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Abstract
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Background and Aims Acetabular fractures are commonly associated with severe postoperative pain, and there is currently no shared consensus regarding analgesia compared to hip fractures. The acetabulum is mainly innervated by the lumbar plexus (LP), however the posterior approach to the LP is technically difficult and associated with serious complications of spinal and epidural spread, intravascular injection with local anaesthetic systemic toxicity and retroperitoneal haemorrhage.
Methods A 62-years-old male, ASA2, 67kg, underwent open reduction internal fixation of double column acetabular fracture. Supra-inguinal fascia iliaca (FI) compartment block was performed after induction of general anaesthesia. The ultrasound probe was positioned in a parasagittal plane inferomedial to the anterior superior iliac spine, the iliacus muscle, internal oblique and sartorius forming the bow-tie sign and the deep circumflex iliac artery were identified. Needle was introduced in-plane in caudal to cranial direction, 40ml 0.3% ropivacaine was given with hydrodissection and cranial spread of local anaesthetic deep to the fascia iliaca into the iliac fossa visualised.
Results In the first 48 hours postoperatively, patient reported a numerical rating scale for pain < 4. Bromage score was 0. Multimodal analgesia was initiated with paracetamol, etoricoxib, sustained-release oxycodone/naloxone and oxycodone for breakthrough pain. Patient took total 47.5mg oxycodone. Pain control was satisfactory.
3D reconstruction of CT showing right double column acetabular fracture
X-Ray showing anatomical reduction of right acetabular fracture with plates and screws
Anatomical and ultrasound landmarks for supra-inguinal fascia iliaca compartment block (Image used with permission from Source: NYSORA.com)
Conclusions High volume supra-inguinal FI block aims to improve cranial spread of local anaesthesia high in the iliac fossa to consistently block the femoral nerve, lateral femoral cutaneous nerve and obturator nerve which contribute to acetabulum innervation. It is a safe technique that provides effective postoperative analgesia in acetabular fracture surgery.