Superficial Peroneal Nerve Block

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Emergency practitioners and other clinicians working in acute care settings frequently encounter patients who have trauma to or pathology of the dorsum of the foot and require anesthesia for treatment and repair.

Regional block of the superficial peroneal nerve allows for rapid anesthetization of the dorsum of the foot, which allows for management of lacerations, fractures, nail bed injuries, or other pathology involving the dorsum of the foot. Regional blocks have several advantages compared to local infiltration, such as fewer injections required to attain adequate anesthesia, smaller volume of anesthetic required, and less distortion of the wound site. ^[1] Because of the lower number of injections, this procedure is better tolerated by the patient and limits the chance of a needle stick injury to the provider.

This procedure, often overlooked in the emergency department, is safe, is relatively easy to perform, and can provide excellent anesthesia to the foot. ^{[2, 3, 4]} In one study, regional anesthesia of the foot and ankle, when performed by surgeons, was completely successful 95% of the time. ^[5]

Understanding the anatomical distribution of the superficial peroneal nerve is helpful in performing a successful blockade of this nerve. The superficial peroneal nerve arises from the common peroneal nerve, which also gives rise to the deep peroneal nerve. The superficial peroneal nerve originates between the peroneus longus muscle and the fibula. It courses down the lateral compartment of the lower leg along with the peroneus longus muscle and the peroneus brevis muscle. It then descends posterolaterally to the anterior crural intermuscular septum. It runs anterolateral to the fibula between the peroneal muscles and the extensor digitorum longus, eventually supplying the peroneal muscles.

In the distal third of the leg, it pierces the deep fascia to become superficial. The nerve splits into the medial dorsal cutaneous nerve and the intermediate dorsal cutaneous nerve, which give rise to the dorsal digital nerves. These nerves supply the skin of the anterolateral distal third of the leg, most of the dorsal foot, and the digits. However, this nerve does not supply the web space between the first and second digits or the lateral fifth digit. At the level of ankle, the superficial peroneal nerve splits to fan out between the medial and lateral malleoli.

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Wound repair or exploration of the dorsal regions of the foot

As part of an ankle block required to manipulate a fracture or dislocated ankle (A combination of posterior tibial, saphenous, superficial peroneal, deep peroneal, and sural nerve blocks results in complete block of sensory perception beneath the ankle. Compared with more proximal approaches to the ankle block, motor block is rarely a concern with the ankle block. ^[6] See the image below.

Incision and drainage of an abscess in the dorsal regions of the foot

Removal of foreign body in the dorsal regions of the foot

Toenail repair (Toenail repair on the lateral first digit and medial second digit also requires deep peroneal nerve block.)

Symptomatic relief of compression of the common peroneal nerve (along with the deep peroneal nerve block)

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Allergy to anesthetic solution or additives (eg, ester, amide)

Overlying cellulitis

Severe bleeding disorder or coagulopathy

Preexisting neurological damage

Patient uncooperativeness (Pediatric or elderly patients may need sedation.)

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Lidocaine, the most commonly used anesthetic, has a fast onset of action and a duration of action of 30-120 minutes, which is increased to 60-400 minutes with the addition of epinephrine. ^{[7, 8]} The total cumulative dose of lidocaine to be infiltrated is 4.5-5 mg/kg (not to exceed 300 mg) if lidocaine without epinephrine is used, and 7 mg/kg (not to exceed 500 mg) if lidocaine with epinephrine is used. For more information, see Local Anesthetic Agents, Infiltrative Administration.

Topical anesthetics may be needed in children or uncooperative adults. For more information, see Anesthesia, Topical.

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Needle, 4 cm, 25 gauge (ga)

Needle, 18 ga

Syringe, 10 mL

Marking pen

Sterile gloves

Antiseptic solution (eg, povidone iodine [Betadine] or chlorhexidine gluconate [Hibiclens]) with skin swabs

Alcohol swabs

Sterile drape

Lidocaine 1%, 10 mL

Facial mask with eye shield

Sterile gauze

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Position the patient supine, with the ankle supported by a pillow or rolled sheet, optimizing comfort.

Alternatively, the patient may sit and face the physician while maintaining a similar leg elevation.

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Explain the procedure, benefits, risks, and complications to the patient and/or patient’s representative, and inform the patient of the possibility of paresthesia during the procedure.

Obtain informed consent in accordance with hospital protocol.

Perform and document neurovascular and musculoskeletal examinations prior to the procedure. Testing the superficial peroneal nerve prior to performing the block includes the following:

Sensation of dorsum of the foot (See the image below.)

Foot eversion

Expose the area of injection and identify the medial and lateral malleoli by palpation.

Draw a line from the distal anterior aspect of the lateral malleolus to the anterior border of the medial malleolus. See the image below.

Wipe the area with an alcohol pad and clean the site thoroughly with antiseptic solution, moving outward in a circular fashion.

Maintaining sterile technique, place an initial skin wheal of lidocaine anterior to the distal lateral malleolus using a 25-ga needle.

Insert the 25-ga needle through the skin wheal and infiltrate 6-10 mL in a transverse fashion until the medial malleolus is reached. See the image below.

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Equipment preparation and proper patient positioning may make the difference between success and failure.

In children or noncompliant adults, consider using topical anesthetic mixtures, such as lidocaine, epinephrine, tetracaine (LET) or a eutectic mixture of lidocaine and prilocaine (EMLA cream).

Pediatric or elderly patients may require additional sedation for compliance.

Consider a hematoma block or bier block to attain more effective analgesia when a fracture exists or when more extensive manipulation of the foot is expected. ^{[9, 10]}

Adding a buffering solution, like sodium bicarbonate, can significantly decrease the pain of the injection when performing a nerve block. ^{[11, 12]} Add 1 mL of sodium bicarbonate (44 mEq/50 mL) to 9 mL of lidocaine.

Warming the anesthetic solution to body temperature can significantly decrease the pain of the injection. ^[12]

When unassisted, tape a bottle of lidocaine upside down to the wall prior to the procedure. If more anesthetic is needed during the procedure, it can be obtained from this bottle without compromising the sterility of gloves and equipment.

See the list below:

Infection: Infection occurs when the puncture site is not clean. Avoid puncture through infected skin or skin lesions. Be sure to use sterile technique during the procedure, as the risk of infection is insignificant when sterility is properly maintained.

Intravascular injection: ^[13] Intra-arterial injection may result in vasospasm and lead to ischemia of the limb tissue. Intravenous injection can lead to systemic toxicity when high doses of anesthetic are injected. Tissue texture changes revealing pallor, bogginess, and cool temperature may indicate that either intravascular injection or vascular compression has occurred. Always aspirate the syringe to rule out intravascular placement before injection. Alpha-adrenergic antagonists (eg, phentolamine 0.5-5 mg diluted 1:1 with NaCl 0.9%) can be administered by local infiltration to relieve arterial vasospasm secondary to intra-arterial injection. ^[12]

Nerve injury: Patients may develop paresthesia, sensory deficits, or motor deficits secondary to inflammation of the nerve. Most often, this type of neuritis is transient and resolves completely. During the procedure, pull back gently after induction of paresthesia so as to not inject the nerve directly. Make sure to document a complete neuromuscular examination both before and after the procedure. ^[14]

Hemorrhage: Reports of significant hemorrhage during regional anesthesia are rare, even in patients who have blood coagulopathies. ^[11] A hematoma may develop with intravascular puncture. If prolonged bleeding occurs, attempt to obtain hemostasis with direct pressure and elevation.

Allergic reaction: Allergic reactions to local anesthetics occur at a rate of 1%. ^{[7, 12]} Reactions range from delayed hypersensitivity (type IV) to anaphylactic (type I). ^[15] Although rare, the most common cause of such an allergic reaction is the preservative (eg, methylparaben) in the local anesthetic solution. Preservative-free lidocaine (typically found in cardiac solutions) is an alternative, since it does not contain the preservative. Alternatively, a 1-2% diphenhydramine solution can be used as a local anesthetic. ^[12]

Exceeding total dose of anesthesia: The dose of 1% lidocaine without epinephrine should not exceed 5 mg/kg. If lidocaine with epinephrine is used, total dose should not exceed 7 mg/kg. Systemic toxicity manifests in the central nervous and cardiovascular systems. ^{[7, 16]} Signs such as tremors, convulsions, tachycardia, or respiratory compromise should alert the physician to stop the procedure and reassess the patient.

A disadvantage of the ankle block is that it usually requires large volumes of local anesthetic. According to Frederickson, these volumes can be reduced with the use of ultrasonographic guidance because of the more precise needle placement and real-time repositioning that such guidance allows. ^[6] This reference concludes that typical volumes of 30 mL can be reduced to 15 mL for the entire ankle block.

Four of the five nerves in the ankle block can be approached with an in-plane needle transducer orientation directly, using a vessel as a guide, except for the superficial peronieal nerve. ^[6] These nerves and their corresponding vessels are as follows:

Deep peroneal nerve – Lateral to anterior tibial artery

Posterior tibial nerve – Posterior to posterior tibial artery

Saphenous nerve – Adjacent to the long saphenous vein

Sural nerve – Adjacent to the short saphenous vein

As noted by Frederickson, the superficial peroneal nerve is approaced in a traditional manner, as it does not travel with a vessel. ^{[6, 17]}

Crystal CS, Blankenship RB. Local anesthetics and peripheral nerve blocks in the emergency department. Emerg Med Clin North Am. 2005 May. 23(2):477-502. [Medline].

Salam GA. Regional anesthesia for office procedures: Part II. Extremity and inguinal area surgeries. Am Fam Physician. 2004 Feb 15. 69(4):896-900. [Medline].

Davies T, Karanovic S, Shergill B. Essential regional nerve blocks for the dermatologist: Part 2. Clin Exp Dermatol. 2014 Dec. 39 (8):861-7. [Medline].

Russell DF, Pillai A, Kumar CS. Safety and efficacy of forefoot surgery under ankle block anaesthesia. Scott Med J. 2014 May. 59 (2):103-7. [Medline].

Myerson MS, Ruland CM, Allon SM. Regional anesthesia for foot and ankle surgery. Foot Ankle. 1992 Jun. 13(5):282-8. [Medline].

Fredrickson MJ. Ultrasound-guided ankle block. Anaesth Intensive Care. 2009 Jan. 37(1):143-4. [Medline].

Gmyrek R. Local anesthesia and regional nerve block anesthesia. Medscape Reference. January 29, 2007. [Full Text].

Norris RL Jr. Local anesthetics. Emerg Med Clin North Am. 1992 Nov. 10(4):707-18. [Medline].

Crystal CS, Miller MA, Young SE. Ultrasound guided hematoma block: a novel use of ultrasound in the traumatized patient. J Trauma. 2007 Feb. 62(2):532-3. [Medline].

Luhmann JD, Schootman M, Luhmann SJ, Kennedy RM. A randomized comparison of nitrous oxide plus hematoma block versus ketamine plus midazolam for emergency department forearm fracture reduction in children. Pediatrics. 2006 Oct. 118(4):e1078-86. [Medline].

Reichman EF, Tolson DR. Regional nerve blocks (regional anesthesia). Reichman EF, Simon RR, eds. Emergency Medicine Procedures. New York, NY: McGraw-Hill; 2004. 965-81.

McGee D. Local and Topical Anesthesia. Roberts Jr, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, PA: WB Saunders; 2004. 541-5.

Greensmith JE, Murray WB. Complications of regional anesthesia. Curr Opin Anaesthesiol. 2006 Oct. 19(5):531-7. [Medline].

Borgeat A. Neurologic deficit after peripheral nerve block: what to do?. Minerva Anestesiol. Jun 2005. 71(6):353-5. [Medline].

Haugen RN, Brown CW. Case reports: type I hypersensitivity to lidocaine. J Drugs Dermatol. 2007 Dec. 6(12):1222-3. [Medline].

Ludot H, Tharin JY, Belouadah M, Mazoit JX, Malinovsky JM. Successful resuscitation after ropivacaine and lidocaine-induced ventricular arrhythmia following posterior lumbar plexus block in a child. Anesth Analg. 2008 May. 106(5):1572-4, table of contents. [Medline].

Fredrickson MJ, White R, Danesh-Clough TK. Low-volume ultrasound-guided nerve block provides inferior postoperative analgesia compared to a higher-volume landmark technique. Reg Anesth Pain Med. 2011 Jul-Aug. 36(4):393-8. [Medline].

Kelly JJ, Spektor M. Nerve blocks of the thorax and extremities. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa: WB Saunders; 2004. 584-9.

Moore K. The lower limb. Clinically Oriented Anatomy. 3rd ed. Baltimore, Md: Williams and Wilkins; 1992. 446-9.

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Paris PM, Yearly DM. Pain management. Marx JA, ed. Rosen’s Emergency Medicine Concepts and Clinical Practice. 5th ed. St. Louis, Mo: Mosby; 2002. 2571-3.

Richardson, EG. Surgical techniques. Canale ST, ed. Campbell’s Operative Orthopaedics. 10th ed. St. Louis, Mo: Mosby; 2003. 3911-4.

Heather Tassone, DO Attending Physician, Department of Emergency Medicine, Albert Einstein School of Medicine, Jacobi and Montefiore Medical Centers

Disclosure: Nothing to disclose.

Matthew A Silver, MD Staff Physician, Department of Emergency Medicine, Kaiser Permanente, San Diego Medical Center; Voluntary Clinical Instructor, University of California, San Diego, School of Medicine

Matthew A Silver, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Phi Beta Kappa, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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.

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.

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.

Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center

Andrew K Chang, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American Academy of Pain Medicine, American College of Emergency Physicians, American Geriatrics Society, American Pain Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

Superficial Peroneal Nerve Block

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