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We describe two cases illustrating the use of bedside ultrasonography in the trauma room, to confirm femoral fracture, and to guide accurate placement of femoral nerve block.
A 13 year old boy was brought to the emergency department (ED) by ambulance. He was undergoing leg lengthening surgery and had an external fixation device attached to his left femur. He had fallen onto his left knee at school, with subsequent pain and inability to bear weight. There was a tender swelling over the lateral supracondylar area of his left femur, with severe pain on minimal movement. Bedside ultrasonography in the ED was used to confirm the clinical suspicion of a distal femoral fracture. Ultrasonography was then used to image the anatomy of the femoral vessels in the left groin permitting identification of the correct location for placement of a femoral nerve block.
A 39 year old female pedestrian was brought to the ED by ambulance having been struck by a car while crossing a road. She was alert and complained only of pain above her right knee. Her vital signs were stable. After major truncal injury had been excluded, including the use of focused assessment by sonography in trauma (FAST), ultrasound imaging was used to confirm a distal femoral fracture (fig 1). The patient complained of severe pain despite large doses of morphine. Again ultrasound was used to locate the correct position for femoral nerve block (fig 1) providing sufficient analgesia to permit application of a traction splint and subsequent transfer for definitive radiographs.
Bedside ultrasonography is being used increasingly by emergency physicians and trauma surgeons in the ED. The FAST scan has become common practice in many trauma centres and has been shown to be accurate in detecting intraperitoneal haemorrhage.1 The use of ultrasound in the diagnosis of long bone fracture in pregnancy has also been described.2 Although ultrasound has been used to guide placement of regional nerve blocks electively,3 there are no reports of this use in the ED setting.
The cases presented illustrate how ultrasound can be used to help confirm the clinical suspicion of long bone fracture in the trauma or resuscitation room. Often the trauma patient may be haemodynamically too unstable for transfer to the radiology department, or there may be delays in obtaining limb radiographs. Confirmation of femoral fracture permits early planning for traction splint application and contributes to the resuscitative process.
The accurate placement of a femoral nerve block in this clinical setting also offers significant benefits for the patient. The traditional method of using a nerve stimulator to locate the femoral nerve can be extremely painful for the awake patient with a femoral fracture (personal observation), yet the blind introduction of local anaesthetic into the femoral region risks ineffective nerve block. Ultrasound offers a non-invasive, painless method of identifying the local anatomy, specifically the femoral vein and artery. The introduction of local anaesthetic lateral to the femoral artery can then be visualised directly, increasing the likelihood of effective block.3
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