Tibial plateau fracture

[BLADEMDA]

I see quite a few of these in my practice. I used to do a Femoral plus sciatic block.
These days I'm doing an Adductor canal with a popliteal block.

My concern is that 1-2 percent of patients with a tibial plateau fracture may develop a foot drop due to injury of the common peroneal nerve. Thus, I may be asking for more liability by doing a popliteal nerve block. Perhaps, a subgluteal sciatic or high popliteal would be safer for medico-legal purposes.


Any comments?

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[BLADEMDA]

2.2.4 Tibia/fibula fractures
Fractures of the tibia and fibula may occur due to indirect (torsional injuries) or direct impact [Johner et al., 2000]. Open tibia and fibula fracture injuries occur due to high-velocity trauma, such as motor vehicle accidents [Ivarsson et al., 2008], while closed injuries occur due to falls or a sports-related injury. Isolated fibula fractures without concurrent tibial fractures are rare and usually require nonoperative treatment.
The tibia and fibula are predominantly innervated by the sciatic nerve. More proximally, the bones may receive innervation from the femoral nerve. For proximal tibia and fibula fractures, a combined femoral and sciatic nerve block is needed for more complete analgesia, especially if regional anesthesia is utilized for surgical repair Continuous blockade is the technique typically employed for proximal fractures, as many of these patients continue to have severe pain after surgical stabilization. Continuous blockade will also allow monitoring for severe pain out of proportion to what is deemed an appropriate analgesic regimen, as this may signify a developing compartment syndrome. It is important to be aware that patients with tibial fractures are at a particularly high risk of developing compartment syndrome [Park et al., 2009] (discussed in more detail below).

 

[lane]

We never blocked plateau fractures in my residency training or in private practice due to the risk of compartment syndrome, and its inability to be promptly diagnosed if the leg is numb. Do you share those reservations?

 

[sevoflurane]

I see quite a few of these in my practice. I used to do a Femoral plus sciatic block.
These days I'm doing an Adductor canal with a popliteal block.

My concern is that 1-2 percent of patients with a tibial plateau fracture may develop a foot drop due to injury of the common peroneal nerve. Thus, I may be asking for more liability by doing a popliteal nerve block. Perhaps, a subgluteal sciatic or high popliteal would be safer for medico-legal purposes.


Any comments?

You can still get foot drop with a sugluteall or high pop. So if it does present itself I think you are still going to worry a little... and the lawyers still know you have deep pockets.

Either way, my choice is high pop/low sciatic with fem. You more reliably get the patellar plexus (and more lateral coverage) with a fem. nerve block.

 

[periopdoc]

We never blocked plateau fractures in my residency training or in private practice due to the risk of compartment syndrome, and its inability to be promptly diagnosed if the leg is numb. Do you share those reservations?

I don't share that concern (ischemic pain >> proper nerve block IMHO), but many of my ortho's do/did.

If my ortho was ok with a block, I did the pop-sci block with adductor canal block with good results.

- pod

 

[sevoflurane]

We never blocked plateau fractures in my residency training or in private practice due to the risk of compartment syndrome, and its inability to be promptly diagnosed if the leg is numb. Do you share those reservations?

I used to. Not anymore. I've yet to encounter a true compartment syndrome that is masked by a regional block. I've had extensive conversations with all our senior and junior orthopods about this. They all say true compartemt syndrome always breaks through the block.

If I'm worried, I don't aim to create a surgical block... but an analgesic block instead.

 

[sevoflurane]

 

[Gaseous Clay]

I see quite a few of these in my practice. I used to do a Femoral plus sciatic block.
These days I'm doing an Adductor canal with a popliteal block.

My concern is that 1-2 percent of patients with a tibial plateau fracture may develop a foot drop due to injury of the common peroneal nerve. Thus, I may be asking for more liability by doing a popliteal nerve block. Perhaps, a subgluteal sciatic or high popliteal would be safer for medico-legal purposes.


Any comments?

Does anyone know what the likelihood a lawsuit from a neuropathy would be after surgery with a PNB? I'd imagine it'd be very difficult to prove to a jury that your PNB resulted in a foot drop or other type of nerve damage after a surgical procedure from a knife wielding surgeon. At the same time, I'd rather not find out personally.

 

[Planktonmd]

Does anyone know what the likelihood a lawsuit from a neuropathy would be after surgery with a PNB? I'd imagine it'd be very difficult to prove to a jury that your PNB resulted in a foot drop or other type of nerve damage after a surgical procedure from a knife wielding surgeon. At the same time, I'd rather not find out personally.

Actually if there is neuropathy and you have done a nerve block, you will always be the first to be blamed.
The ortho surgeon will be the first to point fingers at you.
The question whether the surgery was the cause or not, and the percentage of liability that you will be responsible for, will be decided by lawyers and eventually jurors.
The insurance company will most likely settle the case and you will be guilty of negligence.

 

[Mman]

I never do a sciatic block of any kind in a tibial plateau fracture simply because of the risk of nerve injury related the fracture and/or repair of it. I find that a femoral (or saphenous or whatever branch you want to hit) adds little benefit overall. They just don't hurt that much. I load up on adjuvants like tylenol and ketamine and then top off with iv narcotics postop and they do just fine. If the patient has a decent amount of anterior pain afterwards, I'll add a femoral block if needed, but that is quite rare IMHO.

 

[BLADEMDA]

I never do a sciatic block of any kind in a tibial plateau fracture simply because of the risk of nerve injury related the fracture and/or repair of it. I find that a femoral (or saphenous or whatever branch you want to hit) adds little benefit overall. They just don't hurt that much. I load up on adjuvants like tylenol and ketamine and then top off with iv narcotics postop and they do just fine. If the patient has a decent amount of anterior pain afterwards, I'll add a femoral block if needed, but that is quite rare IMHO.

I've had a few patients screaming in pacu after the repair of this fracture. The nerve blocks reduced their pain to zero.

I respect your opinion to not get involved with doing nerve blocks with tibial plateau fracture; but, why not at least see if a femoral block would help some? The medico legal risk from this block is minimal.

 

[BLADEMDA]

Actually if there is neuropathy and you have done a nerve block, you will always be the first to be blamed.
The ortho surgeon will be the first to point fingers at you.
The question whether the surgery was the cause or not, and the percentage of liability that you will be responsible for, will be decided by lawyers and eventually jurors.
The insurance company will most likely settle the case and you will be guilty of negligence.

If the sciatic nerve block was labat or subgluteal EEG studies would isolate the injury more distally absolving you as the cause of the neuropathy.

 

[sevoflurane]

If the sciatic nerve block was labat or subgluteal EEG studies would isolate the injury more distally absolving you as the cause of the neuropathy.

Yep. 👍

Been there after a TKA with a foot drop.

 

[sevoflurane]

Yep. 👍

Been there after a TKA with a foot drop.

I see your logic in wanting to move more proximal Blade.

 

[Planktonmd]

If the sciatic nerve block was labat or subgluteal EEG studies would isolate the injury more distally absolving you as the cause of the neuropathy.

Yes... Good luck with that 🙂
There will be two experts interpreting the nerve conduction studies: Your expert and the plaintiff's expert.
You don't win a litigation just because science says you did nothing wrong.

 

[Gas you down]

If the sciatic nerve block was labat or subgluteal EEG studies would isolate the injury more distally absolving you as the cause of the neuropathy.

i was trained similar to Lane's position, but this is interesting. i prob wont do any blocks on these routinely, but if i have someone screaming in the pacu (and the ortho comes by and checks it out first) then i may now consider fem/sciatic. nice post

 

[sevoflurane]

Yes... Good luck with that 🙂
There will be two experts interpreting the nerve conduction studies: Your expert and the plaintiff's expert.
You don't win a litigation just because science says you did nothing wrong.

Doing it more proximal is def. not going to get you out of hot water. I agree with that, but may help with the EMG studies later.

This is how my case went down (actually my wife's case years ago).

Fem, sciatic for TKA.
Foot drop POD 1,2,3...
Orthopod tries to blame it on her.
This low life writes on the neuro consult: "foot drop secondary to nerve block" 😡
Neuro consult. EMG early and later. Both come back in bold Jet style print:

FOOT DROP NOT DUE TO FEMORAL OR SCIATIC NERVE BLOCK

(we absolutely loved the consult note.... )

We still keep a copy of this consult in our office to remind him of his douche-baggyness. Almost wrote him up because of this.... probably should have, but we actually play nice in the sand box.

Lesson to be learned here?

Know your orthopods.

 

[sevoflurane]

Fortunately, our current set of orthopods are excellent at what they do and are super friendly in and out of the OR.

 

[pgg]

If the sciatic nerve block was labat or subgluteal EEG studies would isolate the injury more distally absolving you as the cause of the neuropathy.

It definitely helps. Our foot drop case from about a year ago. Short version: ACL repair, femoral + infragluteal sciatic blocks, severe foot drop, EMG clearly demonstrated lesion at the level of the knee, anesthesiologist off the hook. Glad we did an infragluteal sciatic and not something more distal.

 

[BLADEMDA]

So for Legal Purposes I'm better off doing a subgluteal sciatic block over a U/S guided popkiteal block under direct vision? How screwed up is our system.

In order to better insulate myself from a recognized complication of a Tibial Plateau fracture the patient must get NO BLOCK or a blind stab at his/her Sciatic nerve in the ass. The best care would be a u/s guided block under direct vision with the needle tip visualized the entire time.

Instead, I'm limited to a Femoral Block and no sciatic unless the patient doesn't get good relief from the Femoral block. Then, I must do a Labat, Franco, RAj/Subgluteal "blind" stick.

 

[Planktonmd]

So for Legal Purposes I'm better off doing a subgluteal sciatic block over a U/S guided popkiteal block under direct vision? How screwed up is our system.

In order to better insulate myself from a recognized complication of a Tibial Plateau fracture the patient must get NO BLOCK or a blind stab at his/her Sciatic nerve in the ass. The best care would be a u/s guided block under direct vision with the needle tip visualized the entire time.

Instead, I'm limited to a Femoral Block and no sciatic unless the patient doesn't get good relief from the Femoral block. Then, I must do a Labat, Franco, RAj/Subgluteal "blind" stick.

Exactly

 

[Mman]

I respect your opinion to not get involved with doing nerve blocks with tibial plateau fracture; but, why not at least see if a femoral block would help some? The medico legal risk from this block is minimal.

Never see the need. They just don't hurt that much when given a good multimodal analgesic approach. Pain is orders of magnitude lower than a TKA.

 

[excalibur]

So for Legal Purposes I'm better off doing a subgluteal sciatic block over a U/S guided popkiteal block under direct vision? How screwed up is our system.

In order to better insulate myself from a recognized complication of a Tibial Plateau fracture the patient must get NO BLOCK or a blind stab at his/her Sciatic nerve in the ass. The best care would be a u/s guided block under direct vision with the needle tip visualized the entire time.

Instead, I'm limited to a Femoral Block and no sciatic unless the patient doesn't get good relief from the Femoral block. Then, I must do a Labat, Franco, RAj/Subgluteal "blind" stick.

Blade, what about anterior sciatic block under US with your badass Pajunk needles? You can combine this with a femoral or the adductor canal block. That way you use ultrasound for each, you block the sciatic proximally, the needle entry points are right next to each other so the anesthesiologist doesn't have to change position, and the patient is always supine.

When we get the echogenic needles I ordered, I will explore anterior sciatic under US for reasons mentioned above.

 

[Oggg]

Let us know how anterior sciatic goes.
There is a true anterior approach, with the knee straight, and the leg either neutral or slightly internally rotated(ext?), and the there is an anteomedial approach, with the leg externally rotated and knee bent -- unfortunately, some people call this "anterior" sciatic as well (usra.ca), so you have to look at the leg positioning (it's also been called medial sciatic).

After reading neuraxiom's website, I tried it out. Keep in mind neuraxiom is written by a non CRna nurse. So the science and anatomy is not quite exact. My experience was that the nerve depth is the deepest of any block, and many patients have thunder thighs. It turns out to be quite painful. Since it is so deep, an in plane technique is almost impossible, and in plane makes the needle track even longer. You will need 10cm and 15cm needles. To make matters worse, the nerve is exceedingly hard to see with the leg straight. Neuraxiom's three methods are bull crap. If you inject in the plane after you lose direct muscle stim, you will not get a good block because you'll be outside the epineurium. He also writes about the big triangle and small triangle, but these are useless because his triangles are neither equilateral nor right angle, so even if you find two points, the third can be anywhere. For me, if I have to do a true anterior sciatic, I sedate the hell out of the pt. Use the US only for OOP guidance to avoid vessels, and to find the femur. I go right next to the femur (or walk off), and then fan laterally, using NS. I've never been able to do US only. With the antero medial approach, I can see the nerve most of the time, but I still need NS and I use OOP except in the skinniest of pts. The big downside is the frogleg positioning.

 

[sevoflurane]

Ant. sciatics are easy and as mentioned above, very nice when combining them with a fem. nerve block (saves time, efficient combo). I wouldn't do catheters, but single shots are not a problem.

The best part of this approach is that it is farthest away from the tourniquet. Therefore, foot drop from tourniquet ischemia isn't necessarily as blurred like with a subgluteal approach.

 

[excalibur]

Oggg, what type of needle were you using for your in plane anterior sciatics? Was it an echogenic needle? Obviously the angle is very steep. Also were you using a curvilinear probe? I ask because we just have a linear at my institution.

 

[imfrankie]

You folks seem to have brushed off the compartment syndrome issue. It doesn't matter whether it doesn't block ischemic pain: if the patient develops a tight compartment that isn't treated quickly enough and appropriately; guess who gets to "come on down"? You and I do.

 

[Oggg]

1. RAPM just had an article where a CPNB with 0.2%ropiv did not mask a compartment syndrome.

2. If I do an anterior or anteromedial sciatic block In Plane, I use a Sonoplex 21g x 100mm (pajunk). I rarely do these in plane.

 

[Oggg]

3. Anterior sciatic - curved probe C60.
Anteromedial sciatic - usually C60. There was a Japanese article that used an L38 with depth up to 10cm.

 

[climbingak]

So for Legal Purposes I'm better off doing a subgluteal sciatic block over a U/S guided popkiteal block under direct vision? How screwed up is our system.

In order to better insulate myself from a recognized complication of a Tibial Plateau fracture the patient must get NO BLOCK or a blind stab at his/her Sciatic nerve in the ass. The best care would be a u/s guided block under direct vision with the needle tip visualized the entire time.

Instead, I'm limited to a Femoral Block and no sciatic unless the patient doesn't get good relief from the Femoral block. Then, I must do a Labat, Franco, RAj/Subgluteal "blind" stick.

Why can't you do an ultrasound guided subgluteal sciatic block? Pretty easy to see here if you have the curvilinear probe.

Also super easy to block between the greater troch and ischial tuberosity via ultrasound.

I do one of the above for ACLs with a hamstring autograft. High popliteals sometimes dont cover the graft site for me.

 

[reanimatore]

Why can't you do an ultrasound guided subgluteal sciatic block? Pretty easy to see here if you have the curvilinear probe.

Also super easy to block between the greater troch and ischial tuberosity via ultrasound.

I do one of the above for ACLs with a hamstring autograft. High popliteals sometimes dont cover the graft site for me.

Exactly. In most patients you can see the sciatic well-delineated in between the bony landmarks you mentioned. If you're unsure of whether you're visualizing the nerve, just find it distally (in the popliteal position if needed) and scan back up keeping it in view for confirmation. If needed, the curvilinear probe will provide a more favorable angle of incidence to accommodate a steeper needle approach. In an obese or edematous patient where visualization is more challenging, you can always add in nerve stim to the US guidance for additional localization.

Downside is that you can't leave them supine for this approach.

 

[BLADEMDA]

Exactly. In most patients you can see the sciatic well-delineated in between the bony landmarks you mentioned. If you're unsure of whether you're visualizing the nerve, just find it distally (in the popliteal position if needed) and scan back up keeping it in view for confirmation. If needed, the curvilinear probe will provide a more favorable angle of incidence to accommodate a steeper needle approach. In an obese or edematous patient where visualization is more challenging, you can always add in nerve stim to the US guidance for additional localization.

Downside is that you can't leave them supine for this approach.

Or, a simple Franco or Labat Sciatic Nerve Block as I have done for over 20 years.
The Franco Sciatic Block works quite well with morbidly obese patients unlike U/S guided blocks in the Gluteal region.

 

[BLADEMDA]

 

[Oggg]

Franco's technique is to start 10cm from midline and start fishing. My impression is that this technique is for someone who is already a block wizard and can sense where the nerve should be (likely from lots of NS experience). Otherwise you could be fishing for a long time, which necessitates lots of sedation.

 

[BLADEMDA]

Franco's technique is to start 10cm from midline and start fishing. My impression is that this technique is for someone who is already a block wizard and can sense where the nerve should be (likely from lots of NS experience). Otherwise you could be fishing for a long time, which necessitates lots of sedation.

Average number of passes is 2-3 and then that is only because the morbid obesity creates a lot of difficult in getting the 10 cm mark perfectly correct.

I don't think doing any kind of high Sciatic nerve block in these morbidly obese patients will be a slam dunk all the time (even with U/S).

Nothing prevents you from marking the location of the nerve using Labat or Franco method then placing the probe over that mark. Just make sure you are using the low freq curved probe because you will need it. Depth of the nerve can easily be 10-12 cm in this subgroup.

 

[BLADEMDA]

Subgluteal U/S guided block

 

[BLADEMDA]

This block has been used by most Anesthesiologists (with a nerve stimulator) for 25 years.


http://www.nysora.com/peripheral_ne...0-sciatic-nerve-block-posterior-approach.html

 

[BLADEMDA]

http://jvsmedicscorner.com/Anaesth-Regional_Anesthesia_files/Posterior approach to sciatic nerve.pdf

Read the article. The block can bail you out when the U/S simply isn't cutting it on the obese patient.

 

[climbingak]

Or, a simple Franco or Labat Sciatic Nerve Block as I have done for over 20 years.
The Franco Sciatic Block works quite well with morbidly obese patients unlike U/S guided blocks in the Gluteal region.

Yeah you can definitely do that. Just seemed like you were fretting that you were forced into a "blind" stick. Just trying to provide other options for you.

 

[BLADEMDA]

Yeah you can definitely do that. Just seemed like you were fretting that you were forced into a "blind" stick. Just trying to provide other options for you.

I was just noting we practice based on fear of malpractice more often than we realize.
If I was in miltary medicine (or unable to be sued) I would block the Popliteal nerve every time in these patients as I believe it is the best care for the patient.

Common Peroneal nerve injury would NOT be due to an U/S guided nerve block in a patient with Tibial Fracture as this inury to the nerve is a recognized complication of the fracture.

That said, I do a selective Tibial block instead of a popliteal block for my Total knee replacement patients in order to avoid "blame" for tourniquet related sciatic nerve injury.

How many of us avoid Regional anesthesia in patients to avoid be blamed for pre-existing nerve injury or myopathy?