Bilateral adductor canal block and sciatic nerve block for multiple fracture reduction in a patient affected by osteogenesis imperfecta: A case report

Abstract text (incl. references and figure legends)

A 44 year old male affected by osteogenesis imperfecta type 3 was brought to the E.R. following an inadvertent fall from his wheelchair resulting in probable multiple closed fractures of both legs. A primary survey reported a stable patient with no apparent pelvic fracture and markedly deformed lower limbs, no compound fractures were noted. A pedideal pulse was present in both feet and no nerve damage was appreciated. The NRS 10 when moved even slightly. Past medical history included numerous fractures involving all four limbs with some requiring surgery, severe deformity of both the thorax and the thoracic spinal segments; no active medication was reported. Since the patient was stable, a CT scan of the pelvis and both legs was ordered in order to clearly diagnose the fractures (fig.1). The CT reported "displaced intercondylar fracture of the left femur, displaced fracture of the left distal tibia and fibula, a displaced fracture of the right medial tibia and fibula". A full stomach was noted on the scans. The orthopedic surgeon opted for an attempt at a non-operative reduction of both fractures. The patient refused to be undressed without first receiving deep sedation or general anesthesia. The on-call anesthesiologists were consulted. Given the high risk involved in securing the airway for general anesthesia or deep sedation, a combined approach of i.v. analgesia and light sedation (RASS-1/-2) with a peripheral nerve block was chosen. A bilateral ultrasound guided abductor canal block coupled with a bilateral sciatic nerve block was performed. Both fractures were reduced and splinted, the patient reported a NRS 1 and RASS 0. The following day a perineural catheter was placed in the right abductor canal. Only one dose of PRN rescue oral opioids was requested by the patient during his stay. We showed how non O.R. regional anesthesia can be used to perform a fracture reduction in a patient with a difficult and high risk airway and limit opioid use post procedure.

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