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Emergency Ultrasound

Fellow’s Corner: Case Report - Right Hip Pain and Ultrasound-Guided Femoral Nerve Block

Charles Draznin MD and Peter Keenan MD

Chief Complaint: Right hip pain after a fall

Figure 1
HipPain1


Questions:

What anatomy and pathology are shown in these Figures 1-3?

  1. How can ultrasound be used in the treatment of this pathology?
  2. What are some of the advantages of using ultrasound to guide pain control for this condition?


Case Presentation

An 87-year-old man with a history of stroke with right-sided weakness presents with severe right hip pain after a fall while walking with his cane. On exam his right leg is shortened, externally rotated, and tender over the right hip. His x-ray shows an intertrochanteric hip fracture (Fig 1). Orthopedics is consulted and IV pain medication is administered but he continues to complain of pain.

Following discussion with the patient and his family members, a femoral nerve block is administered (Fig 2 and 3).    

 

Figure 2 Figure 3 Click Here for Video
 HipPain2   HipPain3             


Within 20 minutes, the patient states his pain is significantly improved. The next day he goes to the operating room for placement of an intramedullary nail. No additional pain medication is needed from the time of the nerve block until operative fixation. He is weight bearing as tolerated following the procedure and is discharged to rehab facility on hospital day 5.

Role of Emergency Ultrasound in Pain Control

In patients with hip fractures, adequate analgesia can be difficult to obtain with oral or parenteral methods. Larger doses of narcotics carry risks of sedation, especially with elderly patients. Inadequate pain control has been shown to be associated with delirium in elderly patients.1

Regional anesthesia for pain control related to orthopedic injuries and procedures has long been practiced by anesthesiologists, but its widespread use by other fields is more recent. An increasing body of practice and literature documents its use in emergency medicine. Regional anesthesia via femoral nerve block for hip fractures has been shown to decrease patient pain and amount of parenteral narcotic analgesia required in the ED setting.2

Another option is the fascia iliaca compartment block (FICB). Rather than visualizing a nerve directly and injecting near it, this technique relies on instilling anesthetic into a compartment, and letting spread of the anesthetic provide the block. The femoral, lateral cutaneous, and obturator nerves can be blocked with the FICB. It requires a higher total volume of anesthetic than a femoral nerve block as it is a compartment block. Use of the FICB has also been described in the ED setting.3,4 Table 1 compares three local anesthetic approaches to treat hip fracture pain.

Answers to questions:

  1. Figure 1: The x-ray shows a right hip intertrochanteric fracture. Figure 2: The ultrasound images show the femoral nerve, artery, and vein. Figure 3: Shows the nerve block needle being repositioned lateral to the femoral nerve.
  2. Ultrasound can be used to guide nerve blocks to supply improved analgesia for hip fractures. Options include a femoral nerve block (or 3-in-1 variation) and the fascia iliaca compartment block.
  3. Ultrasound guidance allows for precise placement of the needle tip prior to injection rather than the traditional blind technique which relies on anatomic landmarks and the feel of different tissue planes. This may help prevent nerve injury, intravascular injection, and reduce the total amount of anesthetic needed.

Internet Resources:
SonoGuide
Ultrasound Guided Regional Nerve Blocks
Video by Mike Stone discussing FICB technique
NYSORA.com
NYSORA.com - US Guided femoral nerve block

Table 1:

   Femoral nerve block 3 in 1 femoral nerve block Fascia iliaca compartment block
Landmarks 1 cm distal to inguinal ligament, femoral nerve is lateral to femoral artery 1 cm distal to inguinal ligament, femoral nerve is lateral to femoral artery 1 cm distal to the inguinal, identify hyperechoic fascia iliaca superficial to iliacus
muscle lateral to femoral nerve (1/3 distance from ASIS to pubic tubercule)
Volume reported 10-20 ml injected surrounding femoral nerve 25 ml injected along nerve sheath surrounding nerve 30-40ml injected just deep to fascia iliaca
Distribution Anterior and medial thigh and knee, medial leg and foot, fibers to hip and knee joints Anesthetic passes cephalad in nerve sheath to anesthetize the lateral cutaneous and obturator nerves in addition to the femoral nerve Anesthetic passes cephalad in fascial plane to anesthetize the lateral cutaneous
and obturator nerves in addition to the femoral nerve
Notes May not provide reliable analgesia for hip fractures Hold pressure 1cm below injection site for 30 seconds to 5 minutes Femoral, lateral cutaneous, and obturator nerves run under fascia iliaca
Strengths Lowest volume of anesthetic used Lower volume of anesthetic used compared with FICB Lower risk of intravascular injection and nerve injury since needle tip distant from vessels and nerve
Citations Parker et al. Beaudoin et al. Haines et al.


   
References:

  1. Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003;58(1):76–81.
  2. Beaudoin FL, Haran JP, Liebmann O. A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial. Acad Emerg Med. 2013;20(6):584–91.
  3. Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J Emerg Med. 2012;43(4):692–7.
  4. Elkhodair S, Mortazavi J, Chester A, et al. Single fascia iliaca compartment block for pain relief in patients with fractured neck of femur in the emergency department: a pilot study. Eur J Emerg Med. 2011;18(6):340–3.
  5. Parker MJ, Griffiths R, Appadu BN. Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures. Cochrane Database Syst Rev. 2002:CD001159.



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