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Which block?
12 short patient stories. Choose the block you would offer, then see the reasoning.
Read the patient's story, choose the block you would offer, then see the reasoning. These cases are for learning: always weigh the individual patient, your own skills and your local policy. Anticoagulant timings follow the joint ESAIC/ESRA 2022 guideline.
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CASE 01
Hip fracture on apixaban
An 89-year-old woman with a fractured neck of femur arrives in the emergency department in severe pain. She takes apixaban 5 mg twice a day for atrial fibrillation; the last dose was 10 hours ago. She is frail and confused by pain.
Which block would you offer now, in the emergency department?
A fascia iliaca block is an anterior, compressible plane block that is widely used for hip fracture pain, and it reduces opioid needs and delirium. The lumbar plexus block and a spinal are deep, non-compressible procedures, so the neuraxial interval applies: 72 hours after a therapeutic dose of apixaban. Opioids alone give poorer pain relief and more confusion in frail patients.
Read more: Suprainguinal fascia iliaca · Femoral · Lumbar plexus · Anticoagulation guidelines
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CASE 02
Shoulder surgery with poor lungs
A 68-year-old man with severe COPD (FEV1 40% of predicted) is listed for arthroscopic rotator cuff repair. He becomes breathless walking across the room.
Which block gives good shoulder analgesia with the least risk to his breathing?
A standard interscalene block paralyses the hemidiaphragm in almost every patient, which he may not tolerate. Suprascapular plus axillary nerve blocks cover most of the shoulder and spare the phrenic nerve. A superior trunk block with a small volume is a reasonable alternative, with a lower but not zero risk. A supraclavicular block still often affects the diaphragm.
Read more: Suprascapular · Axillary nerve · Superior trunk · Interscalene
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CASE 03
Wrist fracture fixation
A 45-year-old woman needs plate fixation of a distal radius fracture as a day case. She would like to stay awake.
Which block would you choose for surgery?
The axillary block (a Plan A block) reliably covers the forearm and hand, including the ulnar side, and keeps clear of the phrenic nerve and the pleura. An interscalene block often misses the C8 and T1 roots, so the ulnar side of the hand may not be numb. Supraclavicular, infraclavicular and costoclavicular blocks are good alternatives.
Read more: Axillary · Supraclavicular · Infraclavicular · Costoclavicular
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CASE 04
Knee replacement, walking the same day
A fit 62-year-old man is having a total knee replacement on an enhanced recovery pathway. The physiotherapists want him walking on the day of surgery.
Which block combination gives knee analgesia and keeps his quadriceps strong?
The adductor canal block covers the front and inside of the knee (saphenous nerve and nerves to vastus medialis) with little quadriceps weakness; the IPACK block adds the back of the knee without blocking the sciatic nerve's motor fibres. A femoral or lumbar plexus block weakens the quadriceps and increases the risk of falls.
Read more: Adductor canal · IPACK · Genicular nerves · Femoral
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CASE 05
Midline laparotomy without an epidural
A 70-year-old man is having an open bowel resection through a midline incision. An epidural is not possible because of previous spinal fusion.
What would you offer for the wound?
A midline wound is supplied by the anterior branches of T7 to T12 on both sides as they enter the rectus sheath. Bilateral rectus sheath blocks, ideally with catheters for intermittent top-ups, cover it well. A single-sided block covers only half the wound.
Read more: Rectus sheath · TAP block · Quadratus lumborum
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CASE 06
Day-case inguinal hernia
A 35-year-old man is having an open repair of a right inguinal hernia as a day case.
Which block targets the nerves of the groin?
The ilioinguinal and iliohypogastric nerves supply the inguinal skin and canal. Blocking them between transversus abdominis and internal oblique, just medial to the anterior superior iliac spine, gives good analgesia. The genital branch of the genitofemoral nerve may need a separate block or local infiltration by the surgeon.
Read more: Ilioinguinal · Genitofemoral · TAP block
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CASE 07
Rib fractures on enoxaparin
A 74-year-old man has four fractured ribs on the left after a fall. He cannot cough. He had prophylactic enoxaparin 40 mg six hours ago.
Which technique could you start now?
A thoracic epidural needs 12 hours after a prophylactic dose of LMWH, and the paravertebral block is deep and non-compressible, so the same interval applies. The erector spinae plane block is a fascial plane block away from the neuraxis and major vessels; with a catheter it can be started now, after weighing the risks. A serratus anterior plane block is another option for lateral fractures.
Read more: Erector spinae plane · Serratus anterior plane · Thoracic paravertebral · Thoracic epidural · Anticoagulation guidelines
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CASE 08
Mastectomy with axillary clearance
A 52-year-old woman is having a mastectomy with axillary node clearance under general anaesthesia.
Which block covers the breast and the axilla best?
The Pecs II block includes the interpectoral injection and a second injection between pectoralis minor and serratus anterior, which reaches the lateral intercostal branches, the intercostobrachial nerve and the long thoracic nerve. Pecs I alone covers the pectoral nerves but not the axilla. A parasternal block can be added for the medial breast; serratus anterior and erector spinae blocks are alternatives.
Read more: Pectoserratus (Pecs II) · Interpectoral (Pecs I) · Serratus anterior plane · Superficial parasternal (SPIP)
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CASE 09
Ankle fracture fixation
A 40-year-old man needs open fixation of a bimalleolar ankle fracture. He has a thigh tourniquet.
Which combination covers the ankle for surgery and after?
The popliteal sciatic block covers almost all of the leg below the knee; the saphenous nerve (from the femoral nerve) supplies the skin over the medial malleolus and is blocked in the adductor canal. An ankle block is too distal for fracture fixation. The thigh tourniquet may still need general or spinal anaesthesia.
Read more: Popliteal sciatic · Adductor canal · Ankle · CAPS
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CASE 10
Hip replacement, motor sparing
A 66-year-old woman is having a total hip replacement under spinal anaesthesia. The team wants good analgesia without leg weakness.
Which block suits best?
The PENG block targets the articular branches of the femoral, obturator and accessory obturator nerves to the front of the hip capsule, with little quadriceps weakness. Adding a lateral femoral cutaneous nerve block helps with the skin incision. A femoral block weakens the quadriceps; the others do not reach the hip.
Read more: PENG · Lateral femoral cutaneous · Suprainguinal fascia iliaca
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CASE 11
Clopidogrel stopped two days ago
A 71-year-old man is listed for a total knee replacement. He stopped clopidogrel two days ago. He asks for a spinal anaesthetic.
What is the safest plan?
Clopidogrel needs to be stopped for 5 to 7 days before neuraxial or deep blocks, so a spinal, an epidural or a lumbar plexus block is not advised today. Superficial, compressible blocks such as the adductor canal and IPACK can be done after weighing the risks. Another option is to postpone surgery, after discussion with his cardiologist, if a spinal is important.
Read more: Adductor canal · IPACK · Spinal · Lumbar plexus · Anticoagulation guidelines
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CASE 12
Cardiac surgery through a sternotomy
A 64-year-old man is having coronary artery bypass grafting through a median sternotomy. He will be fully heparinised on bypass.
Which block helps with sternotomy pain?
The anterior branches of the intercostal nerves T2 to T6 supply the sternum. Bilateral parasternal blocks (superficial or deep) cover them, away from the neuraxis, and can be done after induction. A thoracic epidural carries a risk of epidural haematoma with full heparinisation. TAP blocks cover only the abdominal wall.
Read more: Superficial parasternal (SPIP) · Deep parasternal (DPIP) · Erector spinae plane
Cases written by the Nerve Blocks team for teaching. They are not a substitute for clinical judgement or local guidelines.