It lies outside of the femoral sheath that contains the femoral vessels. knee arthroscopies, ACL reconstructions, patella ligament realignment), For anterior knee procedures: A femoral nerve block alone may suffice, For coverage of the medial aspect of the knee: Obturator nerve block should be added, For coverage of the lateral aspect of the knee: Lateral femoral cutaneous nerve block should be added, For coverage of the posterior aspect of the knee: Sciatic nerve block should be added, Anterior thigh (e.g. As the nerve is lateral to other structures, it can usually be reached without accidental vascular puncture. A guide for ultrasound guided femoral nerve blocks from Vancouver POCUS and Dr. Tommy Merth. The femoral nerve is consistently lateral to the femoral artery, deep to the fascia iliaca and superficial to the iliopsoas muscle. Place the probe along the line of the inguinal crease. FNB is given as a single injection or as continuous infusion of numbing medication in the groin area. Treasure Island (FL): StatPearls Publishing; 2020-. The transducer is placed transversely on the femoral crease, over the pulse of the femoral artery, and moved slowly in a lateral-to-medial direction to identify the artery. Position the patient supine with mild abduction of the ipsilateral leg. Table 1. Femoral Nerve Block for Total Knee Arthroplasty Paul et al. The knee joint is innervated by the femoral, obturator, and sciatic nerve. Anatomy. Sykes Z(1), Pak A(1). The femoral nerve is the largest branch of the lumbar plexus. The femoral nerve is one of the largest nerves in the body. It also innervates the hip, knee, and ankle joints (Figure 3). This adjustment helps bring out the image of the nerve, making it distinct from the background. If 2 arteries are seen, move your probe cephalad. If this is not immediately visible: Slide the transducer medially or laterally. For anterior knee procedures: A femoral nerve block alone may suffice 4; For coverage of the medial aspect of the knee: Obturator nerve block should be added 4; For coverage of the lateral aspect of the knee: Lateral femoral cutaneous nerve block should be added 4; For coverage of the posterior aspect of the knee: Sciatic nerve block should be added 4 Choose a high frequency linear probe (the femoral nerve is fairly superficial). The equipment recommended for a femoral nerve block includes the following: Learn more about Equipment for Peripheral Nerve Blocks 2019 Aug 21. Spread should be visualised below the fascia iliaca and ideally surrounding and highlighting the nerve (“doughnut sign”). With the patient in the supine position, the skin over the femoral crease is disinfected and the transducer is positioned to identify the femoral artery and nerve. Circumferential spread of local anesthetic around the nerve is not necessary for this nerve block. Femoral nerve block results in anesthesia of the anterior and medial thigh down to and including the knee, as well as a variable strip of skin on the medial leg and foot. This video describes in a practical way the steps to perform a femoral nerve block. It enters the thigh posterior to the inguinal ligament, where it is positioned immediately lateral and slightly posterior to the femoral artery (Figure 1). • With US guidance, nonstimulating catheters are used for continuous femoral nerve block. Video referent to Femoral Nerve Block in collaboration between SonoSite & Temena Group. It is the largest branch of the lumbar plexus, and arises from the dorsal divisions of the ventral rami of the second, third, and fourth lumbar nerves (L2, L3, and L4).. A line is drawn from the ASIS to the pubic tubercle, in order to outline the inguinal ligament. Femoral nerve is the major nerve supplying the anterior compartment of the thigh. Best practice will be to consult with one’s surgical colleagues as to the likelihood of compartment syndrome. skin graft from the anterior aspect of the thigh). This may be achieved by placing yourself on the side to be blocked and the machine on the far side of the patient. Applying pressure to the transducer often optimizes the image of the femoral nerve but may collapse veins, obscuring them from the examiner’s eye. Learn ultrasound anatomy of Femoral Nerve Block on NYSORA SIMULATORS™. Femoral nerve block with or without a perineural infusion provides continuous pain relief after knee replacement surgery, fractures of the femoral shaft, and skin grafts from the anterior thigh. Attention should be paid to ergonomics to facilitate successful block placement. It can also be used as an alternative to procedural sedation for patients who require a painful procedure (e.g. The goal of the continuous femoral nerve block is the placement of the catheter within the vicinity of the femoral nerve just deep to the fascia iliaca. See also. In such cases, using a wide silk tape to retract the abdomen is a useful maneuver prior to skin preparation and scanning (Figure 4). The femoral nerve is the largest branch of the lumbar plexus. The block is typically performed around the level of the inguinal crease. An In Plane, lateral to medial approach is preferred. Ultrasound-guided lateral femoral cutaneous nerve block for meralgia paresthetica. Within the femoral triangle, it divides into the anterior and posterior divisions: Sensory: Intermediate & medial cutaneous nerves of the thigh. Stimulating catheters also may lead to unnecessary needle and catheter manipulation to obtain the motor response, when in fact the catheter is often in the proper place even when there is no motor response. Commonly, the femoral artery and the deep artery of the thigh are both seen. Arthur Atchabahian, Ine Leunen, Catherine Vandepitte, and Ana M. Lopez. It is formed by the dorsal divisions of the anterior rami of the L2, L3, and L4 spinal nerves. The ultrasound (US)-guided technique of the femoral nerve blockade allows the practitioner to monitor the spread of local anesthetic and needle placement and make appropriate adjustments to accomplish the desired disposition of the local anesthetic. This nerve block typically is performed with the patient in the supine position, with the bed or table flattened to maximize operator access to the inguinal area. It is derived from the anterior rami of nerve roots L2-4. Once the needle tip is adjacent (either above, below, or lateral) to the nerve (Figure 6), and after careful aspiration, 1–2 mL of local anesthetic is injected to confirm proper needle placement (Figures 7 and 8). Femoral Nerve Block. Rapid Summary. Read more about Optimizing an Ultrasound Image. Position the ultrasound machine so that visualisation of the screen, ultrasound probe and the operator’s hands can be done without needing to turn one’s head. Medial aspect of the leg (by blocking the saphenous nerve—a terminal cutaneous branch of the femoral nerve). It is often compressed by the probe during nerve block performance; being aware of the position of the vein helps decrease the risk of inadvertent intravascular injection. Applying forceful pressure to the transducer will compress the tissue below it, making injection more difficult and possibly interfering with the spread between the fascial layers. guided Continuous Femoral Nerve Block Vs Continuous Fascia Iliaca Compartment Block for Hip Replacement in the ElderlySonoanatomy for AnaesthetistsPediatric Atlas of Ultrasound- and Nerve Stimulation-Guided Regional AnesthesiaUltrasound-Guided Regional Anesthesia in ChildrenEssentials of Trauma AnesthesiaUltrasound Guided Regional Anesthesia and Pain MedicinePediatric Emergency … 2008;106:1021-2. Femoral Nerve Block versus Spinal Anesthesia for Lower Limb Peripheral Vascular Surgery By Ahmed Mansour, MD Assistant Professor of Anesthesia, Faculty of Medicine, Alexandria University. Inject the local anaesthetic in small aliquots with intermittent aspiration, observing the image for local anaesthetic spread and the patient for signs of discomfort (if awake) or toxicity. Move your probe up and down and left to right, identifying the surrounding structures and their relationships. The femoral nerve is lateral to the vessel and covered by the fascia iliaca; it is typically hyperechoic and roughly triangular or oval in shape (Figure 2a, b). The femoral nerve branches off of the lumbar plexus and courses along the psoas muscle, before passing beneath the inguinal ligament lateral to the femoral artery within the femoral triangle. Never inject against high resistance to injection because this may signal an intrafascicular needle placement or needle tip position in a wrong fascial plane. A pool of local anesthetic immediately adjacent to either the posterolateral or the anterior aspects is sufficient. The femoral vein is typically medial to the artery, but it can occasionally lie deep or even lateral to it. Locate the femoral vein, releasing pressure on the transducer, using color Doppler if needed. Femoral nerve blockade comprises an injection of LA underneath the iliacus fascia or between two layers of the iliac fascia that envelop the femoral nerve (Figure 12.9).The block is typically performed around the level of the inguinal crease. Ultrasound Guided Femoral Nerve Blocks. It emerges from the lateral border of the psoas muscle, approximately at the junction of the middle and lower thirds of that muscle. LANDMARKS AND PATIENT POSITIONING Therefore, the transducer pressure should be released and vasculature re-ascertained before injection. Situations where dense sensory block may mask the onset of lower extremity compartment syndrome (especially if combined with a sciatic block). The femoral nerve is one of the major branches of the lumbar plexus. A 22g 50mm needle is usually adequate. Able to see the length of the needle and the needle tip during advancement. In addition, a needle passage through the fascia iliaca is often felt. Českomoravská 2510/19 The femoral nerve is the largest nerve that arises from the lumbar plexus, which forms within the body of the psoas major muscle. Sonocharacteristics of the femoral nerve: Figure 2: Sonoanatomy of the femoral nerve, Figure 3. In this video we describe the anatomy and technique for ultrasound guided blockade of the femoral and LFC nerves It is also important to follow the nerve proximally and distally to ensure that it is not a lymph node. Fresh fractures of the tibia/ fibula, or extensive and traumatic elective orthopaedic procedures to the tibia and fibula. In: StatPearls [Internet]. Femoral nerve blockade comprises an injection of LA underneath the iliacus fascia or between two layers of the iliac fascia that envelop the femoral nerve (Figure 12.9). Alternative approaches, such as the oblique approach, have also been suggested. Nerve blocks are a specific regional anesthesia technique that blocks nerve function distal to the injection site. HIghlights the anatomy and landmarks and nerve stimulator block technique of the femoral nerve. Transducer position: Transverse, inferior to the anterior superior iliac spine; the lateral edge of the sartorius muscle should be visualized with ultrasound Portions of the knee Aspirate before injection. I thought the evidence for femoral nerve blocks would have been stronger than it is. The nerve usually appears as a hyperechoic speckled triangular or oval shaped structure lateral to the artery.

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