Fascia Iliaca Block
Fascia Iliaca Block (FIB)
A structured, OSCE-ready guide for Emergency Medicine trainees performing a fascia iliaca block for
analgesia in neck of femur and femoral shaft fractures.
1. Overview & Indications
Basics
Typical OSCE scenario
“This elderly patient has a fractured neck of femur. Please demonstrate and explain how you would perform a
fascia iliaca block.”
Indications
- Neck of femur fractures
- Femoral shaft fractures
- Hip dislocation or post-operative hip pain
- Severe hip pain where opioid-sparing analgesia is desirable
Key phrase:
This is an excellent regional block for neck of femur fractures, improving analgesia and reducing opioid
requirements and delirium in elderly patients.
This is an excellent regional block for neck of femur fractures, improving analgesia and reducing opioid
requirements and delirium in elderly patients.
Contraindications
Absolute
- Patient refusal
- Allergy to local anaesthetic
- Infection at injection site
Relative
- Anticoagulation / bleeding disorder
- Significant local trauma or previous surgery
- Haemodynamic instability / inability to position safely
2. Preparation, Consent & Equipment
Setup
Equipment
- Local anaesthetic (e.g. 0.25% levobupivacaine or bupivacaine)
- 20–30 mL syringe and drawing-up needle
- Block needle (18–22G) or suitable blunt needle
- Chlorhexidine / antiseptic solution and sterile gauze
- Sterile gloves and small sterile drape
- Monitoring: ECG, BP, SpO2
- Resuscitation equipment and oxygen
- Sharps bin
- Lipid emulsion (20%) available for LAST management
Consent – suggested wording
“This is an injection of local anaesthetic into the upper thigh to numb the nerves supplying your
hip. It should significantly reduce your pain. Risks include bleeding, infection, nerve injury and
very rarely allergy or toxicity from the local anaesthetic.”
Always check for: allergies, current anticoagulant use and any previous reactions to local anaesthetics.
3. Landmark Anatomy & Technique
Landmarks
Landmark Anatomy
- Identify the anterior superior iliac spine (ASIS).
- Identify the pubic tubercle.
- Imagine a line between the ASIS and pubic tubercle (inguinal ligament).
- The injection site is 1 cm below the junction of the lateral 1/3 and medial 2/3 of this line.
The target is the fascia iliaca compartment, lateral to the femoral nerve, artery and vein, reducing risk
of vascular puncture and nerve damage.
of vascular puncture and nerve damage.
Step-by-step technique
- Perform hand hygiene, don gloves, position patient supine with leg slightly externally rotated.
- Clean skin and apply a small sterile drape.
- Infiltrate skin with a small amount of local anaesthetic if desired.
- Insert needle perpendicular to the skin at the landmark point.
- Advance slowly until you feel two distinct “pops”:
- First: fascia lata
- Second: fascia iliaca
- Aspirate to ensure you are not in a vessel.
- Inject local anaesthetic slowly, aspirating every few millilitres.
- Observe the patient and reassess pain over 10–20 minutes.
Safety phrase:
I aspirate before injection and every 5 mL thereafter to minimise the risk of intravascular injection and
local anaesthetic toxicity.
I aspirate before injection and every 5 mL thereafter to minimise the risk of intravascular injection and
local anaesthetic toxicity.
4. Local Anaesthetics & Dosing
Drugs
Commonly used agents for fascia iliaca blocks in the ED:
| Drug | Typical Concentration | Max Dose (no adrenaline) | Notes |
|---|---|---|---|
| Levobupivacaine | 0.25% – 0.5% | 2 mg/kg (max ~150 mg) | Preferred; reduced cardiotoxicity vs bupivacaine |
| Bupivacaine | 0.25% – 0.5% | 2 mg/kg (max ~150 mg) | Long-acting, more cardiotoxic than levobupivacaine |
| Ropivacaine | 0.2–0.5% | 3 mg/kg | Alternative long-acting agent |
| Lidocaine | 1% | 3 mg/kg (7 mg/kg with adrenaline) | Shorter duration; may be used when rapid offset is needed |
Typical ED regimen (adult): 20–30 mL of 0.25% levobupivacaine (2.5 mg/mL), not exceeding
2 mg/kg.
Example: 70 kg patient → max dose ≈ 140 mg. 30 mL of 0.25% levobupivacaine = 75 mg (well within safe
limits).
“For this fascia iliaca block I would use 20–30 mL of 0.25% levobupivacaine, ensuring I do not exceed
2 mg per kilogram based on the patient’s weight.”
Local Anaesthetic Systemic Toxicity (LAST): watch for tinnitus, metallic taste,
perioral tingling, agitation, seizures and cardiovascular collapse.
Treatment: stop injection, call for help, manage airway and circulation, give 20% lipid
emulsion (initial bolus 1.5 mL/kg over 1 min, then infusion 0.25 mL/kg/min as per local protocol).
perioral tingling, agitation, seizures and cardiovascular collapse.
Treatment: stop injection, call for help, manage airway and circulation, give 20% lipid
emulsion (initial bolus 1.5 mL/kg over 1 min, then infusion 0.25 mL/kg/min as per local protocol).
5. Ultrasound-Guided Technique
Ultrasound
Why use ultrasound?
- Improves accuracy and success rate of the block
- Reduces risk of intravascular injection and nerve injury
- Provides better spread of local anaesthetic and analgesic effect
Probe & view
- High-frequency linear probe, transverse orientation at the inguinal crease.
- Identify (medial → lateral): femoral vein, femoral artery, femoral nerve, iliopsoas muscle, fascia iliaca, sartorius muscle.
The goal is to place local anaesthetic beneath the fascia iliaca, superficial to the iliopsoas muscle, lateral to the femoral nerve.
Ultrasound-guided steps
- Apply sterile gel and probe cover; clean the skin.
- Optimise image to clearly see femoral vessels, nerve and fascia iliaca.
- Insert the needle in-plane from lateral to medial, aiming for the space under the fascia iliaca.
- Confirm needle tip location; inject a small test volume to see hydro-dissection beneath fascia iliaca.
- Once confirmed, inject the remaining volume while continuously visualising spread.
Expected sonographic appearance:
Local anaesthetic accumulating as a hypoechoic layer beneath the bright fascia iliaca line, lifting it from
the iliopsoas muscle.
Local anaesthetic accumulating as a hypoechoic layer beneath the bright fascia iliaca line, lifting it from
the iliopsoas muscle.
“If ultrasound is available, I would use a high-frequency linear probe to identify the femoral vessels,
femoral nerve and fascia iliaca, then advance the needle in-plane and inject under direct vision, seeing
the local anaesthetic spread beneath the fascia iliaca.”
6. Complications & Aftercare
Safety
Complications
- Local anaesthetic systemic toxicity (LAST)
- Intravascular injection
- Haematoma formation
- Infection at injection site
- Failed or incomplete block
- Rare: nerve injury
Aftercare & documentation
- Monitor vitals and pain scores regularly after the block.
- Reassess neurovascular status of the limb.
- Document drug, dose, concentration, route, side, time and operator.
- Record pain score pre- and post-block and any adverse events.
