Three blocks including Pericapsular Nerve Block (PENG) for a femoral shaft fracture pain

Onur Koyuncu Sedat Hakimoğlu Sibel Tugce Polat Merve Yazıcı Kara About the authors

Most of the femoral fracture patients suffer from extreme pain in preoperative period and are exposed to high doses of opiates which have severe adverse effects. Femoral shaft fractures count 2%-6% of all femoral fractures.11 Henry SL, Seligson D. Ipsilateral femoral neck-shaft fractures. J Orthop Trauma. 1991;5:229. PENG (Pericapsular Nerve Group) block is a new published block technique (2018) and mostly used for hip surgery in the literature.22 Girón-Arango L, Peng PWH, Chin KJ, et al. Pericapsular nerve group (PENG) block for hip fracture. Reg Anesth Pain Med. 2018;43:859-63. The main neural targets of this block are the articular branches of obturator, accessory obturator and femoral nerves. Herein, we report the successful use of three blocks in the preoperative period for a femoral shaft fracture pain in a post-polio sequelae patient.

A 51 year-old patient (182 cm, 80 kg) with a fracture extending towards to the head of the femur (Fig. 1) had a complain of severe pain (NRS: 10/10). Therefore, a PENG block was performed using 20 mL of 0.25% bupivakain. Local anesthetic was injected into the musculofascial plane between the psoas muscle anteriorly and the pubic ramus posteriorly (Fig. 2). The pain score was decreased to NRS: 7/10 approximately 3 min later than the block performed. Later, fascia iliaca compartment block was performed using 30 mL of 0.25% bupivakain. The pain score was NRS: 5/10 in 5th min after the second block. And the last performed block was femoral block using 20 mL of 0.25% bupivakain. The pain score was assessed only 4/10 just after the third block and in operation theatre 1 h later. We preferred general anesthesia for the patient because the polio is a relative contraindication for spinal anesthesia.33 Neal JM, Bernards CM, Hadzic A, et al. ASRA practice advisory on neurologic complications in regional anesthesia and pain medicine. Reg Anesth Pain Med. 2008;33:404-15. Patient had general anesthesia with 100 mg tramadol for postoperative analgesia at the end of the operation. In the 24 h follow-up, there was no pain score more than 3 while sitting and lying position. The patient received only 1 g paracetamol two times and did not need any opiate use.

Figure 1
The fracture extending towards to the head of the femur.

Figure 2
Local anesthetic spread on ultrasound.

In the literature, PENG block is mostly recommended for hip fracture pain, however it is also a very effective method for the femoral shaft fracture pain control.

References

  • 1
    Henry SL, Seligson D. Ipsilateral femoral neck-shaft fractures. J Orthop Trauma. 1991;5:229.
  • 2
    Girón-Arango L, Peng PWH, Chin KJ, et al. Pericapsular nerve group (PENG) block for hip fracture. Reg Anesth Pain Med. 2018;43:859-63.
  • 3
    Neal JM, Bernards CM, Hadzic A, et al. ASRA practice advisory on neurologic complications in regional anesthesia and pain medicine. Reg Anesth Pain Med. 2008;33:404-15.

Publication Dates

  • Publication in this collection
    10 Feb 2020
  • Date of issue
    Nov-Dec 2019

History

  • Published
    18 Oct 2019
Sociedade Brasileira de Anestesiologia R. Professor Alfredo Gomes, 36, 22251-080 Botafogo RJ Brasil, Tel: +55 21 2537-8100, Fax: +55 21 2537-8188 - Campinas - SP - Brazil
E-mail: bjan@sbahq.org