INTRODUCTION — Traumatic orthopedic injuries can range in severity from isolated wounds to complex injuries involving multiple organ systems. Patients with orthopedic injury may require anesthesia for emergency repair or damage control surgery, or for semielective procedures after evaluation and stabilization.
This topic will discuss the general approach to anesthesia for adult patients with orthopedic injuries, anesthesia for specific categories of orthopedic injury, and options for both regional and general anesthesia for these cases. Initial management of trauma in adults, damage control surgery and resuscitation, anesthesia for patients with spinal cord injury, anesthesia for patients with traumatic brain injury, and management of the difficult airway are discussed separately.
●(See "Initial management of trauma in adults".)
●(See "Anesthesia for adult trauma patients".)
●(See "Anesthesia for adults with acute spinal cord injury".)
●(See "Management of the difficult airway for general anesthesia in adults".)
●(See "Anesthesia for patients with acute traumatic brain injury".)
●(See "Severe pelvic fracture in the adult trauma patient".)
PREOPERATIVE EVALUATION — Preanesthesia evaluation of patients with orthopedic trauma should be as thorough as the urgency of the situation allows. Initial assessment should be guided by advanced trauma life support (ATLS) protocols. (See "Initial management of trauma in adults", section on 'Primary evaluation and management'.)
When possible, the full extent of the patient's injuries, course since injury, medical history, allergies, medications, and last oral intake should be reviewed. An airway assessment and directed physical examination should be performed. The patient may be unable to provide an accurate medical history because of head trauma, alcohol or illicit drug use, dementia, or severe pain.
Results of laboratory testing should be reviewed, including electrolytes, glucose, hemoglobin, platelet count, coagulation parameters, and lactate. Hemoglobin may be normal in patients who are hypovolemic, and may drop as the patient is resuscitated.
Other diagnostic studies, dictated by the patient's other injuries, should be reviewed as well. Preoperative cardiac evaluation should be guided by the patient's clinical status and cardiac risk factors. In general, preoperative cardiac testing beyond an electrocardiogram (ECG) should be performed only if it will change anesthetic or medical management. The authors have a low threshold to order a preoperative echocardiogram in older patients with suspected valve disease or dyspnea of unknown origin (see "Evaluation of cardiac risk prior to noncardiac surgery" and "Preoperative evaluation for anesthesia for noncardiac surgery", section on 'Cardiovascular disease').
Signs and symptoms of severe associated injuries may be delayed in patients who have sustained multitrauma. The anesthesia and surgical teams should maintain a high index of suspicion for pneumothorax, internal bleeding, brain injury, and pulmonary or cardiac contusion throughout the perioperative period.
TIMING OF SURGERY — Patients with orthopedic trauma should be managed according to advanced trauma life support (ATLS) protocols, which include initial evaluation, stabilization, resuscitation, and determination of the extent of injury and need for further treatment.
●Multitrauma – Unstable patients with severe trauma impacting multiple organs may be treated according to damage control protocols. For patients with orthopedic injury, this may mean initial quick application of external fixation, rather than definitive repair. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury" and "Surgical management of severe lower extremity injury", section on 'Damage control surgery'.)
●Orthopedic emergencies – Fractures that result in neurovascular compromise are true emergencies. Vascular injury can be limb-threatening and, in proximal vessels, life-threatening. Decompressive fasciotomy for compartment syndrome is also an emergent, limb-saving, and potentially life-saving procedure. Open fracture debridement should be considered an urgent but not emergency procedure. Early debridement (ie, within six hours) has not been shown to reduce the risk of infection compared with intravenous (IV) antibiotics and delayed debridement [1]. (See "Osteomyelitis associated with open fractures in adults".)
●Nonemergent injury – For those whose initial or definitive surgery can be delayed, the patient should be physiologically stabilized and medically evaluated prior to entering the operating room. This includes older patients with hip fracture. In general, we perform surgery for hip fracture within 24 to 48 hours for patients who are medically stable, without significant comorbid illness. We wait up to 72 hours for surgery in patients with active comorbidity who would benefit from preoperative medical evaluation and management. Medical evaluation for patients with hip fracture is discussed more fully separately. (See "Hip fracture in adults: Epidemiology and medical management".)
Surgery that is urgent should not be delayed to allow the stomach to empty. Pain and opioid medications slow or stop gastric emptying; the fasting interval should be the time between last oral intake and the injury. Therefore, most patients with orthopedic trauma are at risk for aspiration during induction of anesthesia and should be managed with rapid sequence induction and intubation (RSII). (See "Rapid sequence induction and intubation (RSII) for anesthesia".)
SURGICAL COORDINATION — Preoperative multidisciplinary communication among the anesthesia and surgery teams should be comprehensive and include the following:
●The planned procedure or procedures, and sequence of procedures, including the early placement of continuous peripheral nerve blocks for pain control prior to definitive procedure
●Urgency of surgery
●Intraoperative positioning
●Expected blood loss
●Expected duration of surgery
●Use of tourniquet
CHOICE OF ANESTHETIC TECHNIQUE — The choice of anesthetic technique (ie, general anesthesia, neuraxial anesthesia, or peripheral nerve block) depends on the planned procedures and patient factors, including comorbidities. As examples, neuraxial and regional anesthesia may be beneficial for patients with severe reactive airway disease in order to avoid airway manipulation for general anesthesia. In contrast, the sympathectomy that results from spinal anesthesia may cause severe hypotension for patients with aortic stenosis or unresuscitated hypovolemia. (See "Overview of neuraxial anesthesia", section on 'Physiologic effects of neuraxial anesthesia' and "Anesthesia for adult patients with asthma", section on 'Choice of anesthetic technique'.)
Regional anesthesia may be beneficial, even if it is not the primary surgical anesthetic, as part of a balanced anesthetic along with general anesthesia to reduce intraoperative and postoperative opioid requirements. Regional anesthesia for specific categories of injuries is discussed below and is shown in a table (table 1). (See 'Anesthesia for upper extremity trauma' below and 'Anesthesia for lower extremity trauma' below and 'Pelvic fracture' below.)
General concerns related to the choice of anesthetic technique for orthopedic trauma include the following:
●Multiple injuries – General anesthesia is used for most cases of emergent severe multitrauma and for surgery on more than one area of the body. If RA is employed, multiple sites of orthopedic injury may increase the risk of a wrong-sided block. Generally, the use of continuous RA to control pain in a single extremity is inappropriate when high-dose opioids are required for other injuries.
●Patient cooperation – Patients who are intoxicated, under the influence of illicit drugs, or in severe pain may be unable to cooperate with placement of neuraxial or regional anesthetic blocks. If deep sedation is required either to perform regional anesthesia or during surgery, the risk of aspiration may be high; general endotracheal anesthesia may be preferred for such patients.
●Positioning – Pain or potential for aggravating an injury may make positioning for block placement impossible or inadvisable. However, peripheral nerve block may be used for pain relief to allow positioning for neuraxial anesthesia (eg, femoral block to allow positioning for spinal anesthesia for hip or femur fracture).
In addition, the position for surgery may be uncomfortable and may require deep sedation or general anesthesia.
●Hypovolemia – Preoperative hypovolemia or the expectation of significant intraoperative blood loss may preclude the use of neuraxial anesthesia. Neuraxial techniques cause a sympathectomy that can result in severe hypotension, especially in hypovolemic patients. (See "Spinal anesthesia: Technique", section on 'Hemodynamic management'.)
●Coagulopathy – Neuraxial anesthesia and some regional anesthesia techniques are relatively contraindicated for patients with coagulopathy, which can be the result of anticoagulant or antiplatelet medication, medical disorders, or coagulation abnormalities related to their injuries. Patients may be coagulopathic because of hypothermia or hemodilution from initial trauma resuscitative measures, or due to aggressive deep vein thrombosis (DVT) prophylaxis in these high-risk patients. (See "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication".)
Use of antifibrinolytics, most commonly tranexamic acid (TXA), early after major trauma (eg, pelvic, hip, or femur fracture) may help reduce blood loss and transfusion. This is discussed separately. (See "Coagulopathy in trauma patients", section on 'Management of fibrinolysis' and "Perioperative blood management: Strategies to minimize transfusions", section on 'Antifibrinolytic agents'.)
The plan for postoperative anticoagulation should be coordinated with the surgeon when regional anesthesia is considered.
●Postoperative pain control – RA may be placed for postoperative pain control, even if general anesthesia is used for the primary surgery. Single-injection nerve block can provide pain control for positioning or for the immediate postoperative period, but generally, continuous techniques with epidural or peripheral nerve block catheters are indicated. Patients with a single site of severe pain may benefit from continuous RA techniques while awaiting surgery, to improve mobility and reduce the sympathetic response to pain [2].
The use of opioid and nonopioid analgesics for perioperative pain control (eg, lidocaine infusion, ketamine, gabapentinoids, acetaminophen and nonsteroidal anti-inflammatory drugs [NSAIDs]) is discussed separately. (See "Nonopioid pharmacotherapy for acute pain in adults".)
●Trauma-related nerve injury – Orthopedic trauma may cause nerve injury, which should be documented preoperatively. If regional anesthesia is considered, the potential for masking trauma-related nerve injury or intraoperative nerve injury due to surgery should be discussed with the patient and the surgeon.
●Tourniquet pain – Tourniquet pain is a potent stimulus that increases over time and can break through otherwise adequate sensory peripheral nerve block or neuraxial anesthesia [3]. Beyond 90 minutes of tourniquet time, supplementation with systemic opioid or general anesthesia may be required.
●Intraoperative monitoring – Transesophageal echocardiography (TEE) may help guide fluid therapy and can be used to monitor for embolic phenomena associated with the fracture itself, debris from placement of a prosthesis or intramedullary rod, and air embolism from open venous sinuses. General anesthesia is required for the use of TEE.
ANESTHESIA FOR UPPER EXTREMITY TRAUMA — Upper extremity injury may include trauma from the clavicle to the wrist.
Proximal upper extremity fractures — Proximal upper extremity orthopedic injuries include clavicle fractures, acromioclavicular joint injuries, shoulder dislocations, and proximal humerus fracture.
●Choice of anesthetic technique – General anesthesia is required for surgery for proximal and mid clavicle fracture. Peripheral nerve blocks can provide anesthesia for surgery on the distal clavicle, though in practice, general anesthesia is often preferred by patients and clinicians because the surgical field is very close to the face and airway (table 1).
The distal clavicle and the anterior superior shoulder are innervated by both the cervical plexus and the brachial plexus. Interscalene block (ISB) can be used for anesthesia and postoperative analgesia for distal clavicle or shoulder surgery, since it may include the supraclavicular branch of the superficial cervical plexus. If a very low volume of local anesthetic (LA) solution is used for ISB to avoid phrenic nerve block, the superficial cervical plexus may be missed, and a separate injection may be required.
The recently introduced clavipectoral block provides analgesia for midclavicular and distal fracture with motor sparing effects. For this block local anesthetic is deposited on both sides of a clavicle fracture deep to the clavipectoral fascia compartment. The superficial cervical plexus is also missed with this block and may require supplementation (table 1). (See "Upper extremity nerve blocks: Techniques", section on 'Brachial plexus blocks'.)
●Associated injuries – Some proximal upper extremity injuries are associated with specific nerve damage, which should be documented preoperatively. Trauma of the clavicle and/or first rib may be associated with brachial plexus injury. Severe acromioclavicular joint separation can result in mechanical stretch injury of the brachial plexus, and humeral neck fractures are associated with axillary nerve trauma.
Clavicle fracture is also associated with injury of the subclavian artery. Screws used for plating of the proximal clavicle may be placed near the subclavian artery. Significant hemorrhage may occur intraoperatively, either during fracture manipulation or hardware placement.
●Shoulder dislocation – Immediate relocation of a shoulder can often be performed using shoulder manipulation techniques without the use of sedatives, analgesics, or LAs. (See "Shoulder dislocation and reduction", section on 'Reduction procedure'.)
Procedural sedation or intraarticular injection of LA may also be used. (See "Shoulder dislocation and reduction", section on 'Analgesia and sedation'.)
If anesthesia is required, options include short acting ISB (eg, with 1% lidocaine) or a brief general anesthetic. Prolonged dense regional block is not advised, as the dislocation may recur with the muscle relaxation associated with the block, and prolonged pain relief is not required. Once the shoulder is relocated, pain dissipates quickly.
Neuromuscular blocking agents (NMBAs) are not usually required for shoulder relocation during general anesthesia. If necessary, succinylcholine should be used, or a small dose of a vecuronium or rocuronium reversed with sugammadex, to avoid prolonged neuromuscular block after this brief procedure. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Succinylcholine' and "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Sugammadex'.)
Midhumerus fracture — Most proximal and midshaft humerus fractures are nondisplaced and are treated conservatively. However, there are a number of indications for surgery for these injuries, including open fractures, neurovascular compromise, and excessive angulation. (See "Midshaft humerus fractures in adults", section on 'Orthopedic consultation or referral'.)
●Choice of anesthetic technique – Either general or regional anesthesia may be used for isolated midhumeral shaft fracture. Brachial plexus block using an interscalene, supraclavicular, or infraclavicular approach may be used, supplemented with an intercostobrachial nerve block (table 1).
Continuous supraclavicular or infraclavicular block may be performed for postoperative pain control.
Phrenic nerve block is almost universal with standard dose interscalene block, common with supraclavicular block, and less likely but possible with infraclavicular block. The resulting hemidiaphragmatic paralysis may be poorly tolerated in patients with poor pulmonary reserve. Techniques for these blocks and phrenic nerve block as a side effect are discussed separately.
•(See "Interscalene block procedure guide".)
•(See "Upper extremity nerve blocks: Techniques", section on 'Supraclavicular block'.)
•(See "Infraclavicular brachial plexus block procedure guide".)
•(See "Upper extremity nerve blocks: Techniques", section on 'Intercostobrachial nerve block'.)
●Associated injury – Radial nerve injury occurs in approximately 11 percent of midshaft fractures. Deficits should be documented preoperatively and discussed with the surgeon and patient prior to peripheral nerve block. (See "Midshaft humerus fractures in adults", section on 'Radial nerve injury'.)
Elbow fracture — Either general or regional anesthesia may be used for fractures around the elbow (ie, distal humerus, proximal radius or ulna). Brachial plexus block using supraclavicular, infraclavicular, or axillary approaches may be used, supplemented with an intercostobrachial block (table 1). (See "Upper extremity nerve blocks: Techniques".)
When the patient will be placed in the lateral position for surgery, general anesthesia may be preferred for the following reasons:
●The patient may face away from the anesthesia clinician, which makes access to the airway difficult
●The lateral position may be uncomfortable for the patient, especially during longer procedures
●The surgical drapes and the surgeons may be very close to the patient's face
Fracture distal to the elbow — Distal upper extremity fractures include injuries of the radius, ulna, wrist, and hand.
●Choice of anesthetic technique – Either general or regional anesthesia can be used for distal procedures on the upper extremity. Supraclavicular, infraclavicular, and axillary brachial plexus blocks can be performed for these patients [4]. In our experience, a tourniquet is well tolerated without the addition of an intercostobrachial block for tourniquet times less than 75 to 90 minutes (table 1) [5]. (See "Upper extremity nerve blocks: Techniques", section on 'Interscalene block' and "Upper extremity nerve blocks: Techniques", section on 'Supraclavicular block' and "Upper extremity nerve blocks: Techniques", section on 'Infraclavicular block' and "Upper extremity nerve blocks: Techniques", section on 'Axillary block'.)
A continuous nerve block with a perineural catheter may be particularly beneficial after upper extremity reimplantation surgery, as the sympathectomy associated with the block may improve blood flow across vascular anastomoses.
Closed reduction of phalanx fractures can often be performed with a digital block. (See "Digital nerve block".)
●Associated injuries – Median nerve injury, manifested as acute carpal tunnel syndrome, may occur with distal radius fracture and is most common with severely comminuted or displaced fractures, or after multiple reductions. (See "Distal radius fractures in adults", section on 'Early complications'.)
Nerve deficit should be documented and discussed with the patient and surgeon prior to performing a peripheral nerve block.
Compartment syndrome may rarely occur after distal radial fracture and should be suspected with increasing severe pain 12 to 48 hours after injury. (See "Distal radius fractures in adults", section on 'Early complications'.)
When continuous block is performed for postoperative pain, low-dose LA (eg, 0.1% bupivacaine or 0.2% ropivacaine) should be used, rather than more concentrated solutions, to facilitate assessment for compartment syndrome.
ANESTHESIA FOR LOWER EXTREMITY TRAUMA — This section will discuss the anesthetic concerns for orthopedic injuries from the hip to the ankle. Acetabular fracture is discussed separately. (See 'Pelvic fracture' below.)
Hip fracture — Hip fracture is a common injury that often occurs in older patients with multiple comorbidities. Most fractures are repaired surgically to provide analgesia, facilitate mobilization and rehabilitation, and thereby reduce the risk of complications, including deep vein thrombosis (DVT), pneumonia, and decubitus ulcers. Surgical repair may include a variety of procedures with a range of complexity and blood loss, including percutaneous pinning, open reduction and internal fixation (ORIF), hemiarthroplasty, and total hip replacement.
We usually perform surgery early after injury to improve outcomes, preferably within 24 to 48 hours for patients who are medically stable and within 72 hours for those who would likely benefit from medical evaluation and management prior to surgery. Timing of surgery for hip fracture is discussed separately (see "Hip fracture in adults: Epidemiology and medical management", section on 'Timing of surgical intervention').
Surgery for periprosthetic fractures is longer and involves greater blood loss and use of large volumes of cement for fixation. In one study, patients with periprosthetic fractures had higher inpatient mortality, longer duration of hospital stay, and greater dependency on discharge, though the study did not specify how many were hip fractures [6].
The epidemiology, risk factors, types of fractures, and preoperative medical evaluation of these patients are discussed separately. (See "Overview of common hip fractures in adults" and "Hip fracture in adults: Epidemiology and medical management".)
Enhanced recovery protocols for hip fracture — Enhanced recovery after surgery protocols may result in reduced hospital length of stays and improved outcomes [7]. Principles and components of ERAS protocols are discussed separately. (See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)".)
ERAS components specific to anesthesia for hip fracture include the following:
●Preoperative
•Use preoperative multimodal analgesia that includes regional anesthesia (eg, femoral nerve block, fascia iliaca block, pericapsular nerve group [PENG] block) and minimize opioids.
•Maintain preoperative hydration. Avoid prolonged preoperative fasting, but recognize that gastric motility may be altered in patients with hip fracture.
●Intraoperative
•Minimize postoperative nausea and vomiting (PONV), using anesthetic techniques that reduce PONV (ie, neuraxial anesthesia or total intravenous anesthesia), and prophylaxis. Avoid anticholinergic and antihistamine antiemetics in older patients, due to increased risk of confusion or agitation.
•Individualize fluid management, use of tranexamic acid for reduced blood loss, and targets for glycemic control.
●Postoperative
•Use a multimodal opioid sparing analgesic strategy including peripheral nerve blocks when possible, nonopioid analgesics (eg, acetaminophen and/or nonsteroidal anti-inflammatory drugs), and possibly tramadol, adjusted for patient factors. (See "Management of acute perioperative pain in adults", section on 'Strategy for perioperative pain control' and 'Peripheral nerve blocks for hip fracture' below.)
•Avoid gabapentinoids in older patients and concomitantly with other sedatives and respiratory depressants.
Choice of anesthetic technique for hip fracture — Options for anesthesia for hip fracture repair include general anesthesia and neuraxial anesthesia (table 1). Peripheral nerve blocks are options for postoperative analgesia, as discussed below. The choice of anesthetic technique should be based on patient comorbidities and the anticipated procedure; for patients in whom either general or neuraxial anesthesia would be appropriate, we suggest neuraxial anesthesia. Compared with general anesthesia, neuraxial anesthesia may allow earlier return to baseline mental status in the immediate postoperative period due to lower doses of systemic anesthetics and reduced need for postoperative mechanical ventilation, which may improve postoperative outcomes. In addition, neuraxial anesthesia has less of an impact on the environment. (See 'Choice of anesthetic technique' above.)
The influence of anesthetic technique for hip fracture on postoperative morbidity and mortality has been a subject of study for decades. Retrospective studies suggest benefits of neuraxial anesthesia compared with general anesthesia, whereas randomized trials have found similar outcomes with the two techniques. Although widely subscribed to by surgeons and anesthesiologists, the use of neuraxial techniques (avoidance of general anesthesia) to reduce the incidence of cognitive dysfunction in older patients with hip fractures is not supported by evidence [8]. The effects of other aspects of anesthetic technique on the incidence of postoperative delirium are discussed separately. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Choice of anesthetic technique'.)
●Observational studies – Several large retrospective studies have reported a reduction in pulmonary complications and mortality with regional anesthesia compared with general anesthesia for hip fracture [9,10]. As an example, a propensity score matched pairs cohort study including over 1700 patients who underwent surgery for hip fracture found a weak association between spinal anesthesia and lower 90-day mortality, compared with general anesthesia (risk ratio 0.74, 95% CI 0.48-1.0) [11]. In this study, spinal anesthesia was also associated with reduced rates of pulmonary embolism and major blood loss, and reduced length of hospital stay.
In a large database study of patients who underwent surgery for hip fracture, use of neuraxial anesthesia was associated with a slight decrease in postoperative delirium (odds ratio 0.91, 95% CI 0.85-0.91), though conclusions from this study are limited by its retrospective nature [12].
Analysis of prospectively collected observational data on over 11,000 hip fracture surgeries reported no difference in mortality at 5 or 30 days between spinal and general anesthesia [13]. Intraoperative hypotension with either technique was associated with an increase in mortality.
●Randomized trials – In a multi-institutional trial (Regional versus General Anesthesia for Promoting Independence after Hip Fracture [REGAIN]) including approximately 1600 patients over the age of 50 who underwent surgery for hip fracture between 2016 and 2021 and were randomly assigned to spinal versus general anesthesia, death and ability to walk at 60 days postoperatively, postoperative delirium and time to discharge were similar in the two groups [14]. In this study, shorter term outcomes such as death during hospitalization, acute kidney injury, and critical care admission appeared more favorable in the spinal anesthetic group, though these outcomes were not analyzed statistically. Limitations of this study include a large screening:recruitment ratio, a significant amount of missing data, and significant crossover between groups (15 percent conversion to general anesthesia in the spinal anesthesia group and 3.5 percent change to spinal anesthesia in the general anesthesia group), all of which raise questions about generalizability.
In a secondary analysis of the REGAIN trial data, there was a statistically significant but clinically unimportant increase in pain the first 24 hours after surgery in patients who had spinal anesthesia (7.9 versus 7.6, mean difference 0.4, 95% CI 0.12-0.68, on a 0 to 10 scale), with similar pain at other time points [15]. Conclusions are limited by lack of information on the type and dose of drugs that were used for spinal anesthesia (long versus shorter acting) and the perioperative multimodal regimen, which would affect the degree of pain after the spinal anesthetic resolved.
A meta-analysis of small randomized trials found similar rates of postoperative pneumonia, myocardial infarction, risk of DVT when prophylaxis was used, confusion, or mortality at one month in patients who received general versus regional anesthesia though the quality of data was judged to be low [16].
General anesthesia may be preferable for hip fracture in the following clinical scenarios, in addition to others related to the patient's medical status (see 'Choice of anesthetic technique' above):
●Patients for whom deep sedation would be required for placement of a regional anesthetic or for the patient to tolerate the position for surgery (eg, because of dependent shoulder pain in the lateral position).
●Patients who are receiving anticoagulant or antiplatelet medication or who are coagulopathic for other reasons, such that neuraxial anesthesia and deep peripheral nerve blocks are relatively contraindicated. (See "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication" and "Lower extremity nerve blocks: Techniques", section on 'Side effects and complications'.)
●Longer surgical procedures and those with expected major blood loss (eg, repair of periprosthetic fracture).
General anesthesia — Induction and maintenance of general anesthesia are discussed separately. (See "Induction of general anesthesia: Overview" and "Maintenance of general anesthesia: Overview".)
Neuraxial anesthesia — Single-shot spinal, continuous spinal anesthesia (CSA), epidural, and combined spinal-epidural (CSE) anesthesia neuraxial techniques can be used for hip fracture.
Choice of neuraxial technique
●Single-injection spinal is technically easier to perform than continuous spinal or epidural, and is the most commonly used neuraxial technique for hip fracture. Single injection spinal can result in abrupt, sometimes severe hypotension, especially in older or hypovolemic patients with high spinal block. Thus, patients should be volume resuscitated as necessary to achieve euvolemia prior to spinal injection, and blood pressure should be monitored closely, often with intraarterial catheters.
●Single injection spinal anesthesia can be technically challenging in elderly patients with spinal deformities and suboptimal positioning due to pain. Larger bore spinal needles (eg, 22- to 24-gauge) needles may provide better tactile feedback and higher spinal anesthetic success rates than smaller needles. We typically use pencil point needles rather than cutting tip needles, particularly with larger gauge needles, to reduce the risk of postdural puncture headache. (See "Post dural puncture headache", section on 'Procedural risk factors'.)
●CSA with an intrathecal catheter allows titration of the anesthetic level and the sympathectomy associated with spinal anesthesia, and may reduce the incidence and severity of hypotension [17,18]. CSA allows the use of a lower initial dose of local anesthetic, and extension of the anesthetic when necessary. However, CSA is technically more difficult than single-injection spinal and is associated with a higher risk of block failure, paresthesias, and bloody tap [19]. Postdural puncture headache, which is more likely with CSA than single-shot spinal, is less common in older patients and is thus less of a concern in patients with hip fracture.
●Spinal anesthesia provides greater motor relaxation and is less subject to unilateral blockade compared with epidural anesthesia [20].
●Combined spinal-epidural anesthesia using a sequential technique results in less hypotension than single shot spinal. Sequential CSE involves injection of only a portion of the usual single shot spinal dose of local anesthetic (LA; usually half), with subsequent epidural injections (eg, 3 to 5 mL LA) titrated to achieve adequate surgical anesthesia. (See "Epidural and combined spinal-epidural anesthesia: Techniques", section on 'Dose of spinal drugs'.)
●In our experience, epidural block is less reliable in older patients than spinal anesthesia because the loss of resistance that identifies the epidural space tends to be less clear in older patients than in younger patients. In addition, LA may spread less extensively in the epidural space in older patients. Epidural anesthesia may provide less motor block than spinal anesthesia.
Spinal anesthesia — A T10 spinal level is required for hip fracture repair. (See "Spinal anesthesia: Technique", section on 'Spinal injection' and "Spinal anesthesia: Technique", section on 'Continuous spinal'.)
●Avoiding hypotension – We follow the following steps to reduce the incidence of severe hypotension and other complications of spinal anesthesia in older orthopedic patients:
•Aim for a spinal level no higher than low thoracic, using an appropriate LA dose (eg, 7.5 to 15 mg bupivacaine). Isobaric bupivacaine can provide reliable anesthesia without need for changes in patient positioning. (See "Spinal anesthesia: Technique", section on 'Baricity' and "Spinal anesthesia: Technique", section on 'Choice of spinal drugs'.)
•Ensure euvolemia prior to spinal injection.
•Avoid abrupt head-up positioning.
•Treat reduction in blood pressure (BP) immediately, with intravenous (IV) fluid and vasopressors (eg, phenylephrine 40 to 80 mcg IV bolus or infusion, or ephedrine 5 to 10 mg IV bolus titrated to effect). In patients with heart failure, the use of inotropes and vasopressors is preferable to IV fluids.
For those at high risk of severe hypotension as a result of the sympathectomy that accompanies spinal anesthesia (especially older, frail female patients), we prefer CSA with incremental dosing (eg, bupivacaine 5 mg subarachnoid bolus with subsequent 2.5 mg boluses repeated at three- to five-minute intervals as necessary). Dosing for CSA should be performed in the operating room with appropriate hemodynamic monitoring and assessment of the level of the block.
●Intrathecal morphine or hydromorphone – Intrathecal hydrophilic opioids (ie, morphine or hydromorphone) may be options for postoperative analgesia for hip arthroplasty. Morphine is more commonly used; a dose of 100 mcg of intrathecal morphine may provide improved analgesia up to 16 hours after injection, but with increased risks of pruritus, sedation, and nausea and vomiting [21]. Use of intrathecal morphine may be limited by the need for close monitoring for respiratory depression (every 1 to 2 hours) in the first 24 hours after injection [22]. Thus, intrathecal morphine would not be appropriate for patients admitted to lower intensity monitored settings.
Epidural anesthesia — Lumbar epidural anesthesia can also be used for hip fracture repair. Similar to CSA, the sensory level and sympathetic block can be achieved gradually with an epidural catheter. In contrast with CSA, an epidural catheter can remain in place for several days after surgery for postoperative pain control. Intraoperatively, high-concentration LA (eg, 0.75% ropivacaine, 0.25 to 0.5% bupivacaine, or 1.5 to 2% lidocaine up to 10 to 12 mL in divided doses) is administered with or without opioid (eg, fentanyl 50 to 100 mcg), with vasoconstrictors, such as phenylephrine or epinephrine to enhance anesthesia and motor block for hip surgery. (See "Epidural and combined spinal-epidural anesthesia: Techniques", section on 'Adjuvants'.)
Removal of the epidural catheter must be coordinated with postoperative administration of anticoagulant and antiplatelet drugs. (See "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication".)
Combined spinal–epidural — CSE anesthesia provides the dense symmetric block from the spinal injection with the option to extend the analgesia and provide postoperative pain control with the epidural catheter. The epidural catheter in this setting is untested until it is activated, during or after the resolution of the spinal block.
Peripheral nerve blocks for hip fracture — In general, peripheral nerve blocks do not reliably provide surgical anesthesia for hip fracture surgery because of inadequate coverage of both cutaneous and bony innervation. The hip joint receives innervation from the femoral, obturator, sciatic, and superior gluteal nerves. Branches from the femoral and obturator nerves to the hip joint branch off proximal to the inguinal ligament. In addition, cutaneous innervation is derived from the low thoracic to upper lumbar nerve roots. Paravertebral blocks, or combined psoas compartment/sciatic nerve blocks, can provide anesthesia for the lower extremity caudal to the inguinal ligament and have been used for hip fracture repair in selected patients as an alternative to spinal anesthesia [23,24].
Preoperative analgesia — Peripheral nerve blocks may be performed to provide analgesia for hip fracture prior to surgery [25], and have been used where available in prehospital and emergency department settings (see "Overview of common hip fractures in adults", section on 'Initial assessment and medical management').
Options for preoperative analgesia are those blocks that include components of the femoral nerve (ie, femoral nerve block, fascia iliaca block, lumbar plexus block or continuous epidural analgesia, and the pericapsular nerve group [PENG] block [26-28]). (See "Lower extremity nerve blocks: Techniques" and "Epidural and combined spinal-epidural anesthesia: Techniques".)
Continuous nerve blocks may be particularly beneficial if surgical repair cannot be performed within 24 hours of fracture, since single-injection blocks rarely provide analgesia for more than 16 to 20 hours.
Intraoperative and postoperative analgesia — Peripheral nerve blocks can also be used for intraoperative and postoperative analgesia, for selected patients who undergo hip fracture surgery:
●Peripheral nerve blocks in combination with general anesthesia can reduce intraoperative opioid requirements and the stress response to surgical pain [29,30].
●Single-injection peripheral nerve block can be performed for analgesia during positioning for a neuraxial technique [25,31,32].
●Continuous block can be performed for postoperative analgesia.
The decision to use peripheral nerve blocks for intraoperative and postoperative pain control should be individualized, and practice varies. For many patients, the pain after hip fracture surgery, whether ORIF, percutaneous pinning, or arthroplasty, is managed adequately and safely with multimodal pain control strategies without the use of regional analgesia techniques [33,34]. In a single institution randomized trial of 60 patients who underwent hip arthroplasty with a multimodal analgesic regimen including acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), ketamine, dexmedetomidine, dexamethasone, and local anesthetic infiltration intraoperatively, the addition of a subpectineal obturator block did not reduce opioid consumption and pain scores in the first 24 hours after surgery [34].
However, especially in older patients, the authors use regional analgesia techniques as part of a multimodal strategy for limiting systemic analgesics. For patients who would particularly benefit from peripheral nerve block, we prefer the following peripheral nerve blocks: (table 1):
●Percutaneous nail or ORIF – Peripheral nerve blocks for analgesia after percutaneous femoral nail or ORIF should block the femoral nerve, similar to the options for preoperative analgesia. We perform continuous femoral nerve block with the catheter tunneled cephalad and medially, out of the surgical field. We choose femoral block for these procedures because it is generally effective, easily performed, and is safer than psoas compartment block. (See "Lower extremity nerve blocks: Techniques", section on 'Perineural catheter femoral block'.)
●Partial or total hip arthroplasty – Nerve block for postoperative analgesia after hip arthroplasty should provide coverage for sensory innervation of the anterior hip capsule and acetabulum, which usually includes branches of the femoral and obturator nerves. Options include epidural analgesia, lumbar plexus block, fascia iliaca block, and lumbar paravertebral block. For patients with contraindications to these proximal regional anesthesia techniques (eg, coagulopathy, spine abnormalities or instrumentation), options include a more distal femoral nerve block combined with a subpectineal obturator block and/or a PENG block, and/or local anesthetic infiltration intraoperatively by the surgical team. (See "Epidural and combined spinal-epidural anesthesia: Techniques" and "Lower extremity nerve blocks: Techniques", section on 'Perineural catheter lumbar plexus block'.)
Lumbar plexus and lumbar paravertebral blocks are deep, advanced-level blocks that should only be performed by experienced clinicians, and are associated with a high risk of complications. They are relatively contraindicated for patients with abnormal clotting function. These blocks also require large volumes of LA and may result in high plasma LA levels. Older patients and those with decreased cardiovascular reserve may be at higher risk of LA systemic toxicity (LAST) with these blocks. (See "Overview of peripheral nerve blocks", section on 'Local anesthetic systemic toxicity' and "Lower extremity nerve blocks: Techniques", section on 'Lumbar plexus (psoas compartment) block'.)
A fascia iliaca block can be used for coverage of branches of the femoral and lateral femoral cutaneous nerve. Obturator nerve coverage may be less reliable with this block. Fascia iliaca blocks can be performed with a suprainguinal or infrainguinal approach. The purported advantage of the suprainguinal approach is that the local anesthetic may more reliably spread to the more proximal branches of the femoral nerve to the iliacus muscle and acetabulum as well as the lateral femoral cutaneous nerve before it exits this plane [35]. (See "Lower extremity nerve blocks: Techniques", section on 'Ultrasound-guided fascial iliaca block'.)
If a nerve block or epidural is placed postoperatively, the proceduralist must be cautious with patient positioning to avoid hip subluxation. Hip subluxation is most common with the posterior approach to hip replacement; positioning should avoid flexion, adduction, and internal rotation of the hip. In patients with anterior approaches to the hip arthroplasty, positioning should avoid hip extension, external rotation, and adduction. Older patients and those with neurologic disorders that affect muscle tension are at higher risk for dislocation after arthroplasty (eg, Parkinson disease and cerebral palsy) [36-38].
For patients who cannot have peripheral nerve blocks or who refuse, intrathecal morphine is another option for postoperative analgesia. (See 'Spinal anesthesia' above.)
Monitoring — Continuous intraarterial BP monitoring for older patients who undergo anesthesia for hip fracture surgery is frequently indicated based on the patient's comorbidities and current hemodynamic status. Intraarterial monitoring allows rapid treatment of hemodynamic changes and facilitates blood sampling during surgery.
Positioning — Positioning for repair of hip fracture depends on the planned procedure and the need for fluoroscopy.
Percutaneous pinning and ORIF are often performed with the patient on a fracture table. With this apparatus, the patient lies supine with the operative leg secured in a foot boot and the opposite leg on a support, flexed at the hip and knee. The arm on the operative side is draped across the chest, and the perineum rests against a padded post (figure 1). For arthroplasty, the patient is usually placed in the lateral decubitus position with the operative side up. Older patients are at high risk of pressure-related skin and nerve injury; pressure points must be meticulously padded for these patients.
Midshaft and distal femur fracture — Femoral shaft fractures are often the result of severe trauma or motor vehicle accidents in young patients and are commonly associated with other injuries. Femoral fracture is treated with intramedullary nailing or with ORIF. An external fixator may be placed as a temporary treatment. This section will discuss anesthesia for this injury. The epidemiology and management of midshaft femur fracture are discussed separately. (See "Midshaft femur fractures in adults".)
●Choice of anesthetic technique – General anesthesia, neuraxial anesthesia, and peripheral nerve block can be used for isolated repair of femur fracture. The choice of technique should be based on patient factors and the planned procedure (table 1). (See 'Choice of anesthetic technique' above.)
•Neuraxial anesthesia (ie, spinal, epidural, or combined spinal epidural anesthesia) may be used for surgical repair. Epidural analgesia can be extended into the postoperative period for pain control and must be coordinated with administration of anticoagulant medication for thromboprophylaxis. (See "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication".)
•The lower extremity distal to the groin is innervated by the femoral nerve, lateral femoral cutaneous nerve, obturator nerve, and sciatic nerve. These individual nerves can be blocked to provide complete anesthesia for surgery distal to the groin. (See "Lower extremity nerve blocks: Techniques", section on 'Femoral nerve block' and "Lower extremity nerve blocks: Techniques", section on 'Fascia iliaca (lateral femoral cutaneous) block' and "Lower extremity nerve blocks: Techniques", section on 'Obturator nerve block' and "Sciatic blocks procedure guide".)
A perineural catheter can be placed for continuous femoral block for postoperative pain control. For distal femur surgery, a single-injection or continuous sciatic block may be required in addition to femoral block. (See "Lower extremity nerve blocks: Techniques", section on 'Perineural catheter femoral block'.)
●Fat embolism – Subclinical fat embolism occurs in most patients with long bone fractures and rarely results in fat embolism syndrome. (See 'Fat embolism' below and "Fat embolism syndrome".)
Knee and lower leg fracture — Injuries at or below the knee may result from high-energy trauma, sports injury, or repetitive impact injury. Closed tibial shaft fracture is the most common long bone fracture in adults and children. (See "Overview of tibial fractures in adults", section on 'Epidemiology'.)
●Choice of anesthetic technique – Choices and considerations for the type of anesthetic technique are similar to those that apply to distal femur fracture. If epidural analgesia or anesthesia are used, the catheter should be placed at a low lumbar level (eg, L4-5) to maximize the chance that the required sacral nerve roots will be blocked (table 1). (See 'Midshaft and distal femur fracture' above and "Lower extremity nerve blocks: Techniques", section on 'Innervation: Lower extremity' and "Epidural and combined spinal-epidural anesthesia: Techniques", section on 'Spinal versus epidural anesthesia'.)
The lower extremity below the knee is innervated by the sciatic nerve, with the exception of a strip of medial skin innervated by the saphenous nerve. When supplemented by femoral or saphenous nerve blocks, sciatic nerve block provides analgesia for surgery on the knee, lateral calf, ankle, and foot. (See "Sciatic blocks procedure guide".)
For peripheral nerve block when a thigh tourniquet is used for surgery below the knee, the femoral nerve, lateral femoral cutaneous nerve, obturator nerve, and sciatic nerves must all be blocked if coverage of tourniquet pain is desired.
Indwelling perineural catheters can be placed for continuous sciatic nerve block (either at the popliteal fossa or the proximal thigh) for prolonged postoperative analgesia after knee, lower leg, ankle, or foot surgery. For knee surgery, a continuous femoral nerve block would be required as well, for more complete analgesia. (See "Sciatic blocks procedure guide", section on 'Continuous sciatic nerve block'.)
●Compartment syndrome – Fractures of the tibia, fibula, and, to a lesser extent, the ankle may result in compartment syndrome. Compartment syndrome is a condition whereby tissue ischemia can occur as a result of elevated pressures within a closed, osteofascial compartment that can lead to muscle necrosis and loss of limb. The incidence has been quoted to be 4 to 5 percent in patients with tibial fractures, particularly complex, proximal/midshaft open fractures of the tibia. Compartment syndrome should be suspected with increasing pain, decreased pulses, and tense swelling of affected muscles. Use of regional anesthesia for patients at high risk for compartment syndrome has been controversial due to concerns of masking symptoms of compartment syndrome such as paresthesia and paralysis. Low concentration and stable doses (ie, avoiding boluses) of LAs can be used for continuous nerve block for postoperative pain [39-43]. However, the use of regional anesthesia in these patients requires vigilance for early detection of compartment syndrome. The pain associated with compartment syndrome is usually out of proportion to what is expected of the injury and pain on passive stretch of muscles in the compartment. This pain is usually refractory to low-density regional anesthetic blocks. Measuring compartment pressures may provide a more objective measure of tissue ischemia, though measurements may not be reliable, and there is no consensus on threshold pressures that indicate the need for surgical exploration and fasciotomy [43,44]. (See "Overview of tibial fractures in adults", section on 'Acute compartment syndrome'.)
Ankle and foot fractures — Isolated ankle and foot fractures are increasingly common injuries and are associated with obesity and cigarette smoking. Open or unstable ankle fractures and those with neurovascular compromise often require surgical repair. Fracture dislocations require immediate reduction to prevent severe complications, such as avascular necrosis. (See "Ankle fractures in adults", section on 'Epidemiology and risk factors' and "Ankle fractures in adults", section on 'Complications'.)
●Choice of anesthetic technique – Ankle and foot fractures are highly amenable to regional anesthesia techniques. The combination of a saphenous nerve block (either femoral or adductor canal) and sciatic nerve block (either proximal or at the popliteal fossa) should be adequate for surgical anesthesia and analgesia (table 1) [45].
A thigh tourniquet may be tolerated for up to 60 to 90 minutes with light to moderate sedation, even with a more distal block (popliteal/saphenous). For less pain-tolerant patients or for longer surgical procedures, more proximal blocks (eg, combined spinal and femoral), general anesthesia, spinal anesthesia, or deep sedation may be required to address tourniquet pain.
●Associated injury – Compartment syndrome can occur but is less likely after ankle fracture than after tibial shaft or fibula fracture.
PELVIC FRACTURE — Pelvic injuries range from benign to life-threatening; severe pelvic fracture can result in massive retroperitoneal or intraperitoneal hemorrhage. Pelvic fractures include pelvic ring fractures, acetabular fractures, and avulsion injuries. Patients with these injuries may require anesthesia for arterial embolization, stabilization with external fixation, preperitoneal packing, or laparotomy for internal fixation. The primary anesthetic concern for all of these procedures is the potential for severe hemorrhage.
Pelvic fractures are usually caused by high-energy trauma (eg, motor vehicle accidents) and are often associated with other severe injuries that may affect anesthetic management (eg, head injury, thoracic injury, intraabdominal organ injury, other fractures). Initial evaluation and stabilization are discussed separately. (See "Severe pelvic fracture in the adult trauma patient" and "Pelvic trauma: Initial evaluation and management".)
Pelvic fracture may be complicated by fat embolism and may result in fat embolism syndrome. (See 'Fat embolism' below and "Fat embolism syndrome".)
Anesthetic concerns specific to pelvic fracture include the following:
●Choice of anesthetic technique – General anesthesia is preferred for patients with pelvic fracture. The choice of induction and maintenance techniques and medications must be individualized based on comorbidities, associated injuries, and the urgency of the situation. (See 'Choice of anesthetic technique' above and "Induction of general anesthesia: Overview" and "Rapid sequence induction and intubation (RSII) for anesthesia" and "Maintenance of general anesthesia: Overview".)
Regional anesthesia/analgesia techniques are rarely indicated for pelvic fracture for a variety of reasons, including associated spinal injuries and the potential for massive bleeding and coagulopathy (table 1).
●Venous access – Large-bore intravenous (IV) catheters (eg, 14- or 16-gauge), rapid infusion catheters, or central venous catheters should be placed for pelvic fracture repair to facilitate resuscitation. A fluid warmer should be placed in line to help maintain normothermia with large fluid administration.
●Monitoring – In addition to standard American Society of Anesthesiologists (ASA) monitors (ie, blood pressure [BP], electrocardiogram [ECG], pulse oximetry, oxygen analyzer, end-tidal carbon dioxide [ETCO2], temperature), we place an arterial catheter for patients with pelvic fracture for continuous BP monitoring and to facilitate blood sampling. Repeated measurement of hemoglobin, coagulation parameters, platelet count, electrolytes, blood gases, and lactate is often indicated.
We place other monitors (eg, transesophageal echocardiogram [TEE], intracranial pressure monitor, pulmonary artery catheter) when appropriate, based on clinical factors and comorbidities.
●Fluid management and transfusion – Volume resuscitation for patients with severe trauma, including pelvic fracture, starts in the field or emergency department (ED), but may continue into the operating room. For severe pelvic trauma, large volume resuscitation with IV crystalloid and blood products may be required. If a massive transfusion protocol is in place, it should be activated for the presence or likelihood of severe hemorrhage. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient".)
The optimal goal for hemoglobin in these patients is unclear and depends on multiple factors, including comorbidities, associated injuries, and ongoing blood loss. In other clinical settings, hemoglobin thresholds of 7 to 8 gm/dL for transfusion are often used in healthy patients without cardiac or cerebrovascular disease. However, large-volume blood transfusion in the critically-ill, hemodynamically-unstable patient cannot be guided by hemoglobin levels alone and often cannot await interval measurements of hemoglobin. We typically aim to maintain a hemoglobin >10 g/dL during initial resuscitation and with significant ongoing blood loss, and modify the target down as bleeding slows. (See "Indications and hemoglobin thresholds for red blood cell transfusion in the adult", section on 'Trauma/massive transfusion'.)
Patients with severe trauma and hemorrhage are at risk for trauma or transfusion-related coagulopathy. We follow a damage control approach to these patients and transfuse fresh frozen plasma (in units), red blood cells (in units), and platelets (in units) in a 1:1:1 ratio. (See "Massive blood transfusion", section on 'Trauma'.)
The benefits of tranexamic acid in this patient population have not been firmly established. In trauma patients in general, we suggest administration of tranexamic acid to patients with active hemorrhage, guided by thromboelastography or thromboelastometry, where available (figure 2), and empirically where those monitoring modalities are not available. Use of tranexamic acid during hemorrhage associated with trauma is discussed separately. (See "Coagulopathy in trauma patients", section on 'Thromboelastography-based fibrinolytic phenotypes'.)
●Management of postoperative pain – Regional anesthesia techniques for postoperative pain are not usually practical for patients with pelvic fracture, at least during initial stabilization. We follow a multimodal approach to intraoperative and postoperative pain management for these patients including nonopioid and opioid medications, avoiding nonsteroidal antiinflammatory drugs (NSAIDS) because of their antiplatelet effects. (See "Management of acute perioperative pain in adults" and "Management of acute perioperative pain in adults", section on 'Therapeutic options'.)
●Postoperative disposition – Many patients with severe pelvic fracture require intensive care after surgery because of hemodynamic instability, coagulation abnormalities, ongoing transfusion requirement, or for airway management. The decision to extubate these patients at the end of anesthesia must be individualized based on clinical factors, including the risk of airway edema related to massive volume resuscitation.
FAT EMBOLISM — Subclinical fat embolism occurs in the majority of patients with long bone fractures. Fat embolism syndrome occurs in approximately 0.5 percent of these patients and is more common with bilateral fractures, during reaming for femoral intramedullary nailing [46], and with delayed surgery [47]. Fat embolism syndrome is also associated with pelvic fracture. (See "Fat embolism syndrome".)
Signs and symptoms of fat embolism are nonspecific. Fat embolism should be suspected with sudden intraoperative hypoxia and tachycardia and with neurologic symptoms in awake patients (eg, headache or confusion). Treatment is supportive; rarely, fat embolism syndrome progresses to adult respiratory distress syndrome and multiorgan failure.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Local and regional anesthesia".)
SUMMARY AND RECOMMENDATIONS
●Choice of anesthetic technique – The choice of anesthetic technique should be based on the planned procedures and patient factors (table 1). (See 'Choice of anesthetic technique' above.)
•General anesthesia is usually preferred for uncooperative patients, those with emergent severe multitrauma, those requiring procedures on multiple body areas, and when there is a contraindication to neuraxial or peripheral nerve block (eg, coagulopathy).
Most patients with orthopedic trauma are nonfasting and therefore at risk for aspiration during induction of general anesthesia; such patients should be managed with rapid sequence induction and intubation (RSII).
•Peripheral nerve blocks can be used for surgical anesthesia and for postoperative pain management, and as a supplement to general anesthesia, for upper extremity and lower extremity surgery. (See 'Anesthesia for upper extremity trauma' above and 'Anesthesia for lower extremity trauma' above.)
•Neuraxial anesthesia (ie, spinal, epidural, or combined spinal–epidural [CSE]) can be used for hip and other lower extremity surgery. (See 'Anesthesia for lower extremity trauma' above.)
●Complications of orthopedic trauma – Some orthopedic injuries are associated with specific complications in the perioperative period, and may affect anesthetic care.
•Fat embolism occurs with many long bone and pelvic fractures; most are subclinical, but fat embolism syndrome can occur and is most common with bilateral femur fracture, during reaming for intramedullary rodding, and with delayed surgery. Fat embolism should be suspected with sudden onset of intraoperative hypoxia and tachycardia and with neurologic symptoms in awake patients. (See 'Fat embolism' above.)
•Compartment syndrome can occur with fractures of the tibia and fibula and, more rarely, with distal radius and ankle fractures. When continuous nerve block is performed for postoperative pain, dilute local anesthetic (LA) solutions should be administered for at-risk patients to facilitate evaluation for compartment syndrome. (See 'Fracture distal to the elbow' above and 'Knee and lower leg fracture' above.)
•Fractures are associated with preoperative and surgical injury of nerves near the fracture site. Neurologic deficits should be documented preoperatively and discussed when peripheral nerve block is planned. (See 'Midhumerus fracture' above and 'Proximal upper extremity fractures' above and 'Fracture distal to the elbow' above.)
●Hip fracture – Patients with hip fracture are often older, with comorbidities. The choice of anesthetic technique for these patients should be based on the planned procedure and patient factors. The benefits of regional anesthesia compared with general anesthesia are controversial.
For patients in whom either general or neuraxial anesthesia would be appropriate for hip fracture surgery, we suggest neuraxial anesthesia. (Grade 2C) Compared with general anesthesia, neuraxial anesthesia may allow earlier return to baseline mental status immediately after surgery and reduced need for postoperative mechanical ventilation which may improve postoperative outcomes. Single-injection spinal is the most commonly used neuraxial technique for hip fracture repair. (See 'Choice of anesthetic technique for hip fracture' above.)
●Pelvic fracture – Pelvic fractures are often associated with other traumatic injuries and may cause life-threatening hemorrhage. General anesthesia is usually preferred for damage control surgery (eg, external fixation or preperitoneal packing), arterial embolization, or open internal fixation. Massive transfusion may be required. (See 'Pelvic fracture' above.)
