Femur Fractures
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Femoral Nerve Blocks for Femur Fractures:

     I think the benefits of FNB in the trauma patient are obvious, esp. if
multiple trauma is suspected.  You can provide significant pain relief
without sedating you patient and adversely affecting your abdominal or
neurologic examination.  In fact, you may improve the sensitivity of those
exams by eliminating a major distracting injury from the equation.  I find
that I can usually quickly draw up 10-20cc of 2% plain lidocaine and inject
the femoral nerve (1-2cm below the inguinal lig., LATERAL to the femoral
artery.  If I can elicit a paresthesia I inject all the drug at that site, if
not I inject in the general area in a fan-like fashion.  Be really careful
not to inject directly into the nerve itself or the artery or vein!)  in
~60sec--faster than the nurses can usually find and set up a Hair traction
splint if not already applied.  Once the splint is in place, I let the
lidocaine wear off (~20-30 min.) so I can reassess the limb (sensation,
etc...).  If that checks out OK and I'm not concerned about anything that
might quickly affect the exam, and Ortho has had their shot at an exam, I'll
re-inject with Marcaine for prolonged pain relief.  This block works BEST in
fractures of the middle 1/3 of the femur, but it can also be effective for
femoral neck fractures(8), and should help in more distal shaft fractures.
     Anecdotally, the first patient I tried this on came in complaining about
her leg hurting, screaming and writhing, I placed the block, and 3 minutes
later while we were applying her splint and reducing the fracture she was
complaining about how badly the Foley catheter someone was putting in hurt
instead!  I was a believer!!

Evan Fusco, M.D.

(1) Denton & Manning, _Femoral Nerve Block For Femoral Shaft Fractures In
Children: Brief Report_, J Bone & Joint Surg, 1988; 70-B:84

(2) McGlone, et al,
_Femoral_nerve_block_in_the_initial_management_of_femoral_shaft_ fractures_,
Arch. of Emerg. Med., 1987, 4, 163-168.
*These folks found that patients actually found that patients prefered FNB
over narcotic analgesia!!

(3)Berry, _Analgesia in patients with fractured shaft of femur_, Anaesthesia
1977 Jun; 32(6): 576-7.

(4)Grossbard & Love, _Femoral nerve block: a simple and safe method of
instant analgesia for femoral shaft fractures in children_, Aust N Z J Surg
1979 Oct; 49(5): 592-4.

(5)Brennan, __A case that illustrates the distinct advantages of FNB_
[letter], J Emerg. Med. 1993, Sept.-Oct.; 11(5): 623-4.

(6)Howard, et al, _Forum. Femoral Neck surgery using a local anaesthetic
technique_, Anaesthesia 1983 Oct.; 38(10): 993-4.

(7)Ronchi, et al, _FNB in children using bupivicaine_, Anesthesiology 1989
Apr.; 70(4): 622-4.
*Had 1 failure in 14 children, aveg. time to onset 8.0+/-3.5min, allowing
reduction more than  2 hours later without pain--no complications.

(8)Finlayson & Underhill, _FNB for analgesia in fractures of the femoral
neck_, Arch. Emerg. Med. 1988 Sept.; 5(3): 173-6.
*30/36 patients with subjective pain relief, 29/30 with correlating objective
findings--no complications.

(9)Tondare & Nadkarni, _FNB for fractured shaft of femur_, Can Anaestesia
Soc. J 1982 May; 29(3): 270-1.
*25/25 with good relief if fx in middle 1/3 of shaft.

(10) Grossbard & Love, _A method for providing pain relief for patients with
femoral shaft fractures_ [letter], Injury, 1981 Sept.; 13(2): 173-4.

(11) Roberts & Hedges, _Clinical Proceedures in Emergency Medicine_, 2nd
Edition, Chapter 38, pp.477-8.
*Describes the technique and precautions for the proceedure with
illustrations of the area of distribution of the nerve.