Ultrasound Case #14 – You’re pain in my… hip
A 72 year old female with previous history of COPD and osteoporosis presents via EMS to the EC with complaints of severe left hip pain after sustaining a witnessed fall outside of home. She tells you she was trying to get the newspaper when she slipped on her icy porch and fell onto her left side. She denies any head trauma or loss of consciousness and is not on any oral anticoagulation at home. She just complains of severe hip pain. She is vitally stable, fully alert and oriented. On physical examination her left lower extremity appears deformed, externally rotated, and shorter when compared to the right. When addressing pain control with her, she reports that opioid medications “have never agreed with me” and have caused issues with breathing in the past.
What can you offer this patient for more direct, longer-acting pain control in this setting?
It is very likely that this patient is suffering from a hip fracture based on that nasty fall she took and severe hip pain. It seems that this patient has had issues with opioids for pain control. You could offer lidocaine patches and alternative IV medications such as Toradol but is that going to be enough for her? Probably not.
So what can we do? Experience has probably taught you that aside from being useful for procedural applications, nerve blocks are also great for direct analgesia! In comes the Fascia Iliaca Compartment Block, which is an (ultrasound-guided) injection of a long-acting local anesthetic into the potential space between the iliacus muscle and fascia iliaca overlying it. This space contains the femoral and lateral femoral cutaneous nerves, which provide sensory innervation to the anterior thigh, hip and medal knee/lower leg. As long as our patient here doesn’t have a crush injury, overlying cellulitis, or findings suggestive of compartment syndrome, this could be a good option for her.
Uses:
Local anesthesia, pre-reduction block (in event of hip dislocation), anterior hip, thigh, and femoral shaft surgery.
Here’s how it works: a linear probe (with indicator pointing to patient’s right) is applied transversely to the proximal anterior thigh to locate the great vessels of the lower extremity (medial to lateral: femoral vein, artery, and nerve). Once this neurovascular bundle is located, slide the probe laterally until you locate the sartorius and iliacus muscles. There will be a hyperechoic line overlying the iliacus muscle, this is the fascia iliaca (your target). After you prep the area and apply local anesthetic to your puncture site, insert the introducer needle and visualize this needle in plane with probe (as you would with longitudinal cannulation of a vessel for instance). Once visualized, advance until you are just deep to the fascia iliaca (you may feel a pop as your pass through the fascia). While you hold the needle in place, have an assistance inject around 40cc of 0.2% ropivacaine into the space. Keep your ultrasound on the area to confirm that you injected in the right spot, the fascia should hydrodissect off of the iliacus muscle just deep to it. If all goes well, the patient should have 120-360 minutes of anesthesia.