Fascia Iliaca Nerve Block

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Hip Broke? Hip Block. Use of the fascia iliaca nerve block for analgesia in hip fractures.

Resident Clinical Pearl (RCP) July 2020

Luke Edgar, BScH MD

PGY1 Family Medicine Integrated Emergency Medicine

Dalhousie Saint John

 

Reviewed by Dr. David Lewis

Background

Hip fractures are a common and painful injury diagnosed and treated in the emergency department, with elderly patients representing the majority of cases. Advanced age, comorbidities, and increased sensitivity to side effects from systemic analgesia all pose challenges to achieving adequate pain control.1,2 Additionally, NSAID use in the elderly is frequently contraindicated due renal, cardiac, and gastrointestinal comorbidities as well as drug interactions. In elderly patients, both undertreated pain and opioid analgesia can precipitate delirium.3

Regional nerve blocks for the indication of hip and femoral neck fractures have been shown to reduce pain and need for IV opiates.1 Contraindications include infection over the injection site, patient refusal, and allergy to local anesthetic. Additionally, patients at risk for compartment syndrome (such as those with a concomitant ipsilateral tibial plateau fracture) should be selected cautiously as they may not reliably have increased pain after block.4

There are three main techniques described for regional nerve blocks to provide analgesia for hip and femoral neck fractures.1

  • Fascia Iliaca Nerve Block: Insert a needle through the fascia lata and fascia iliaca, to infiltrate dilute local anesthetic into the fascial compartment which diffuses to block the femoral, lateral femoral cutaneous, and obturator nerves.
  • Femoral Nerve Block: At the level of the femoral triangle, infiltrate local anesthetic around the femoral nerve.
  • 3-in-1 Femoral Nerve Block: At the level of the femoral triangle, infiltrate local anesthetic around the femoral nerve while applying pressure distal to the injection site, encouraging local anesthetic to track superiorly to block the femoral, lateral femoral cutaneous, and obturator nerves.

Figure 1. Lower limb peripheral nerve sensory distribution.5 Circled in red are the nerves blocked using the fascia iliaca technique. Cutaneous distribution of the obturator nerve is not depicted but consists of a small area on the proximal medial thigh.

Technique

Table 1. Supplies and equipment for performing a fascia iliaca nerve block

Table 2. Steps to complete a fascia iliaca nerve block6

Table 3. One person technique  – Steps to complete a fascia iliaca nerve block

Figure 2. Video demonstrating the sonoanatomy of the right femoral triangle. From lateral to medial, femoral nerve, artery and vein (NAVel), labeled with yellow, red, and blue arrows, respectively.

Figure 3. Sonoanatomy of the right femoral triangle, transverse view for the fascia iliaca nerve block.

Figure 4. Sonoanatomy of the right femoral triangle demonstrating ultrasound-guided needle placement using an in-plane technique. Note two pops should be felt as the needle crossed the two fascial planes.

 

For a visual review of these steps and ultrasonographic landmarks, please see the following videos and webpage by EM Ottawa, 5 Minute Sono, and NYSORA:

EM Ottawa

5 Minute Sono

NYSORA

Ultrasound-Guided Fascia Iliaca Block

 

Complications

Serious complications of this procedure are rare, but present.

  • Local Anesthetic Systemic Toxicity (LAST) as a complication of inadvertent intravenous or intra arterial anesthetic injection.7
    1. Incidence is 8 – 30 in 100,0008
    2. Manifestations typically occur within 20 minutes of injection (although onset can be as late as >1 hr) and are primarily neurologic and cardiovascular in nature. Neurologic effects include perioral numbness, metallic taste, mental status change or anxiety, muscle twitches and visual changes, followed by loss of consciousness and seizure. Cardiovascular effects are hypertension and tachycardia followed by arrhythmias, bradycardia, hypotension and cardiac arrest.
    3. Treatment is with intravenous lipid emulsion therapy (Intralipid 20%) 1.5 mL/kg bolus followed by 0.25 mL/kg/min, Maximum total dose 12 mL/kg. Contact your poison control centre if you suspect LAST.
    4. Prior to performing a fascia iliaca block, confirm availability of intralipid within your department to be used in the event of this rare complication.
  • Femoral Nerve injury secondary to intrafascicular injection
    1. Incidence 2-30/100,0008
    2. Most symptoms of paresthesias, numbness, and weakness resolved after several months in the event of this complication8
  • Other complications include infection, nerve block failure, injury secondary to numbness/weakness of limb, and allergy to the local anesthetic.

 

Take Home Message

Femoral nerve blocks are recommended for hip and femoral fractures to reduce pain and opioid analgesia requirements. Given that poor pain control and opioid analgesia are risk factors for delirium in elderly patients, hip blocks may also reduce rates of delirium (further study required). A fascia iliaca block with 20 cc of 0.5% bupivacaine is a well described technique with very few contraindications. To reduce the risk of complications, these blocks should be completed using sterile technique under ultrasound guidance with the help of an assistant. Hip broke? Hip block.

 

 

References

  • Ritcey B, Pageau P, Woo M, Perry J. Regional Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review. CJEM 2015;18(1):37-47.
  • Hwang U, Richardson LD, Sonuyi TO, Morrison RS. The effect of emergency department crowding on the management of pain in older adults with hip fractures. J Am Geriatr Soc. 2006;54(2):270-5.
  • 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.
  • Erak M, EM Ottawa Grand Rounds. Ah, that feels better! The Use of Nerve Blocks in the ED. 2016. https://emottawablog.com/2016/10/ah-that-feels-better-the-use-of-nerve-blocks-in-the-ed/. Accessed July 25, 2020.
  • Gray H. 1918. Nerve supply of the leg. Anatomy of the Human Body. Image retrieved from https://en.wikipedia.org/wiki/Nerve_supply_of_the_human_leg. Accessed July 24, 2020
  • Woo M. How to perform the Ultrasound Guided Femoral Nerve Block. EM Ottawa. 2018. https://youtu.be/_OugsPA4rxY Accessed July 25, 2020.
  • Warren L, Pak A. Local anesthetic systemic toxicity. UpToDate. 2019. uptodate.com/contents/local-anesthetic-systemic-toxicity. Accessed July 25, 2019.
  • Helman, A, Morgenstern, J, Spiegel, R, Lee, J. Regional Nerve Blocks for Hip Fractures. Emergency Medicine Cases. August, 2018. https://emergencymedicinecases.com/regional-nerve-blocks-hip-fractures/. Accessed July 25, 2020.
  • Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J of Ultrasound in Emergency Medicine 2012;43(4):692-697.

 

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