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COPYRIGHT 2008

BY

THE JOURNAL

OF

BONE

AND JOINT

SURGERY, INCORPORATED

Femoral Nerve Block for Diaphyseal


and Distal Femoral Fractures
in the Emergency Department
Surgical Technique
By Christopher E. Mutty, MD, Erik J. Jensen, MD, Michael A. Manka Jr., MD, Mark J. Anders, MD, and Lawrence B. Bone, MD
Investigation performed at Erie County Medical Center, an affiliate of the State University of New York at Buffalo, Buffalo, New York
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 89-A, pp. 2599-603, December 2007

ABSTRACT FROM THE ORIGINAL ARTICLE


BACKGROUND: Diaphyseal and distal femoral fractures are painful injuries that are frequently seen in patients requiring a
trauma work-up in the hospital emergency department prior to definitive management. The purpose of this study was to
determine whether a femoral nerve block administered in the emergency department could provide better pain relief for
patients with femoral fractures than currently used pain management practices.
METHODS: Patients who presented with an acute diaphyseal or distal femoral fracture were identified as potential candidates for this study. Eligible patients were randomized by medical record number to receive either (a) the femoral nerve
block (20 mL of 0.5% bupivacaine) along with standard pain management or (b) standard pain management alone (typically intravenous narcotics). The pain was assessed with use of a visual analog scale at the initial evaluation and at five,
fifteen, thirty, sixty, and ninety minutes following the initial evaluation. Fifty-four patients were enrolled in the study from
April 2005 to May 2006. Thirty-one patients received a femoral nerve block, and twenty-three patients received standard
pain management alone.
RESULTS: Baseline scores on the visual analog pain scale did not differ between the groups at the initial evaluation. The
patients who received a femoral nerve block (along with standard pain management) had significantly lower pain scores
at five, fifteen, thirty, sixty, and ninety minutes following the block than did the patients who received standard pain management alone (p < 0.001). The score on the visual analog pain scale across these time points was an average of 3.6
points less (on a 10-point scale) for those who received the block. There were no infections, paresthesias, or other complications related to the femoral nerve block.
CONCLUSIONS: The acute pain of a diaphyseal or distal femoral fracture can be significantly decreased through the use of
a femoral nerve block, which can be administered safely in the hospital emergency department.
LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.
ORIGINAL ABSTRACT CITATION: Femoral Nerve Block for Diaphyseal and Distal Femoral Fractures in the Emergency Department (2007;89:2599-603).

DISCLOSURE: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of
their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial
entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit
organization with which the authors, or a member of their immediate families, are affiliated or associated.
J Bone Joint Surg Am. 2008;90 Suppl 2 (Part 2):218-26 doi:10.2106/JBJS.H.00314

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INTRODUCTION
In most emergency departments, the pace is fast and there
is a constant flow of personnel.
Amid all of this activity, addressing the acute pain of a femoral
fracture may not be a top priority. However, most patients use
descriptors such as excruciating or the worst pain imaginable when describing the acute
pain that they experienced in association with a femoral fracture.
A femoral nerve block can provide effective pain relief and can
be delivered safely in the emergency department with the appropriate equipment and
education of the staff.
SURGICAL TECHNIQUE
After the primary and secondary assessments have been
completed and it has been deter-

FIG. 1
Nerve stimulator and injection kit.

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mined that the patient does not


require an immediate trip to the
operating room, temporary stabilization of orthopaedic injuries
is undertaken in the form of
splinting or traction. Concurrent with this process, the orthopaedic surgeon should perform
a careful neurovascular examination of the extremities. Dorsalis pedis and posterior tibial
pulses are palpated. The patient
should demonstrate intact anterior tibialis, extensor hallucis
longus, gastrocnemius/soleus,
and toe flexor motor function as
surrogates for the integrity of the
peroneal and tibial divisions of
the sciatic nerve. In addition,
sensation across the dermatomes
of the injured lower extremity is
assessed. These are critical first
steps in deciding whether a patient is an appropriate candidate

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for a femoral nerve block. Patients with abnormal findings on


the neurovascular examination
or those who are unable to participate in the examination are
not candidates for a nerve block.
The thigh on the affected side
should be carefully examined.
Patients with a rigid, tensely
swollen thigh or those with a
rapidly expanding hematoma
are also not candidates for a regional block. The history of the
injury is then reviewed. If the
history is consistent with a
mechanism that places the patient at high risk for compartment syndrome (such as a
crushing injury or a prolonged
extrication secondary to an
entrapped lower extremity),
then a femoral nerve block is
contraindicated.
Once it has been deter-

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FIG. 2
Contents of the nerve block kit: stimulating needle assembly, 35-mL syringe, 18-gauge needle, 25-gauge needle, prepackaged lidocaine syringe, grounding electrode (with spare), povidone-iodine swabsticks (three), sterile gloves, 30 mL of 0.5% bupivacaine.

mined that the patient is a suitable candidate for a regional


block, the risks and benefits of
the procedure are explained to
the patient in straightforward
terms. If the patient wishes to
proceed with the block, a nerve
stimulator and an injection kit
are set up at the bedside (Fig. 1).
The stimulator and injection kits
should be maintained in a secure
and convenient location to ensure that the stimulator is in
good working order and that the
contents of the kit have not expired. Typically, there will be a
lot of activity around the patient; it is important that all
members of the trauma team be
familiar with the nerve block
procedure so that efforts such as
ensuring appropriate resuscitation, blood drawing, and Foley

catheter placement can be coordinated with the administration


of the block. The injection kit is
opened, and the contents are reviewed to ensure that nothing is
missing (Fig. 2) (see Appendix
for a complete list of supplies).
The protective cap on the 30-mL
bottle of 0.5% bupivacaine is removed, and the expiration date is
checked. The stimulator is
turned on and is checked for appropriate settings; generally, a
current of 0.8 mA at 2 Hz will
provide an excellent visual (patellar twitch) cue that the needle
tip is in the immediate vicinity of
the femoral nerve without causing increased pain for the patient. The stimulating needle
package is opened, and the tubing and wire are carefully removed so as to maintain sterility

of the needle. The wire from the


needle is connected to the stimulator lead. Twenty milliliters of
bupivacaine are drawn into the
35-mL syringe with use of the
18-gauge needle. This needle is
then removed, and the stimulator needle and tubing are attached to the syringe. The
electrocardiogram electrode is
placed on the patients abdomen, and the grounding clip
from the stimulator is connected.
The Mayo stand or table on
which the equipment is placed
should be positioned immediately adjacent to the stretcher on
the patients affected side at the
level of the upper abdomen so
the stimulator will be clearly visible and the equipment will be
within easy reach (Fig. 3).
Landmarks on the patient

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FIG. 3
Patient and equipment positioning.

are palpated (Fig. 4-A). The inguinal ligament is palpated from


the anterior superior iliac spine
to the pubic tubercle. The femoral artery pulse is then located 3
to 4 cm distal to the inguinal ligament (at the level of the inguinal crease). The femoral nerve
is lateral to the artery (Fig. 4-B),
and this location is marked with
a pen. A small indentation can be
made with a pen cap so that the
location will be visible after sterile preparation of the skin. The
groin on the affected side is then
prepared with povidone-iodine
swabsticks. The skin at the
marked site is anesthetized with
the injection of approximately
0.5 mL 2% lidocaine with use of
the preloaded 5-mL syringe and
25-gauge needle provided in the
kit, resulting in a wheal (Fig. 5).
Sterile surgical gloves are donned

after it has been verified that all


connections have been made and
the stimulator has been turned
on. The stimulating needle is
withdrawn from its package and,
with one hand being used to stabilize the skin, the needle is advanced through the skin at the
previously made mark. The stimulating needle has a relatively
blunt tip that requires quick,
firm, and controlled pressure in
order to penetrate the skin. The
needle is then slowly advanced
with the tip angled about 30
cephalad. The femoral nerve has
a proximal branch that extends
to the sartorius, and this muscle
often will be the first to exhibit a
twitch in synchrony with the
stimulators audio tone and
flashing indicator. The needle
should continue to be advanced
until the patella is noted to

twitch in concert with the cues


from the stimulator. At this
point, in a patient with an average body habitus, the needle tip
typically has been advanced 2 to
3 cm and is in the immediate vicinity of the femoral nerve. If the
needle is advanced and no twitch
is elicited, the needle should be
withdrawn to the level of the skin
and reinserted in a slightly more
lateral direction. In order to
avoid penetration of the femoral
artery, the needle should never
be redirected medially toward
the fingers lying over the pulse of
that vessel. Once the patellar
twitch has been elicited, the needle is stabilized in position with
one hand and the syringe is
picked up with the other hand
(Figs. 6-A and 6-B). An attempt
at aspiration is first made to ensure that the needle is not within

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FIG. 4-A
Regional landmarks. A = anterior superior iliac spine, B = pubic tubercle,
and C = inguinal crease.

FIG. 4-B
Pertinent underlying anatomical structures include the femoral nerve, artery, and vein; the
inguinal ligament; and the sartorius, iliopsoas, and pectineus muscles.

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FIG. 5
Injection of 2% lidocaine at the anticipated site of stimulating needle placement.

the artery (signified by the presence of easily aspirated bright red


blood). If the needle has been inadvertently advanced into the artery, it should be withdrawn and
pressure should be applied for
five minutes before resuming the
procedure. Approximately 1 to 2
mL of bupivacaine are slowly injected, and the patellar twitch
should stop at this point. If the
patient experiences a sudden increase in pain or if the patellar
twitch continues, the needle tip
may be within the nerve itself
and should be withdrawn
slightly. The remainder of the
bupivacaine is then injected in a
controlled fashion over the
course of sixty seconds. Aspiration is attempted periodically to
verify that the needle is not
within a blood vessel, and the pa-

tient is asked about the development of circumoral numbness,


tinnitus, or blurred vision. Any
of these symptoms may indicate
an intravascular injection, and
the procedure is discontinued if
this occurs. After 20 mL of bupivacaine have been injected, the
needle is withdrawn, the site is
checked for bleeding, and the
stimulator is returned to the appropriate location.
Most patients begin to report a diminution of pain
within five minutes and experience more than ninety minutes
of effective pain relief with a satisfactory femoral nerve block.
The trauma team initially may
be apprehensive about the block
being performed early in the
process of the trauma workup.
Through education with an at-

tending anesthesiologist and the


acquisition of good technical
skills, junior residents at our institution have been able to perform the block safely and
efficiently and there have been
no cases in which the procedure
was a rate-limiting step in the
patients evaluation. By providing the block before transporting the patient to the radiology
department, we are able to provide effective pain relief when it
is needed mostduring transfers to and from the imaging tables. The duration of pain relief
beyond ninety minutes is less
well defined; however, on the
basis of the 3.5-hour half-life of
bupivacaine in adults, the effect
can be expected to last throughout the duration of the trauma
evaluation.

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FIG. 6--A
Localization of the femoral nerve with the stimulating needle. The palpating hand is positioned with the fingers overlying the femoral artery
pulse. The patella (shown covered in this image) should be visible during this process so patellar twitch can be seen.

FIG. 6-B
Administration of the block.

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CRITICAL CONCEPTS
INDICATIONS:
Femoral nerve block placement in the emergency department has been shown to be effective during the treatment of diaphyseal and/or distal femoral fractures (both closed and open) in awake and alert adults who are able to respond appropriately to questions and who have a normal neurovascular examination of the injured extremity.
CONTRAINDICATIONS:
Intubated or obtunded patients or other patients who are not able to respond to questions and follow commands,
thereby precluding an adequate examination.
Patients with an injury history that is consistent with a crushing or other mechanism that places them at increased risk
for compartment syndrome.
Patients with physical examination findings that are consistent with compartment syndrome or impending compartment
syndrome.
Patients with an abnormal neurovascular examination or an unstable spine injury.
Patients with a history of a bleeding diathesis or an abnormal coagulation profile associated with a potential risk for
the development of an injection site hematoma.
PITFALLS:
Inability to access the necessary equipment in a timely fashion. This pitfall can be avoided through communication with
the emergency department staff and the trauma team before implementation of the technique and by performing a dry
run of the procedure in the trauma bay before performing it in a tense environment with an actual trauma patient.
Local anesthetic toxicity. This pitfall can complicate regional anesthetic techniques secondary to two primary mechanisms. Either the administration of an excessive amount of local anesthetic or inadvertent intravascular injection can
result in severe patient compromise. Gross overdose is readily avoided by adhering to maximum dosing guidelines; in
this case, no more than 3 mg/kg of bupivacaine is injected into the perineural space. As an example, an 80-kg patient
may safely receive 240 mg of bupivacaine (48 mL of a 0.5% bupivacaine solution). Note that this dose represents a
true minimum toxic dose yet is >50% greater than the dose that was delivered in our study population. Substantially
lower doses can produce toxic responses if injected intravascularly. Intravascular injection is avoided by frequent aspiration for blood and incremental injection with continuous monitoring for signs of toxicity such as tinnitus, circumoral
numbness, tachycardia, nystagmus, and central nervous system excitation or depression. Current approaches to
the management of local anesthetic toxicity include the selection of less toxic alternatives, such as ropivacaine or
levobupivacaine, ultrasound guidance to identify and avoid vascular structures, and the immediate availability of a lipid
emulsion such as Intralipid (Fresenius Kabi, Uppsala, Sweden). A lipid emulsion acts as a lipid sink for the fat-soluble
local anesthetics. Use of this agent has resulted in markedly improved survival after local anesthetic overdose-induced
cardiac and central nervous system dysfunction1. Unidentified intravascular injection or gross overdose are unlikely
events when this procedure is performed while carefully following the technique as described; neither has been reported in the peer-reviewed literature, to our knowledge.
Technical pitfalls, including equipment failure. A battery that lacks a full charge or improper electrical connections can
result in inadequate current delivery and failure to elicit a twitch response. The former problem can be prevented by ensuring that the stimulator is maintained with a charged battery. The latter problem can be avoided by understanding the
circuit between the patient and the stimulator required for proper stimulator function. Current delivery depends on a
closed circuit. If the light-emitting diode fails to flash, the electrocardiogram electrode and the wire connections should
be checked.
Injection of anesthetic too far distant from the femoral nerve. As mentioned above, the branch of the femoral nerve to
the sartorius muscle tends to arise anterior to the main trunk of the femoral nerve. The sartorius twitch response is
frequently encountered en route to the true quadriceps twitch of the femoral nerve itself. Premature injection on the
sartorius twitch will result in an excellent block of the sartorius but a failed femoral nerve block, which will provide inadequate anesthesia. Elicitation of a true quadriceps twitch is essential.
continued

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CRITICAL CONCEPTS
PITFALLS (CONTINUED):
Prolonged paresthesias in the femoral nerve distribution. This complication has been reported to occur very rarely, with an
incidence of 0.03%2. Brull et al. recently reported on neurological complications after regional anesthesia3. Their review of
13,378 femoral nerve blocks from four studies revealed fifty-two instances of prolonged paresthesias and one case that
had failed to resolve completely after twelve months. The cause of this complication is most likely multifactorial and may
be due to direct nerve injury, compression by hematoma, or local anesthetic toxicity. While this complication has been
shown to be rare, it should be included in the discussion of risks and benefits with the patient.
AUTHOR UPDATE:
Current data suggest that the utilization of ultrasound-guided nerve localization hastens, simplifies, and improves the accuracy of regional anesthetic/analgesic techniques4. This technique has not been reported in the emergency department
scenario and is not currently used in our facility. Our results with the simple nerve stimulator technique for nerve localization demonstrated that this method is effective. Nevertheless, ultrasound is being used for regional anesthesia needle
guidance in the elective setting and, if it can be carried out as efficiently in the emergency department setting as is the
technique of localization with the use of the nerve stimulator, a future study comparing the effectiveness of the two techniques will be undertaken.

APPENDIX: FEMORAL NERVE


BLOCK SUPPLIES

Disposables, Hartland,
Wisconsin).

1. Peripheral nerve stimulator


(STIM300; B Braun
Medical, Bethlehem,
Pennsylvania).

7. BIOTAC Ultra 7300 series


foam electrode (two)
(#50007361; Kendall,
Mansfield, Massachusetts).

2. Stimuplex insulated needle


(STIM-A2250; B Braun
Medical, Bethlehem,
Pennsylvania).

8. Triflex sterile surgical gloves


(#2D7255; Cardinal Health,
McGaw Park, Illinois).

3. 30-mL 0.5% bupivacaine


(Marcaine; AstraZeneca,
Wilmington, Delaware).
4. 5-mL 2% lidocaine-prefilled
syringe (#3390; International
Medication Systems, South
El Monte, California).
5. 35-mL MONOJECT syringe
(#1183500777; Kendall,
Mansfield, Massachusetts).
6. Povidone iodine swabsticks
(three) (#10-4101; Triad

9. 18-gauge 1.5-in (3.8-cm)


sterile needle (#305196; BD,
Franklin Lakes, New Jersey).
10. 25-gauge 5/8-in (1.6-cm)
sterile needle (#305122;
BD, Franklin Lakes,
New Jersey).

Erik J. Jensen, MD
Michael A. Manka Jr., MD
Mark J. Anders, MD
Lawrence B. Bone, MD
Departments of Anesthesiology (E.J.J.), Emergency
Medicine (M.A.M. Jr.), and Orthopaedic Surgery
(M.J.A. and L.B.B.), Erie County Medical Center,
462 Grider Street, Buffalo, NY 14215
The line drawings in this article are the work of
Jennifer Fairman (jfairman@fairmanstudios.com).

REFERENCES
1. Whiteside J. Reversal of local anaesthetic
induced CNS toxicity with lipid emulsion. Anaesthesia. 2008;63:203-4.
2. Auroy Y, Benhamou D, Bargues L, Ecoffey
C, Falissard B, Mercier FJ, Bouaziz H, Samii
K. Major complications of regional anesthesia in France: The SOS Regional Anesthesia
Hotline Service. Anesthesiology. 2002;
97:1274-80. Erratum in: Anesthesiology.
2003;98:595.

NOTE: The authors thank Mark Barnett and Van Sikes for
their assistance with the preparation of the figures for this
article.

3. Brull R, McCartney CJ, Chan VW, El-Beheiry


H. Neurological complications after regional
anesthesia: contemporary estimates of risk.
Anesth Analg. 2007;104:965-74.

Christopher E. Mutty, MD
Department of Orthopaedic Surgery, Wake Forest
University Health Sciences, Medical Center Boulevard, Winston-Salem, NC 27157. E-mail address:
cmutty@buffalo.edu

4. Dingemans E, Williams SR, Arcand G,


Chouinard P, Harris P, Ruel M, Girard F. Neurostimulation in ultrasound-guided infraclavicular block: a prospective randomized trial.
Anesth Analg. 2007;104:1275-80.