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Emergency Ultrasound

Tips & Tricks: Ultrasound guided “3 in 1” nerve block

By Drew Jones, MD and Laleh Gharahbaghian, MD, FACEP
Stanford University, School of Medicine - Department of Emergency Medicine

Let’s reduce our reliance on opiate analgesia in the elderly patients who present with hip fractures!

Hip fractures, defined as fractures to the femur from the femoral neck to 6 cm distal to the lesser trochanter, are a significant source of morbidity and mortality in the elderly.1-3 The mainstay of pain control in the acute setting is parenteral opiate medications, which also carry significant risks, namely: increased incidence of respiratory depression, hypotension, and delirium. That makes it pretty tough to obtain surgical consent, communicate about the plan of care, and to get true pain control. Regional anesthesia has been a mainstay in the perioperative and post-operative care of these patients.4 In an effort to decrease morbidity for these patients in the acute setting and improve patient experience, the femoral nerve block or “3 in 1” nerve block, so called as it promotes diffusion of local anesthetic to the femoral, obturator, and lateral femoral cutaneous nerve, has gained traction with institutions including this as part of hip fracture protocols.

Recent Cochrane systematic review concluded that there was high quality evidence that femoral nerve blocks reduce pain at 30 minutes following injection.5 Further, small studies performed on ED populations show a statistically significant reduction in opiate usage in patients who received the block.6-7 In addition, femoral nerve blocks are equally effective for both intra- and extra-capsular hip fractures.8 Point of care ultrasound (POCUS) has the ability of defining the anatomy in real time, visualizing the needle track and target, and increasing the efficacy of the nerve block while minimizing complications.

Tips for Ultrasound guided femoral nerve block:

First: Ensure no contraindications: coagulopathy, distorted anatomy, dementia/unconscious

Second: Do a pre-procedure function exam of the nerve you are about to block

Third: Choose the appropriate anesthetic and amount (duration of action, effects)

Last: perform these tips for the procedure:

  1. Sterile procedure (skin prep, barrier methods, sterile gloves, probe covers)
  2. Probe: Linear probe, adjust depth so your femoral sheath is in the center of view
  3. Identify your anatomy: Target is femoral nerve lateral to femoral artery/vein, inferior to fascia iliaca, immediately caudle to inguinal canal.
  4. Needle approach: An in-plane approach moving from lateral to medial will allow maximal visualization of the needle and minimize the risk of intravascular injection.
  5. “3-in-1” nerve block is ideal: provides anesthesia for femoral nerve, lateral femoral cutaneous nerve, and obturator nerve.
  6. Use an appropriate quantity of local anesthetic, 20-30 ml for “3 in 1” nerve block.
  7. Apply direct pressure 2-4 cm distal to the injection site for 5-10 minutes during injection. This allows the anesthetic to spread medial/lateral to the obturator nerve and lateral femoral cutaneous nerve, respectfully.
  8. Inject slowly in target region and visualize the anesthetic surrounding the structures of interest. (YouTube Video)

There is considerable debate within the literature as to whether the femoral and “3 in 1” nerve block is functionally the same block with the latter promoting increased diffusion by virtue of higher anesthetic volume and direct pressure distal to the injection site to promote medial/lateral spread. In the acute setting, the principle goal is adequate analgesia while minimizing risks of interventions. Nomenclature aside, the “3 in 1” technique has been shown to be both efficacious and safe. It is, therefore, a reasonable first-line intervention in the acute setting for our elderly patients who present with hip fractures.


  1. Buecking B, Eschbach D, Knobe M, et al. Predictors of noninstitutionalized survival 1 year after hip fracture: A prospective observational study to develop the Marburg Rehabilitation Tool for Hip fractures(MaRTHi). Medicine (Baltimore). 2017 Sep;96(37):e7820. doi: 10.1097/MD.0000000000007820.
  2. Dick AG, Davenport D, Bansal M, et al. Hip Fractures in Centenarians: Has Care Improved in the National Hip Fracture Database Era? Geriatr Orthop Surg Rehabil. 2017 Sep;8(3):161-165. doi: 10.1177/2151458517722104. Epub 2017 Aug 8.
  3. Moore J, Carmody O, Carey B, et al. The cost and mortality of hip fractures in centenarians. Ir J Med Sci. 2017 Mar 4. doi: 10.1007/s11845-017-1589-9. [Epub ahead of print]
  4. Opperer M, Danninger T, Stundner O, et al. Perioperative outcomes and type of anesthesia in hip surgical patients: An evidence based review. World J Orthop. 2014 Jul 18; 5(3): 336–343. Published online 2014 Jul 18. doi: 10.5312/wjo.v5.i3.336
  5. Guay J, Parker MJ, Griffiths R, et al. Peripheral nerve blocks for hip fractures. Cochrane Database Syst Rev. 2017 May 11;5:CD001159. doi: 10.1002/14651858.CD001159.pub2.
  6. Beaudoin FL1, 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 Jun;20(6):584-91. doi: 10.1111/acem.12154.
  7. Morrison RS, Dickman E, Hwang U, et al. Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial. J Am Geriatr Soc. 2016 Dec;64(12):2433-2439. doi: 10.1111/jgs.14386. Epub 2016 Oct 27.
  8. Dickman E, Pushkar I, Likourezos A, et al. Ultrasound-guided nerve blocks for intracapsular and extracapsular hip fractures. Am J Emerg Med. 2016 Mar;34(3):586-9. doi: 10.1016/j.ajem.2015.12.016. Epub 2015 Dec 14.

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