Hello all! This week’s VOTW is brought to you by myself!
Hospital course
70 y/o F presented to the ED after a fall onto her left hip. XR imaging confirmed a left femoral neck fracture. Instead of using IV opioids, a PENG block was done to relieve the patient’s pain!
Ultrasound
Above we can see the important anatomical landmarks of the pericapsular nerve group (PENG) block. The femoral artery and veins (FA, FV) were identified using color doppler as shown. The bony land marks are the anterior inferior iliac spine (AIIS) and iliopubic eminence (IPE), with the ilium in between. The psoas tendon (PT) is seen along the groove created by the iliopsoas notch.
Here we can see the needle inserted under the psoas tendon with injection of local anesthetic which hydrodissects, or lifts, the psoas tendon off the bone. The spread of the local anesthetic is indicated by the dotted blue line.
See the clips to see the needle insertion and hydrodissection in action!
Case Conclusion
The patient had excellent pain relief after the PENG block and the patient was taken to the OR later that day for surgical repair.
PENG (Pericapsular Nerve Group Block) block
· This block targets the terminal sensory branches of the femoral, obturator, and accessory obturator nerves. It is ideal for pain control in the setting of intertrochanteric hip and femoral neck fractures, as well as acetabulum and pubic rami fractures. This block primarily targets sensory nerves, preserving motor function!
· The probe should first be placed in transverse orientation over the proximal thigh, inferior to the inguinal ligament. After identifying the femoral head, the probe should be moved up until the AIIS and IPE of the ilium are visualized. Key anatomical landmarks to note are the femoral artery and psoas tendon which runs along the groove created by the iliopsoas notch. In general, the femoral nerve lies above the psoas tendon, lateral to the femoral artery.
· The needle should be inserted in a lateral-to-medial approach until it contacts the ilium bone underneath the PT. Hydrodissection of local anesthetic should lift the PT off the ileum.
· When inserting the needle take care to avoid going near the femoral nerve and femoral artery!
Happy scanning!
Sono team
Resources to review:
· https://nerveblock.app/nerve-blocks/peng/
· https://www.nysora.com/education-news/the-hip-block-new-addition-to-nysoras-web-app/
· https://www.acepnow.com/article/benefits-of-using-the-pericapsular-nerve-group-peng-block/