Review Article
Preoperative Peripheral Nerve Blocks in
Orthopaedic Trauma Surgery: A Guide to
Diagnosis-Based Treatment
Downloaded from http://journals.lww.com/jaaos by g2VIwjYxOCUJeoKj3tIr1bezaSX5XiI4mfEPc9+bkpVm8YHAqD+bJH+4K15aWRjzwk4uMRvQ8ftsWYVVteh1LlwOHU5ENMjaN30HGx9ASmTrlxVbfZdueVAF3QVJy8nns42hchlFUfDR9C9Gd/r5orLnpBhpRF1m on 02/16/2022
Utku Kandemir, MD
Charles J. Cogan, MD
From the Orthopaedic Trauma Service,
Department of Orthopaedic Surgery, University
of California—San Francisco, San Francisco, CA.
Neither of the following authors nor any
immediate family member has received anything
of value from or has stock or stock options held
in a commercial company or institution related
directly or indirectly to the subject of this article:
Kandemir and Cogan.
J Am Acad Orthop Surg 2021;29:820-826
DOI: 10.5435/JAAOS-D-20-01325
Copyright 2021 by the American Academy of
Orthopaedic Surgeons.
820
JAAOS®
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
ABSTRACT
Perioperative pain management remains an important focus of both
patient and provider attention in orthopaedic trauma surgery. There is a
constant effort to improve pain management while decreasing opioid
consumption, and peripheral nerve blocks are a safe and effective way
to achieve these two goals. This is particularly relevant because more
procedures are being done in outpatient surgery centers, and the need
to safely provide analgesia without the systemic risk of opioid
medications is paramount. The primary goal of this article was to
describe the diagnosis-based approach for the utilization of
preoperative peripheral nerve blocks in perioperative care for
orthopaedic trauma surgery procedures based on the experience and
current practice at our center.
R
egional anesthesia plays an important role in orthopaedic trauma
surgery by decreasing perioperative pain, providing site-specific
analgesia, and decreasing systemic opioid consumption.1 Regional
anesthesia is broken down into neuraxial blocks, which focus on the spinal
cord and nerve roots within the thecal sac, and peripheral nerve blocks
(PNBs), where local anesthetics are used to provide analgesia to peripheral
nerves. Given the advantage of limited adverse effects and the beneficial
safety profile of regional anesthesia, PNBs are becoming increasingly more
common in the past decade.2,3 The role of PNBs is primarily in the appen-
dicular skeleton, and it can be used in both acute injury and planned out-
patient procedures, which is particularly relevant because some procedures
that were once inpatient have been moved to the outpatient setting.4
With a rising tide of opioid-related deaths and complications, there is con-
stant need for the development of new strategies to achieve pain control without
dependence on opioid medications.5 This is particularly pertinent in the United
States, where reliance on opioid medications for pain control far surpasses that
of other countries. For instance, although the United States makes up less than
5% of the global population, they account for 80% of the world’s oxycodone
consumption.6 Unfortunately, this increased opioid use has not correlated with
improved pain control.7 In addition, PNBs may help control healthcare costs,
given their potential for decreasing general anesthetic (GA) and opioid-related
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October 1, 2021, Vol 29, No 19 © American Academy of Orthopaedic Surgeons

adverse effects, shortening post-anesthesia care unit
(PACU) stay, improving operating room (OR) patient
flow, and decreasing pain-related hospital readmissions.8
One retrospective cohort analysis of more than 65,000
patients with hip fracture showed that PNB decreases
individual length of stay and associated cost of hospi-
talization by more than $1,400.9
Despite a robust body of literature supporting PNBs in
orthopaedic trauma, there is little discussion of guidelines
or algorithms for applying PNBs in a safe, standardized
fashion preoperatively.10-12 In orthopaedic trauma
surgery, it is paramount to balance the goals of pain
control and patient satisfaction with safety and accurate
monitoring of the patient’s neurovascular status. The
goal of this article was to describe an approach to the
utilization of preoperative PNBs in orthopaedic trauma
surgery based on injury diagnosis and to broadly review
the different PNBs used in orthopaedic trauma surgery.
Benefits of Peripheral Nerve Blocks
PNBs play an important role in the multimodal pain
regimen of many orthopaedic patients especially because
the scope and volume of outpatient orthopaedic proce-
dures continue to grow and there is a focus on prolonged
anesthesia without the need for inpatient monitoring.4,13
Decreased Pain and Opioid Consumption
One of the key benefits to regional anesthesia is the decreased
need for intraoperative opioid consumption. It has also
been shown in clinical studies that exposure to opioids in-
traoperatively increases postoperative severe pain and even
increases risk of chronic postoperative pain.14 The develop-
ment of opioid tolerance is a common unintended adverse
effect of opioid use, and a phenomenon known as the opioid
paradox has shown that greater intraoperative opioid use
leads to greater postoperative opioid use.15 Furthermore,
increased intraoperative use of opioids can contribute to
opioid-induced respiratory depression, which can further
complicate postoperative analgesia options.
A Cochrane review of patients undergoing major knee
surgery showed that pain scores and opioid con-
sumptions were markedly lower up to 48 hours after
surgery when receiving PNB as compared with systemic
opioids alone for pain control.16 One study, more spe-
cific to orthopaedic trauma, assessed the use of PNB in
tibial plateau fractures. Postoperative opioid con-
sumption and hospital readmission were retrospectively
evaluated for patients undergoing open reduction and
internal fixation, and they reported a mean decrease of
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JAAOS® October 1, 2021, Vol 29, No 19 © American Academy of Orthopaedic Surgeons
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Utku Kandemir, MD and Charles J. Cogan, MD
Review Article
opioid consumption of 27 mg and a mean decrease of
2.8 days hospital stay for patients who received PNB
versus those who did not.17
In addition to the aforementioned benefits of peri-
operative pain control regarding decreased acute opioid
consumption, it has also been proposed that PNBs
decrease persistent opioid use and abuse postopera-
tively.18 It is proposed that peripheral nerve blockade
reduces the risk of persistent opioid use through two
possible mechanisms, including preventative analgesia.
The first mechanism is the direct blocking of pain impulse
transmission through the local anesthesia effect and the
lack of central, pain-induced sensitization and chronic
neuropathic pain.18 The second mechanism is simply
preventing severe pain postoperatively, which itself is a
predictor of developing chronic pain.18 Interestingly,
local anesthetics have also been shown to inhibit the
inflammatory response to injury that can sensitize noci-
ceptive receptors and contribute to pain-induced sensi-
tization and postoperative hyperalgesia.19
Decreased Systemic Adverse Effects
In addition to improved perioperative pain control,
regional anesthesia has also decreased postoperative mor-
bidity compared with GA. A landmark study by Yeager
et al20 in 1987 demonstrated dramatically reduced mor-
tality for high-risk surgical patients when they underwent
epidural anesthesia compared with GA. A major con-
tributing factor is the inherent risk of GA causing cardiac
depression and hemodynamic instability because of
myocardial injury and vasodilation. Particularly in elderly
patients with poor cardiac function or polytraumatized
patients with shock physiology, these risks of GA are
notable, and the benefit of regional anesthesia is further
recognized.21 Furthermore, PNBs have demonstrated even
less hemodynamic disturbance when compared with spi-
nal anesthesia for lower extremity surgery.22
In addition, the use of PNB has been shown to decrease the
rate of postoperative nausea and vomiting as compared with
GA.16 A variety of factors can contribute to postoperative
nausea and vomiting, such as GA with inhalational anes-
thetics, ketamine, propofol, and other agents, as well as
opioid-induced nausea and vomiting, which occurs through
the stimulation of the chemoreceptor trigger zone in the
medulla.23
Decreased Perioperative Cognitive
Disturbance
Another benefit of PNBs is decreased postoperative
delirium. This is most relevant to patients with higher risk
for developing delirium, such as elderly patients with hip
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fractures, especially when they have preoperative diag-
nosis of dementia because these patients have a twofold
higher mortality risk at 1 year.24 Multiple clinical studies
have demonstrated decreased rates of delirium
throughout hospitalization with the use of fascia iliaca
block.25 This benefit is likely multifactorial, but
decreased opioid consumption and pain along with
earlier mobilization are all likely contributors.
Another interesting area of study is regarding post-
operative cognitive dysfunction (POCD). Postoperative
cognitive dysfunction is a persistent, measurable impair-
ment in cognition measured with neuropsychological
testing in an individual over time.26 This effect is distinct
from postoperative delirium, which is a waxing/waning
change in mental status. The effects of POCD are vari-
able, but it does seem to primarily affect the elderly, with
one study documenting POCD in 41% of patients aged
60 years and older.27 There remains much interest
regarding the effect of anesthetic agents and POCD;
however, there is no conclusive evidence to support the
use of GA or regional anesthesia to decrease the incidence
of POCD.26,28 Additional studies are needed in this
domain to better understand this phenomenon.
Decreased Cost of Treatment
Currently, the United States consumes 99% of the world’s
hydrocodone supply and 80% of the oxycodone; despite
this increased use, there is no corresponding improve-
ment in pain control.6 In addition, this increased reliance
on opioids has had a detrimental effect, costing the US
$50 billion annually in consequences from nonthera-
peutic opioid use.29 Through the use of PNB, there is an
opportunity to decrease the acute and long-term use of
opioids, which will promote cost savings.
Directly related to the decreased pain and opioid con-
sumption, there has been a decreased length of hospital stay
associated with PNB use.3,30 This makes pain management
crucial to both patient satisfaction and cost savings. Fur-
thermore, the improved pain control perioperatively with
continuous nerve block through peripheral nerve catheter
has driven some procedures, such as total knee arthro-
plasty and ankle fractures, to be done on an outpatient
basis. This even further drives cost savings for procedures
that are historically inpatient.
Approach for Preoperative Peripheral
Nerve Blocks
PNBs are widely used for the treatment of perioperative
pain; however, little remains published about guidelines
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for their use in the perioperative period for orthopaedic
trauma surgery. A standard approach or algorithm is
important because it creates a structure for the repro-
ducible, safe, and effective care of patients. It also helps
prevent complications associated with the inappropriate
use of PNB for certain injuries.
The approach outlined in this article was developed
in our level 1 trauma center and has currently been in use
for several years. It was developed for use in the pre-
operative setting to improve and standardize patient
care, promote efficiency of workflow, and avoid unto-
ward complications of inappropriate use. The goal is
that these nerve blocks are completed shortly before the
patient transitions from the preoperative holding area
to the OR so that when the patient is brought back into
the OR, the block is in full effect.
The indications for a preoperative nerve block at our
institution include any patient with an orthopaedic injury
of the appendicular skeleton who does not have neuro-
vascular injury or the need for ongoing monitoring for
acute compartment syndrome (ACS). We have partnered
with our colleagues in the anesthesia department to
create a set of criteria for which injuries fit these in-
dications, which are detailed below.
Our protocol is multidisciplinary with the evaluation
of both orthopaedic and regional anesthesia teams before
surgery. Some of the patients are already inpatient
because of the acuity of injury, and some of the patients
are presenting for outpatient procedure, such as may
be the case with an olecranon or ankle fracture. Re-
gardless of their disposition, all patients are first met
by the orthopaedic provider, where history and physical
examination confirm the diagnosis and site marking and
consent are done. The patient is then evaluated by the
anesthesia team, where the diagnosis-based approach in
Figure 1 helps them determine the eligibility for PNB.
One major benefit to this protocol is that the block team
can safely block the appropriate patients well before the
start of the case so that there is limited delay between
procedures.
To standardize the approach to perioperative PNB
application, the authors have devised a diagnosis-based
approach (Figure 1). They are designed to create a
preoperative workflow for the use of regional anes-
thesia in various orthopaedic trauma settings. This
figure classifies injuries into one of the three categories:
(1) green—PNB is always safe, unless medically con-
traindicated; (2) yellow—PNB should be considered,
but orthopaedic consultation is needed; and (3) red—
PNB is not recommended, unless explicitly discussed
preoperatively. The concerns for the development of
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© American Academy of Orthopaedic Surgeons
 Utku Kandemir, MD and Charles J. Cogan, MD

Review Article
Figure 1

Illustration showing the approach for preoperative peripheral nerve blocks in orthopaedic trauma surgery. PNB = peripheral nerve block

ACS or evolving neurovascular deficit are the primary
factors around the classification of injuries into one of
the three categories.
There are a few considerations to take into account
with this approach because not all patients and injuries fit
the same scenario. There are some instances where an
injury in the yellow or red group may preclude a patient
from getting a preoperative PNB because of the need for
intraoperative nerve monitoring or a postoperative neu-
rologic examination. However, in these circumstances,
the PNB can be done postoperatively after an examina-
tion has been obtained. There are also circumstances
when a PNB may be used for a sensory distribution that
provides analgesia but does not compromise neurologic
examination of other areas at risk. A good example of
this would be a femoral nerve block for tibial plateau
fractures. This would provide analgesia to the medial and
anterior knee and joint capsule while allowing the com-
partments of the leg to be examined without concern. The
time from injury to surgery may also have implications.
Although PNB may be contraindicated in most distal
radius fractures operated within 48 hours, they may be
amenable to PNB if surgery is done later. Clear com-
munication with the anesthesia team is paramount for
such circumstances that are not obvious so that patient
comfort and safety can both be optimized.
Overview of Upper and Lower Extremity
Peripheral Nerve Blocks
There are a number of factors to consider when deciding
on the appropriate PNB for a patient. The most impor-
tant factors to consider are the motor and sensory nerves
that must be affected to obtain appropriate analgesia
intraoperatively and postoperatively. One aspect of the
PNB, which will be unique to each patient and their
anatomy, is the exact location of the block (and possibly
catheter) because it relates to the skin incision and sur-
gical approach. It is important to discuss this with the

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Preoperative Nerve Block Guidelines
anesthesia team ahead of time so that all aspects of the
surgical approach are covered.
Upper Extremity Peripheral Nerve Blocks
A variety of PNBs can be used for upper extremity
orthopaedic trauma surgery, and their utility is deter-
mined based on the effective region in the brachial plexus.
Interscalene Block
Most proximal is the interscalene PNB, which targets the
roots and trunks of the brachial plexus. This is most
effective for shoulder, proximal humerus, and clavicle
injuries and their corresponding surgeries, such as open
reduction and internal fixation, irrigation and débride-
ment of the shoulder, and implant removal. The inter-
scalene block is appropriate for such proximal
procedures because the supraclavicular and supra-
scapular nerves are both captured.31 There is a phe-
nomenon, known as ulnar sparing, which is sparing of
the C8 and T1 nerve roots in this block, which makes
this technique less ideal for injuries distal to the elbow.3
Injuries that are commonly treated with this block are
clavicle fractures, shoulder dislocation, proximal
humerus fractures, scapula, and glenoid fractures.
Periclavicular Blocks
The supraclavicular nerve block targets the brachial
plexus distal trunks and divisions because they are
passing posterior to the clavicle. This block is done
between the anterior and middle scalene muscles at the
level of the first rib.3 Some argue that this block is too
distal from the cervical nerve roots to provide full
anesthesia of the superior shoulder. However, anatomic
studies have shown that local anesthetic has the
potential to migrate cephalad between the scalene
muscles to provide anesthesia to the entire arm.32 This
does make the periclavicular blocks ideal for upper
extremity injuries distal to the shoulder, especially
because there is no ulnar sparing like there is for an
interscalene block.
The infraclavicular nerve block targets the brachial
plexus at the level of the cords. As its name implies, the
anatomic target for this block is distal to the clavicle, as
such there are safety advantages of this approach, in that
incidence of the pneumothorax is much lower compared
with the supraclavicular approach;33 however, it has
even less shoulder coverage than the supraclavicular
block.3 The benefits of safety in this setting must be
weighed with less coverage for proximal procedures.
The periclavicular blocks are most commonly applied
for injuries to the humeral shaft, elbow, and forearm.
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However, caution must be taken, particularly with in-
juries to the forearm, to maintain appropriate moni-
toring for ACS.
Axillary and Suprascapular Blocks
The axillary nerve block targets the terminal branches of
the ulnar, radial, median, and musculoskeletal nerves. It
is named because of the clinical landmark for injection,
not because of the block of the axillary nerve, which it
does not target.3 For this reason, it is an effective block
for injuries distal to the axilla, but anything more
proximal will not be fully covered. For this reason, it is
common for the axillary block to be done in conjunction
with a suprascapular block for procedures involving the
shoulder.3 The shoulder is a complexly innervated
structure, with contributions from suprascapular nerve,
axillary nerve, and lateral pectoral nerves, but the
highest density of nociceptors is in the subacromial
bursa, which is innervated by the suprascapular nerve.34
Lower Extremity Peripheral Nerve Blocks
Lower extremity injuries can be treated with multiple
forms of regional anesthesia, including spinal anesthesia
and PNBs, but for the sake of this discussion, the authors
will focus on PNBs.
Fascia Iliaca Compartment Block
One of the most commonly done PNBs in acute ortho-
paedic trauma is the fascia iliaca compartment block.
This is a block of the fascia iliaca compartment, which
targets the femoral, lateral femoral cutaneous, and
obturator nerves with variable analgesia of the genito-
femoral nerve.35 This provides the sensory block to the
lateral, anterior, and medial thigh, which is effective for
proximal, midshaft, and distal femur fractures. Two
common ways to do this block are under ultrasonog-
raphy guidance or through a “loss of resistance”
technique.
Femoral Nerve Block
Femoral nerve blocks target the posterior branches of L2
to L4 nerve roots and are often used for injuries about the
anterior thigh and knee. A femoral nerve block will
provide the motor nerve blockade to the anterior com-
partment of the thigh and the sensory blockade to the
anterior thigh, medial knee, and medial leg and ankle.2
The procedure is done often with ultrasonography
guidance, given the femoral nerve’s proximity to the
femoral artery and vein, but the general landmark for
injection is at the intersection of a vertical line drawn
from the anterior superior iliac spine and a horizontal
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© American Academy of Orthopaedic Surgeons

line from the symphysis pubis.36 Femoral nerve blocks
are done most commonly for distal femur fractures and
trauma to the knee.
Saphenous Nerve Block (Adductor Canal Block)
The saphenous nerve is the largest cutaneous branch of
the femoral nerve, and it is responsible for sensation to
the medial knee, leg, and ankle. This is an ideal block for
procedures of the knee and leg, such as intraarticular
knee surgery and ankle fractures. For ankle fractures, the
saphenous nerve block is commonly paired with a pop-
liteus nerve block, which is discussed in more detail
below.
Popliteus Nerve Block
The popliteus nerve block is designed to target the sciatic
nerve because it bifurcates into the peroneal nerve and
tibial nerve in the popliteus fossa. This is a common block
for distal leg, ankle, and foot fractures or infection
because of its sensory and motor blockade to the sural,
superficial peroneal, deep peroneal, and tibial nerves. As
mentioned above, this is commonly paired with the
saphenous nerve block to provide the circumferential
sensory nerve blockade to the ankle for foot and ankle
surgery.2
Complications Associated With Peripheral
Nerve Blocks
Although PNBs have numerous benefits, they are not free
from potential risks and complications. A potential
complication with any injection is nerve injury related to
intraneural injection, which in a study of 7,000 PNBs,
there was an incidence of .04%.37,38 Specific complica-
tions associated with various PNBs are specific to their
targeted nerves. Complication associated with the in-
terscalene nerve block, for example, includes phrenic
nerve blockade, sympathetic chain blockade, recurrent
laryngeal nerve blockade, and spinal cord root injury.31
Supraclavicular nerve blocks have a lower risk of
phrenic nerve blockade because of their distance from
the nerve roots; however, they carry a higher risk of
pneumothorax, given their proximity to the pleural
apices. With all PNBs there is a risk of intravascular
injection of large blood vessels.37,39 Fortunately, the use
of ultrasonography guidance for PNB has decreased
these unintended needle puncture risks.3 Risks associ-
ated with lower extremity nerve blocks are also specific
to their targeted nerves; however, the most notable risk
is that of postprocedural falls related to the motor nerve
blockade. This has been identified as a concern partic-
ularly in the case of femoral PNB,2 and the authors
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JAAOS® October 1, 2021, Vol 29, No 19 © American Academy of Orthopaedic Surgeons
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Utku Kandemir, MD and Charles J. Cogan, MD
Review Article
recommend the use of a knee immobilizer postopera-
tively to avoid falls and fractures. The most worrisome
complication of regional anesthesia is that of local
anesthetic systemic toxicity secondary to intravascular
injection, which can range from mild systemic response
with agitation, auditory changes, or metallic taste to
severe life-threatening central nervous system or car-
diovascular complications. Fortunately, the incidence is
currently estimated to be 0.03%; however, this is a
complication that all regional anesthesia teams must be
prepared to treat with lipid infusion.40
Summary
Pain control during and after surgery remains one of the
most important factors driving patient safety and satis-
faction with orthopaedic surgery. Optimizing patient
comfort while minimizing adverse effects from systemic
opioid administration remains a challenge, and utiliza-
tion of alternative pain control strategies remains
important, with PNB being a viable alternative. Im-
plementation of guidelines and protocols for preopera-
tive PNB administration in orthopaedic trauma surgery
warrants additional consideration and study.
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