Peripheral Nerve Blocks in Orthopaedic Trauma Surgery

Abstract and Introduction

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.

Introduction

Regional 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 appendicular skeleton, and it can be used in both acute injury and planned outpatient 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 constant 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 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 hospitalization 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.