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<br /> Philips ultrasound-guided<br /> femoral and saphenous<br /> nerve block tutorial<br /> Francis V. Salinas, MD<br /> Staff Anesthesiologist and Section Head of Orthopedic Anesthesia<br /> Coordinator of Ultrasound-Guided Regional Anesthesia Education<br /> Virginia Mason Medical Center Department of Anesthesiology<br /> Table of contents<br /> Ultrasound-guided femoral and<br /> saphenous nerve block tutorial<br /> 1 Introduction and indications ........................... 3<br /> 2 Clinical anatomy ............................................... 12<br /> 3 Anatomical relationships and the ................30<br /> sonographic appearance of the<br /> femoral and saphenous nerves<br /> 4 Ultrasound anatomy and techniques ..........51<br /> 5 Clinical pearls ................................................... 90<br /> 6 References .........................................................92<br /> Additional resources .................................... 9<a title="Femoral Tutorial page 1" href="http://viewer.zmags.com/publication/11fe6863?page=1"> Philips ultrasound-guided femoral and saphenous n</a> <a title="Femoral Tutorial page 2" href="http://viewer.zmags.com/publication/11fe6863?page=2"> Table of contents Ultrasound-guided femoral and </a> <a title="Femoral Tutorial page 3" href="http://viewer.zmags.com/publication/11fe6863?page=3"> 1 Introduction and indications The femoral nerve</a> <a title="Femoral Tutorial page 4" href="http://viewer.zmags.com/publication/11fe6863?page=4"> 1 Introduction and indications • Common surgical</a> <a title="Femoral Tutorial page 5" href="http://viewer.zmags.com/publication/11fe6863?page=5"> 5</a> <a title="Femoral Tutorial page 6" href="http://viewer.zmags.com/publication/11fe6863?page=6"> 1 Introduction and indications Femoral nerve blo</a> <a title="Femoral Tutorial page 7" href="http://viewer.zmags.com/publication/11fe6863?page=7"> 7</a> <a title="Femoral Tutorial page 8" href="http://viewer.zmags.com/publication/11fe6863?page=8"> 1 Introduction and indications 2. Fascia iliaca </a> <a title="Femoral Tutorial page 9" href="http://viewer.zmags.com/publication/11fe6863?page=9"> Video 1 Peripheral nerve stimulation technique fo</a> <a title="Femoral Tutorial page 10" href="http://viewer.zmags.com/publication/11fe6863?page=10"> 1 Introduction and indications The previously de</a> <a title="Femoral Tutorial page 11" href="http://viewer.zmags.com/publication/11fe6863?page=11"> Saphenous nerve block The saphenous nerve is a pu</a> <a title="Femoral Tutorial page 12" href="http://viewer.zmags.com/publication/11fe6863?page=12"> 2 Clinical anatomy Femoral nerve The femoral ner</a> <a title="Femoral Tutorial page 13" href="http://viewer.zmags.com/publication/11fe6863?page=13"> • As the femoral nerve courses several centimeter</a> <a title="Femoral Tutorial page 14" href="http://viewer.zmags.com/publication/11fe6863?page=14"> 2 Clinical anatomy Figure 3 Illustration of</a> <a title="Femoral Tutorial page 15" href="http://viewer.zmags.com/publication/11fe6863?page=15"> 15</a> <a title="Femoral Tutorial page 16" href="http://viewer.zmags.com/publication/11fe6863?page=16"> 2 Clinical anatomy • The femoral nerve has a fla</a> <a title="Femoral Tutorial page 17" href="http://viewer.zmags.com/publication/11fe6863?page=17"> 17</a> <a title="Femoral Tutorial page 18" href="http://viewer.zmags.com/publication/11fe6863?page=18"> 2 Clinical anatomy • Just distal to the inguinal</a> <a title="Femoral Tutorial page 19" href="http://viewer.zmags.com/publication/11fe6863?page=19"> 19</a> <a title="Femoral Tutorial page 20" href="http://viewer.zmags.com/publication/11fe6863?page=20"> 2 Clinical anatomy • In addition, the lateral fe</a> <a title="Femoral Tutorial page 21" href="http://viewer.zmags.com/publication/11fe6863?page=21"> 21</a> <a title="Femoral Tutorial page 22" href="http://viewer.zmags.com/publication/11fe6863?page=22"> 2 Clinical anatomy One of the most important ana</a> <a title="Femoral Tutorial page 23" href="http://viewer.zmags.com/publication/11fe6863?page=23"> 23</a> <a title="Femoral Tutorial page 24" href="http://viewer.zmags.com/publication/11fe6863?page=24"> 2 Clinical anatomy Figure</a> <a title="Femoral Tutorial page 25" href="http://viewer.zmags.com/publication/11fe6863?page=25"> • The femoral vessels are located in between the </a> <a title="Femoral Tutorial page 26" href="http://viewer.zmags.com/publication/11fe6863?page=26"> 2 Clinical anatomy Saphenous nerve The saphenous</a> <a title="Femoral Tutorial page 27" href="http://viewer.zmags.com/publication/11fe6863?page=27"> Figure 9 Axial section at the proximal-to-mid-thi</a> <a title="Femoral Tutorial page 28" href="http://viewer.zmags.com/publication/11fe6863?page=28"> 2 Clinical anatomy • The saphenous nerve is typi</a> <a title="Femoral Tutorial page 29" href="http://viewer.zmags.com/publication/11fe6863?page=29"> • As the saphenous nerve courses further caudally</a> <a title="Femoral Tutorial page 30" href="http://viewer.zmags.com/publication/11fe6863?page=30"> 3 Anatomical relationships and the sonographi</a> <a title="Femoral Tutorial page 31" href="http://viewer.zmags.com/publication/11fe6863?page=31"> • The fascia iliaca may not be distinctly visible</a> <a title="Femoral Tutorial page 32" href="http://viewer.zmags.com/publication/11fe6863?page=32"> 3 Anatomical relationships • A number of smaller</a> <a title="Femoral Tutorial page 33" href="http://viewer.zmags.com/publication/11fe6863?page=33"> Video 2 Color flow Doppler (CFD) imaging of the f</a> <a title="Femoral Tutorial page 34" href="http://viewer.zmags.com/publication/11fe6863?page=34"> 3 Anatomical relationships • The femoral artery </a> <a title="Femoral Tutorial page 35" href="http://viewer.zmags.com/publication/11fe6863?page=35"> Figure 10a Typical appearance of the femoral nerv</a> <a title="Femoral Tutorial page 36" href="http://viewer.zmags.com/publication/11fe6863?page=36"> 3 Anatomical relationships Figu</a> <a title="Femoral Tutorial page 37" href="http://viewer.zmags.com/publication/11fe6863?page=37"> Figure 10c Note the rounded structure deep to the</a> <a title="Femoral Tutorial page 38" href="http://viewer.zmags.com/publication/11fe6863?page=38"> 3 Anatomical relationships Figu</a> <a title="Femoral Tutorial page 39" href="http://viewer.zmags.com/publication/11fe6863?page=39"> Figure 10e Note the hyperechoic polyfascicular (“</a> <a title="Femoral Tutorial page 40" href="http://viewer.zmags.com/publication/11fe6863?page=40"> 3 Anatomical relationships Figu</a> <a title="Femoral Tutorial page 41" href="http://viewer.zmags.com/publication/11fe6863?page=41"> Figure 10g Color flow Doppler image of the LFCxA </a> <a title="Femoral Tutorial page 42" href="http://viewer.zmags.com/publication/11fe6863?page=42"> 3 Anatomical relationships Figu</a> <a title="Femoral Tutorial page 43" href="http://viewer.zmags.com/publication/11fe6863?page=43"> Figure 10i Color flow Doppler image of the femora</a> <a title="Femoral Tutorial page 44" href="http://viewer.zmags.com/publication/11fe6863?page=44"> 3 Anatomical relationships Saphenous nerve The s</a> <a title="Femoral Tutorial page 45" href="http://viewer.zmags.com/publication/11fe6863?page=45"> Figure 11a The saphenous nerve is located within </a> <a title="Femoral Tutorial page 46" href="http://viewer.zmags.com/publication/11fe6863?page=46"> 3 Anatomical relationships Figu</a> <a title="Femoral Tutorial page 47" href="http://viewer.zmags.com/publication/11fe6863?page=47"> Figure 11c The block needle is inser ted and adva</a> <a title="Femoral Tutorial page 48" href="http://viewer.zmags.com/publication/11fe6863?page=48"> 3 Anatomical relationships Figu</a> <a title="Femoral Tutorial page 49" href="http://viewer.zmags.com/publication/11fe6863?page=49"> Figure 12b The block needle is inser ted and adva</a> <a title="Femoral Tutorial page 50" href="http://viewer.zmags.com/publication/11fe6863?page=50"> 3 Anatomical relationships Figu</a> <a title="Femoral Tutorial page 51" href="http://viewer.zmags.com/publication/11fe6863?page=51"> 4 Ultrasound anatomy and techniques Ultrasou</a> <a title="Femoral Tutorial page 52" href="http://viewer.zmags.com/publication/11fe6863?page=52"> 4 Ultrasound anatomy and techniques frequenc</a> <a title="Femoral Tutorial page 53" href="http://viewer.zmags.com/publication/11fe6863?page=53"> Figure 13a Patient is supine with the leg to be b</a> <a title="Femoral Tutorial page 54" href="http://viewer.zmags.com/publication/11fe6863?page=54"> 4 Ultrasound anatomy and techniques </a> <a title="Femoral Tutorial page 55" href="http://viewer.zmags.com/publication/11fe6863?page=55"> Figure 13c A 21-gauge 100 mm block needle is inse</a> <a title="Femoral Tutorial page 56" href="http://viewer.zmags.com/publication/11fe6863?page=56"> 4 Ultrasound anatomy and techniques </a> <a title="Femoral Tutorial page 57" href="http://viewer.zmags.com/publication/11fe6863?page=57"> • Sonographic anatomy (Figures 10a to 10i): Perfo</a> <a title="Femoral Tutorial page 58" href="http://viewer.zmags.com/publication/11fe6863?page=58"> 4 Ultrasound anatomy and techniques 2. The f</a> <a title="Femoral Tutorial page 59" href="http://viewer.zmags.com/publication/11fe6863?page=59"> Clinical Pearls • An anechoic structure coursing </a> <a title="Femoral Tutorial page 60" href="http://viewer.zmags.com/publication/11fe6863?page=60"> 4 Ultrasound anatomy and techniques • In-pla</a> <a title="Femoral Tutorial page 61" href="http://viewer.zmags.com/publication/11fe6863?page=61"> US beam in relation to the needle. A more deeply </a> <a title="Femoral Tutorial page 62" href="http://viewer.zmags.com/publication/11fe6863?page=62"> 4 Ultrasound anatomy and techniques 4. A 21-</a> <a title="Femoral Tutorial page 63" href="http://viewer.zmags.com/publication/11fe6863?page=63"> Figure 14a Short-axis view of the femoral nerve. </a> <a title="Femoral Tutorial page 64" href="http://viewer.zmags.com/publication/11fe6863?page=64"> 4 Ultrasound anatomy and techniques </a> <a title="Femoral Tutorial page 65" href="http://viewer.zmags.com/publication/11fe6863?page=65"> Figure 14c Needle tip is posterior to the femoral</a> <a title="Femoral Tutorial page 66" href="http://viewer.zmags.com/publication/11fe6863?page=66"> 4 Ultrasound anatomy and techniques Videos</a> <a title="Femoral Tutorial page 67" href="http://viewer.zmags.com/publication/11fe6863?page=67"> Video 4 SAX in-plane approach for a single inject</a> <a title="Femoral Tutorial page 68" href="http://viewer.zmags.com/publication/11fe6863?page=68"> 4 Ultrasound anatomy and techniques </a> <a title="Femoral Tutorial page 69" href="http://viewer.zmags.com/publication/11fe6863?page=69"> Video 6 SAX in-plane approach to a single injecti</a> <a title="Femoral Tutorial page 70" href="http://viewer.zmags.com/publication/11fe6863?page=70"> 4 Ultrasound anatomy and techniques 5. For c</a> <a title="Femoral Tutorial page 71" href="http://viewer.zmags.com/publication/11fe6863?page=71"> Figure 15a Set-up for an ultrasound-guided contin</a> <a title="Femoral Tutorial page 72" href="http://viewer.zmags.com/publication/11fe6863?page=72"> 4 Ultrasound anatomy and techniques </a> <a title="Femoral Tutorial page 73" href="http://viewer.zmags.com/publication/11fe6863?page=73"> Figure 15c The needle insertion site is infiltrat</a> <a title="Femoral Tutorial page 74" href="http://viewer.zmags.com/publication/11fe6863?page=74"> 4 Ultrasound anatomy and techniques </a> <a title="Femoral Tutorial page 75" href="http://viewer.zmags.com/publication/11fe6863?page=75"> Figure 15e The needle is advanced in-plane until </a> <a title="Femoral Tutorial page 76" href="http://viewer.zmags.com/publication/11fe6863?page=76"> 4 Ultrasound anatomy and techniques </a> <a title="Femoral Tutorial page 77" href="http://viewer.zmags.com/publication/11fe6863?page=77"> Figure 15g The needle is withdrawn over the cathe</a> <a title="Femoral Tutorial page 78" href="http://viewer.zmags.com/publication/11fe6863?page=78"> 4 Ultrasound anatomy and techniques </a> <a title="Femoral Tutorial page 79" href="http://viewer.zmags.com/publication/11fe6863?page=79"> Figure 16 2D image of a femoral catheter located </a> <a title="Femoral Tutorial page 80" href="http://viewer.zmags.com/publication/11fe6863?page=80"> 4 Ultrasound anatomy and techniques </a> <a title="Femoral Tutorial page 81" href="http://viewer.zmags.com/publication/11fe6863?page=81"> Video 8 Continuous femoral perineural catheter pl</a> <a title="Femoral Tutorial page 82" href="http://viewer.zmags.com/publication/11fe6863?page=82"> 4 Ultrasound anatomy and techniques Ultrasou</a> <a title="Femoral Tutorial page 83" href="http://viewer.zmags.com/publication/11fe6863?page=83"> Figure 17a The patient is supine with the leg to </a> <a title="Femoral Tutorial page 84" href="http://viewer.zmags.com/publication/11fe6863?page=84"> 4 Ultrasound anatomy and techniques </a> <a title="Femoral Tutorial page 85" href="http://viewer.zmags.com/publication/11fe6863?page=85"> • Sonographic anatomy (Figures 11a, 11b, and 12a)</a> <a title="Femoral Tutorial page 86" href="http://viewer.zmags.com/publication/11fe6863?page=86"> 4 Ultrasound anatomy and techniques 3. Trave</a> <a title="Femoral Tutorial page 87" href="http://viewer.zmags.com/publication/11fe6863?page=87"> 2. The depth of the saphenous nerve is noted (typ</a> <a title="Femoral Tutorial page 88" href="http://viewer.zmags.com/publication/11fe6863?page=88"> 4 Ultrasound anatomy and techniques 5. At t</a> <a title="Femoral Tutorial page 89" href="http://viewer.zmags.com/publication/11fe6863?page=89"> Video 9 The saphenous nerve is visualized as a hy</a> <a title="Femoral Tutorial page 90" href="http://viewer.zmags.com/publication/11fe6863?page=90"> 5 Clinical pearls The adductor canal approach to</a> <a title="Femoral Tutorial page 91" href="http://viewer.zmags.com/publication/11fe6863?page=91"> Disadvantages • The disadvantages include a possi</a> <a title="Femoral Tutorial page 92" href="http://viewer.zmags.com/publication/11fe6863?page=92"> 6 References Anatomy 1. Singelyn F. Femoral ne</a> <a title="Femoral Tutorial page 93" href="http://viewer.zmags.com/publication/11fe6863?page=93"> Saphenous nerve 1. Akkaya T, Ersan Ozkan D, et al</a> <a title="Femoral Tutorial page 94" href="http://viewer.zmags.com/publication/11fe6863?page=94"> Additional resources Additional resources relate</a> <a title="Femoral Tutorial page 95" href="http://viewer.zmags.com/publication/11fe6863?page=95"> Philips Healthcare is part of Royal Philips Elect</a>