In the inguinal region the femoral nerve (FN) runs lateral to the femoral vessels and on top of the iliopsoas muscle
The femoral nerve runs below the iliacus fascia
To reach the nerve with your needle you have to penetrate two fascia: fascia lata and the iliacus fascia
The lumbar part of the lumbosacral plexus emerges from five spinal nerves: T12, L1, L2, L3 and L4
It gives origin to three important nerves in lower limb innervation: The femoral, the obturator and the lateral femoral cutaneous nerves
The most important lumbar plexus nerve concerning basic peripheral nerve blockade is the femoral nerve
It originates from the L2, L3, and L4 spinal nerves of the lumbar plexus
The femoral nerve splits into the anterior and the posterior branch
The femoral nerve innervates the muscles in the anterior compartment of the thigh
The anterior branch of the femoral nerve innervates the sartorius muscle – and sometimes the pectineus muscle
The posterior femoral nerve branch innervates most of the muscles in the anterior compartment of the thigh – i.e. the quadriceps femoris (the rectus femoris and the three vastus muscles)
Before the femoral nerve emerges from under the inguinal ligament it also innervates the iliac muscle and the femoral artery
The femoral nerve runs below the iliacus fascia and on top of the iliacus muscle
Before inserting the needle through the skin, the hose and the needle should be filled with saline or local anaesthetic
Just after insertion of the needle 1/2 ml of fluid should be flushed through the hose and needle to make sure that no air is contained in the “system”
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In the infraclavicular block the local anaesthetic should be injected periarterially in the seven o’clock position (seeing the axillary artery as a clock face)
However, it is often necessary to reposition the needle tip in order to inject local anaesthetic periarterially from the two o’clock position around the artery to the ten o’clock position
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The medial cord is located between the axillary artery and vein around the two o’clock position of the artery
The local anaesthetic does not always spread around the artery to the two o’clock position from a seven o’clock point of injection
In that case the needle tip should be repositioned in front of the axillary artery to the interspace between the axillary artery and vein and local anaesthetic should be injected periarterially
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Repositioning of the needle tip is oftentimes necessary in order to cover all three cords around the axillary artery from two o’clock to ten o’clock
Care should be taken not to pierce the axillary vein
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In the video: Notice that local anaesthetic is injected on the wrong side of the clavipectoral fascia which has to be penetrated by the needle before local anaesthetic spreads appropriately around the medial cord
Colour Doppler can be used to visualise the proxy marker – the axillary artery – and blood vessels that you do not want to perforate with the needle
It is also possible to use colour Doppler to visualise the injection of local anaesthetic
In that case it is an advantage to lower the PRF (Pulse Repetition Frequency) in order to enhance the visibility of the injectate
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The brachial plexus innervates the entire upper limb – except part of the skin of the upper half of the medial arm which is innervated by the intercostobrachial nerve
The intercostobrachial nerve is synonymous to the lateral cutaneous branch of the second intercostal nerve
The intercostobrachial nerve joins the medial cutaneous nerve of the arm to supply the skin of the upper half of the medial arm
