|Level of blockade||Coverage distribution (see Chapter 140)|
- Quadriceps, sartorius muscle, anterior aspect of hip, thigh, and knee, proximal portion of tibia
- Saphenous nerve
- Lateral femoral cutaneous nerve (LFCN) most often blocked as well
- NB: Obturator nerve only rarely blocked (the “3-in-1 block” is a myth)
- Skin of medial aspect of lower leg
- Skin of lateral aspect of hip and thigh
- Femoral nerve, LFCN, and obturator nerve are branches of the lumbar plexus
- In the inguinal area, femoral nerve separated from femoral vessels by fascia iliaca (fascia of psoas–iliacus muscle). Vessels are superficial to the fascia, but the nerve is deep to it (Figure 142-1). The fascia lata is subcutaneous and superficial to all of these structures
- For the fascia iliaca compartment block (FICB), LA is injected under the fascia iliaca, lateral to the femoral nerve, and allowing it to diffuse to both the femoral nerve and the LFCN
Figure 142-1. Anatomy: Transverse Cut at the Level of the Inguinal Crease
LFCN, Lateral femoral cutaneous nerve (this nerve lies initially under the fascia iliaca; it will then traverse fascia iliaca and fascia lata to become subcutaneous); US-in plane: needle approach for the in-plane ultrasound-guided femoral nerve block; NS or US-OOP: needle approach for the neurostimulation technique or for the out-of-plane ultrasound-guided technique; FICB: needle approach for the fascia iliaca compartment block.
Surgery or postoperative analgesia in the coverage distribution of the block:
- Quadriceps tendon repair
- Knee arthroscopy
- Total knee replacement (in association with a sciatic block or spinal/general anesthesia)
- Total hip replacement (less analgesia than psoas compartment block, but lower risk of complication)
- Femoral shaft fracture/ORIF
- Harvest of skin graft from the anterior aspect of the thigh
Neurostimulation technique best not used if femoral vascular bypass (risk of graft injury).
FICB by landmarks (Figure 142-2):
- Patient supine; retract abdominal pannus with tape if needed
- Mark the anterior-superior iliac spine (ASIS) and the femoral pulse in the inguinal crease (these are not the classic landmarks, but they are easier and just as effective)
- Draw a line between the two and mark the center
- Insert needle (either a short-bevel block needle or a spinal needle) perpendicular to the skin, and elicit two “pops” (fascia lata, and then fascia iliaca). Aspirate and inject 20–30 mL of LA, in a fractionated fashion, with aspiration every 5 mL
- This block can be performed using US, but except in the obese patient in whom the pops are poorly felt, there is little advantage, as the beauty of this block lies in its simplicity, and the fact that almost no equipment is needed
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