An elderly male presents with inability to ambulate and R hip pain after sustaining a fall. His right lower extremity is shortened and rotated. Radiograph of the hip shows a femoral neck fracture (Image 1) and he is scheduled for surgery for the next day.
Image 1: Impacted right subcapital femoral fracture.
POCUS shows a nerve block needle entering the hip from lateral to medial (Clip 1 below) coursing in long axis towards the ileopubic eminence. About 20 ccs of a long acting anesthetic is injected (Clip 2 below), with successful placement evidenced by elevation of the Psoas tendon anterior off the ileopubic eminence (Clip 3 below). The patient’s pain level decreased from 10/10 to 7/10 within the first 5 minutes of PENG block administration, and he did not require oral or intravenous pain medication for 18 hours from the time of the procedure until surgery the next day.
POCUS Pearl: In line visualization of your needle is the prerequisite skill for this block and many others. You can practice this skill multiple times a shift with with difficult access ultrasound guided peripheral intravenous catheter placement.
—Dr. R Mirsky
Clip 1: In-line visualization of needle trajectory lateral to medial in front of anterior inferior iliac spine headed towards the ileopubic eminance, just lateral to the psoas tendon. Femoral vessels are medial (screen right).
Clip 2: Visualization of anesthetic being deposited postero-lateral to the Psoas tendon.
Clip 3: Here you see the rise of the Psoas tendon anterior off the ileopubic eminence as anesthetic is deposited.