Techniques in Regional Anesthesia and Pain Management
Lower extremity peripheral nerve blocks in children
Section snippets
Anatomy
The femoral nerve arises from the dorsal division of the anterior rami at L2 to L4. It descends to the pelvis lateral to the psoas major muscle, passes deep to the inguinal ligament, and enters the anterior compartment of the thigh, where it divides into multiple branches supplying the muscle, joints, and skin in that region. At the level of the inguinal ligament, the femoral nerve is positioned lateral to the femoral artery.
Indications
The femoral nerve block is probably the most common peripheral nerve
Anatomy
The lateral femoral cutaneous nerve arises from the L2 and L3 roots of the lumbar plexus and is purely sensory, supplying the anterolateral aspect of the thigh down to the knee. It emerges from the lateral border of the psoas muscle and enters the thigh 1 to 2 cm medial to the anterior superior iliac crest, passing obliquely under the fascia iliaca.
Indications
This nerve block provides analgesia for muscle biopsy,7 skin grafts,8 femoral neck pinning, and femoral plate placement or removal. Blockade is also
Anatomy
Winnie and coworkers have described a newer approach to lumbar plexus block with a single injection of local anesthetic, obtaining analgesia for the femoral, lateral femoral cutaneous, and obturator nerves. In practice, due to different anatomic variants of the obturator nerve, it is difficult to obtain a good analgesia of the obturator nerve distribution by just using the 3-in-1 technique. The sensory area of the anterior branch of the obturator nerve is inconsistent at the medial side of the
Anatomy
The fascia iliaca block produces the blockade of the femoral, lateral femoral cutaneous, and obturator nerves with a single injection of local anesthetic. This nerve block was originally described by Dalens. This block is more reliable in the pediatric population, compared with the adult population.9
These nerves lie in a compartment which is bounded superficially by the fascia iliaca and iliac muscle, superiorly by the iliac crest, and deeply by the psoas muscle.
Technique
The aim of the fascia iliaca
Anatomy
The sciatic nerve is part of the sacral plexus (L4–S3 nerve roots) and is the largest peripheral nerve in the body. The sacral plexus forms on the anterior surface of the lateral sacrum and is assembled into the sciatic nerve on the ventral surface of the piriform muscle. The sciatic nerve exits the pelvis through the greater sciatic notch below the piriformis muscle, and then descends between the greater trochanter of the femur and the ischial tuberosity. The nerve runs along the posterior
Anatomy
The foot below the medial and lateral malleolus is innervated by five nerves derived from both the femoral and sciatic nerves. The medial portion of the ankle below the medial malleolus down to the sole of the foot is innervated by the saphenous nerve, a terminal branch of the femoral nerve. The remainder of the foot is innervated by four terminal branches of sciatic nerve: the sural nerve, the posterior tibial, the deep peroneal, and the superficial peroneal. The deep plantar structures,
Conclusion
Regional anesthesia for lower extremity is gaining popularity in children. The most common peripheral nerve block performed in children is a femoral nerve block. As technique and technology advance, it is easy to see how regional anesthesia can be used in children to a greater degree.
References (16)
- et al.
Ultrasonographic guidance for sciatic and femoral nerve blocks in children
Br J Anaesth
(2007) - et al.
A study of regional nerve blocks and local anesthetic creams (Prilox) for donor sites in burn patients
Burns
(2007) - et al.
Sciatic nerve blocks in children: comparison of the posterior, anterior, and lateral approaches in 180 pediatric patients
Anesth Analg
(1990) - et al.
Surface mapping of peripheral nerves in children with a nerve stimulator
Paediatr Anaesth
(2002) Continuous femoral nerve block to provide analgesia following femur fracture in a paediatric ICU population
Anaesth Intensive Care
(1994)- et al.
Emergency department use of a continuous femoral nerve block for pain relief for fractured femur in children
Emerg Med J
(2007) - et al.
Perioperative continuous peripheral nerve blocks with disposable infusion pumps in children: a prospective descriptive study
Anesth Analg
(2003) - et al.
Femoral and lateral femoral cutaneous nerve block for muscle biopsies in children
Paediatr Anaesth
(1995)