I have been surprised by the lack of pain in some patient with hip fracture. Most I have seen seem to be fine as long as the remain perfectly still. However, how often does that happen? After x-rays, multiple attending and resident exams patient will hate you if their pain is not well controlled.
The femoral nerve block has been around for a long time and several studies have shown it to be effective and safe in the emergency department (1, 2, 3, 4). Patients who receive femoral nerve blocks achieve pain control faster, have lower pain scores and require less opoids.
The best part is, if you’ve ever done an ultrasound guided femoral central line, you already know most of the steps. There are several good resources with in depth guides, so we’ll just go over the highlights.
- Remember the anatomy goes NAVEL (in the direction of the navel), so that’s from Lateral to Medial: Nerve, Artery, Vein, Empty Space, Lymphatics
- Drugs: Lidocaine or bupivacaine. Lido starts working faster. Bupivicaine lasts longer. You can use both mixed together, for faster onset but decrease duration than bupivicaine alone (5). Remember to remain within allowed max per kg doses.
- Clean with antiseptic and use sterile technique.
- It’s 2015, use ultrasound. Guide your needle down, using a lateral approach, into the femoral nerve compartment. It is located superior-medial to the iliac muscle and lateral to the femoral artery. It is a relatively hyperechoic structure. Make sure the needle tip is below the Fascia Iliaca (fascia just above the nerve) otherwise the anesthetic will not reach the nerve.
(Figure 1, ref)
- Aspirate to ensure you are not a vascular structure. If no blood returns, you can inject a 1cc test dose, which will be visible on ultrasound as a hypo-echoic circle in the nerve bundle. Once you are comfortable you are in the nerve compartment, go ahead an inject the rest of the anesthetic.
(Figure 2 ref)
Here’s a 5 minute video review.
- Beaudoin, F. L., Haran, J. P., & Liebmann, O. (2013). 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. Academic Emergency Medicine,20(6), 584-591.
- Beaudoin, F. L., Nagdev, A., Merchant, R. C., & Becker, B. M. (2010). Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures.The American journal of emergency medicine, 28(1), 76-81.
- Fletcher, A. K., Rigby, A. S., & Heyes, F. L. (2003). Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial. Annals of emergency medicine, 41(2), 227-233.
- Hurley, K. (2004). Do femoral nerve blocks improve acute pain control in adults with isolated hip fractures?. CJEM, 6(6), 441.
- Cuvillon, P., Nouvellon, E., Ripart, J., Boyer, J. C., Dehour, L., Mahamat, A., … & de La Coussaye, J. E. (2009). A comparison of the pharmacodynamics and pharmacokinetics of bupivacaine, ropivacaine (with epinephrine) and their equal volume mixtures with lidocaine used for femoral and sciatic nerve blocks: a double-blind randomized study. Anesthesia & Analgesia, 108(2), 641-649.