

  • Surgeries involving the first web space of the foot (eg, Morton neuroma)
  • Component of ankle block (Ankle block is preferred for foot surgeries in patients who may not tolerate epidural or spinal anesthetic.)
  • Treatment of acute or chronic pain conditions involving the foot with entrapment of the deep peroneal nerve at the anterior tarsal tunnel (Anterior tarsal tunnel syndrome is characterized by persistent aching of the dorsum of the foot that is worse at night and is made better by moving the affected toes and ankle. Sometimes, patients experience weakness of toe extensors. Patients with diabetes may be more prone to this condition. It can occur after prolonged squatting or leaning forward.)
  • As a palliative measure and a part of multimodal approach to pain management of acute pain from foot fracture or gouty arthritis
  • As a prelude to neurolysis or radiofrequency ablation of the deep peroneal nerve.
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Contraindications

See the list below:

  • Patient refusal
  • Infection at the injection site
  • Coagulopathy
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Anesthesia

See the list below:

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Equipment

See the list below:

  • Alcohol, povidone-iodine (eg, Betadine), or chlorhexidine (Hibiclens) preparatory solution.
  • Syringe, 5 mL, 25-27 gauge 1-inch needle
  • Anesthetic, 5 mL (lidocaine 1%, bupivacaine 0.5%, or ropivacaine 0.5%)
  • Depot corticosteroid (eg, methylprednisolone acetate [Depo-Medrol] 40 mg, triamcinolone acetonide [Kenalog] 40 mg)
  • Gauze, 2 X 2
  • Sterile gloves
  • All resuscitative equipment
  • Standard monitors
  • Adhesive bandage
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Positioning

See the list below:

  • Position the patient supine with the toes dorsiflexed to identify the tibialis anterior, extensor hallucis longus, and extensor digitorum longus tendons.
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Technique

The deep peroneal nerve is traditionally located by identifying the surface landmarks, shown below. Other methods of identifying the injection site include invoking paresthesia, using a nerve stimulator, and ultrasonographic guidance.[5, 6]

Foot with surface landmarks. Note the course of th Foot with surface landmarks. Note the course of the deep peroneal nerve and its relation to the dorsalis pedis artery.

Perimalleolar approach

See the list below:

  • Perform a careful neurological assessment prior to the procedure.
  • Identify the tendon of extensor hallucis longus by big toe dorsiflexion against resistance. A groove is felt just lateral to the tendon.
  • The deep peroneal nerve lies lateral to the tendon and the dorsalis pedis artery. Lateral to the nerve is the tendon of the extensor digitorum longus. The needle entry site is about 2 cm distal to the intermalleolar line, just lateral to the dorsalis pedis artery pulse.
  • After the skin is prepared, raise a skin wheal with the 0.5-1 mL of the local anesthetic.
  • Next, advance the same needle and syringe that contains the local anesthetic through the skin in a perpendicular manner until bone is encountered, usually within 2-3 cm.
  • Withdraw the needle slightly to prevent periosteal injection.
  • Patients may experience paresthesia in the first web space. If paresthesia occurs, withdraw the needle slightly until the paresthesia disappears.
  • After careful negative aspiration for heme, inject 2 mL of the local anesthetic.
  • To increase the block success, the needle may be redirected 30º medially and laterally and an additional 2 mL of the anesthetic injected.
  • Remove the needle and apply firm pressure to prevent bleeding.
  • If the condition has an inflammatory component, methylprednisolone 40 mg or triamcinolone 40 mg may be added to the injectate.
  • If a nerve stimulator is used (2-3 mA at 0.1 ms), extension of the lateral 4 toes due to muscle twitch of the extensor digitorum brevis may be used to locate the nerve. [7]

Inframalleolar or midtarsal approach

See the list below:

  • Insert the needle immediately lateral to the extensor hallucis longus tendon but medial to the dorsalis pedis artery.
  • After negative aspiration, inject 5 mL of local anesthetic as described above. [8, 9, 10]
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Pearls

See the list below:

  • The deep peroneal nerve is one of the 2 deep nerves at the ankle. The deep peroneal nerve may be blocked as a part of a total ankle block.
  • The deep peroneal nerve innervates the first web space.
  • At the malleolar level, the deep peroneal nerve is located between the tendons of extensor hallucis longus and extensor digitorum longus, in close proximity to the dorsalis pedis artery.
  • To increase the block success, redirect the needle 30º and inject additional local anesthetic after the initial injection.
  • Careful neurological assessment is important prior to the procedure; it helps avoid later attribution of preexisting neurological deficits to the nerve block.
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Complications

The block is essentially safe block to perform, but some complications can occur.

  • Intravascular injection: The dorsalis pedis artery should be carefully palpated to minimize the chance of intravascular injection of local anesthetic.
  • Ecchymosis and hematoma: These complications can be avoided by applying firm pressure to the injection site after the injection.
  • Paresthesia: To avoid needle-induced trauma to the nerve, withdraw the needle slightly before the injection.
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Contributor Information and Disclosures
Author

Meda Raghavendra (Raghu), MD Associate Professor, Interventional Pain Management, Department of Anesthesiology, Chicago Stritch School of Medicine, Loyola University Medical Center

Meda Raghavendra (Raghu), MD is a member of the following medical societies: American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Laurie Scudder, DNP, NP Nurse Planner, Medscape; Senior Clinical Professor of Nursing, George Washington University

Disclosure: Nothing to disclose.

Chief Editor

Alex Macario, MD, MBA Professor of Anesthesia, Program Director, Anesthesia Residency, Professor (Courtesy), Department of Health Research and Policy, Stanford University School of Medicine

Alex Macario, MD, MBA is a member of the following medical societies: American Medical Association, American Society of Anesthesiologists, California Medical Association, International Anesthesia Research Society

Disclosure: Received consulting fee for: Merck.

Additional Contributors

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. Gray H. The sacral and coccygeal nerves. Bartleby.com. Available at http://www.bartleby.com/107/213.html. Accessed: April 21, 2008.

  2. Lee JH, Lee BN, Lee MY, An X, Han SH. The significance of tibial and common peroneal nerves in nerve blocks. Surg Radiol Anat. 2013 Apr. 35(3):211-5. [Medline].

  3. Lawrence SJ, Botte MJ. The deep peroneal nerve in the foot and ankle: an anatomic study. Foot Ankle Int. 1995 Nov. 16(11):724-8. [Medline].

  4. Hoerster W. Blocks in the area of the ankle. Zenz M, Panhans C, Niesel H, eds. Regional Anesthesia. Year book Medical Publishers; 1988. 88.

  5. Ankle block. Dartmouth-Hitchcock Medical Center Web site. Available at http://bit.ly/fGlnLF. Accessed: May 7, 2008.

  6. López AM, Sala-Blanch X, Magaldi M, Poggio D, Asuncion J, Franco CD. Ultrasound-guided ankle block for forefoot surgery: the contribution of the saphenous nerve. Reg Anesth Pain Med. 2012 Sep-Oct. 37(5):554-7. [Medline].

  7. Doty R, Sukhani R. Ankle Block. Benzon HT, Raja SN, Molloy RE, Liu SS, Fishman SM, eds. Benzon's Essentials of Pain Medicine and Regional Anesthesia. 2nd edition. Elsevier; 2005. page 675/ chapter 78.

  8. Kay J, Delmonte RJ, Greenberg PM. Ankle block. Hadzic A, ed. Textbook of Regional Anesthesia. McGraw-Hill; 2007. 546-553/39.

  9. Wassef MR. Posterior tibial nerve block. A new approach using the bony landmark of the sustentaculum tali. Anaesthesia. 1991. 46:841-4.

  10. Sharrock NE, Waller JF, Fierro LE. Midtarsal block for surgery of the forefoot. Br J Anaesthesia. 1986. 58:37-40.

 
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Foot with surface landmarks. Note the course of the deep peroneal nerve and its relation to the dorsalis pedis artery.
Deep peroneal nerve and adjacent structures.
 
 
 
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