Lower extremity peripheral nerve blocks in children

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Children undergo a variety of orthopedic procedures. Although caudal block and opioids are used frequently, peripheral nerve blockade is gaining popularity in the pediatric population due to advancement in technique and technology and also due to the duration of analgesia.

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)

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