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Peripheral nerve blocks for Tibial Plateau fracture (Technique (Femoral…
Peripheral nerve blocks for Tibial Plateau fracture
Nerves to be blocked
Lumbar plexus: femoral nerve
Sacral plexus: sciatic nerve (tibial, common peroneal) - need high approach to cover tibial plateau
Technique
Femoral nerve block
Consent, explanation, absence of CI
IV access
Approp environ with monitoring, skilled assistance, resus eqpt, drugs and recovery facilities
Position - supine
Sterile technique
Stop - timeout before you block
U/S with high freq, linear probe with depth 4cm
In plane from lateral aspect of thigh
US transducer in the transverse position at the inguinal crease, the femoral artery is identified at a depth of 2-4cm
Identify femoral nerve (on iliopsoas muscle, underneath fascia iliaca
22G 50-100mm short bevel echogenic needle
Aspirate then inject 2ml - if ok then inject 20ml 0.375 Ropiv
Endpoint - Femorl nerve lifted off iliopsoas muscle (circumferential spread around nerve not required)
Anterior approach to sciatic nerve block
Useful if cannot be positioned in lateral position
Consent, explain, absence of CI, IV access, environ (monitoring, personnel, drugs, rescue eqpt, recovery)
Position with hip abducted and hip and knee flexed
Sterile, STOP before you block
U/S with low freq, curvilinear probe with depth 8cm - with the US transducer in the transverse position on the proximal medial thigh, the sciatic nerve is identified between adductor magnus and biceps femoris muscles
22G 100mm short bevelled echogenic block needle
End point - spread of LA around Sciatic nerve
Look for plantar flexiaon/inversion of the foot (TN stim)
Other approaches to the sciatic nerve block
All in lateral decubitus position tilted slightly forward, with block side uppermost
Posterior (classic Labat) approach
Draw a line between PSIS and GT
From the midpoint of this line draw a perpendicular line extending 4cm caudal - needle point insertion
Depth 6-8cm
Transgluteal approach (US)
Transducer at gluteal crease between ischial tuberosity and greater trochanter
Sciatic nerve visualised below gluteus maximus, superior to quadratus femoris
In plane with needle lateral to probe
Subgluteal approach (U/S)
Transducer a few cm distal on posterior thigh
Sciatic nerve visualised btw gluteus maximus and quadriceps femoris
Easier - more superficial