Case 16 - Hips don't lie...
Author: Gokul Sagar Bailur Reviewer(s): Nick Mani/Nish Cherian
A 80-year old female presents with a fall and sustains a right neck of femur fracture. She has been given IV paracetamol and morphine but continues to be in pain and discomfort. The relatives and nurses are requesting more analgesia. The Trauma & Orthopaedic specialist is asking for better pain management before transfer to the ward.
You elect to perform an ultrasound-guided compartment block as part of a multi-modal pain management strategy.
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Supra-Inguinal Fascia Iliaca (SIFI) compartment block
Compared to the conventionally taught Infra-Inguinal Fascia Iliaca (IIFI), it is a more proximal approach to blocking the nerves in the compartment (femoral, lateral cutaneous, and obturator). The needle tip is also going away from the femoral vessels and much more shallow, making it an overall more effective and safer approach as shown in the literature.
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Supra-inguinal approach blocks the nerves/branches proximally, and has been shown to have a more effecive analgesia effect compared to the distal infra-inguinal approach.
The needle tip is not directly going towards the femoral vessles, therefore less risk of vascular damage/intravessel local aneasthetic injection particurarly when lose site of the needle tip. The needle tip is also much much superficial, and more likely to be visible sonographically without the need to turn on any extra features on the ultrasound machine (ie needle vis to steer the beam)
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Performed within 6hrs of the same/similar block
Infection over/around the injection site
Open wound at the site of injection/Intravenous drug user with acive injection site
Vascular surgery such as a bypass
NB anticoagulation/potent antiplatellets are ONLY a relative contraindications, much more so for supra- compared to infra-inguinal FICB. It is an absolute contraindication when the procedure is performed anatomically/blind (https://www.ra-uk.org/images/Documents/RAPAC_for_consultation.pdf)
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A - Internal Oblique Muscle
B - Sartorius Muscle
C - Iliacus Muscle
D - Fascia Iliaca
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Recording of vital signs every 5 minutes for a total of 30 minutes.
Due to possibility of opioid toxicity from removal of the pain stimulus post-block.
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Perineural (preservative free) or IV dexamethasone (max dose 8mg) has shown to significantly increase the duration of single shot block.
SONO-ANATOMY & TECHNIQUE
General Approach to Scanning for SIFI Compartment
Place the probe over the Anterior Superior Iliac Spine (ASIS) in parasagittal orientation. Slide the probe inferomedially along the inguinal ligament towards the pubic symphysis. The Anterior Inferior Iliac Spine (AIIS) is a landmark seen as a peaked hyperechoic structure.
Overlying this bony landmark is the Iliacus muscle. Looks for the ‘‘Bow-tie’’ appearance of Internal Oblique (cranially) and Sartorius muscles (caudaly). The Deep Circumflex Iliac Artery (DCIA) is usually seen superficial to the Fascia Iliaca, and is another important landmark.
Insert the needle in-plane with the ultrasound probe. Inject the local anaesthetic just cranially to the AIIS under the fascia Iliaca and observe the hydro-disection with the DCIA displaced upwards.
Image 2 - Surface Anatomy of Different Hip/Pelvis Blocks
FICB (II)- Fascia Iliaca Compartent Blcok Infra-Inguinal, FICB (SI)- Fascia iliaca Compartment Block Supra-Inguinal, FN- Femoral Nerve Block, PENG- Peri-Capsular Nerve Group Block
Image 3- Supra-inguinal (SI) Fascia Iliaca Compartment Block (FICB) (Anterior Pelvic Skeletal View)
ASIS- Anterior Superior Iliac Spine, LFCN- Lateral Femoral Cutaneous Nerve, FN- Femoral Nerve, ON- Obturator Nerve
Image 4- Ergonomicology/Safety
Patient, Performer, Assistant, Equipment, Monitoring, Check-list/Stop Before You Block
Note- the ultrasound machine is at the SAME side of the bed for this block
Image 5- Cartoon Demo of Supra-inguinal (SI) Fascia Iliaca Compartment Block (FICB) In-Plane
DCIA- Deep Circumflex Iliac Artery, PB- Pelvic Brim
SM- Sartorius Muscle, IPM- Iliopsoas Muscle, IOM- Internal Oblique Muscle, FL- Fascia Lata, FI- Fascia Iliaca
Case Resolution
The patient had effective analgesia with the US-guided SIFI block, and was admitted to the orthopaedic ward overnight and operated on the following day.
Take Home Message
Supra-inguinal FICB has shown to be more effective than infra-inguinal approach, is relatively easy to perform and safe, and is recommended for FICB.
