Case study: Bimalleolar fracture

Case presentation

A 70-year-old patient with a history of renal insufficiency presented at our facility with a bimalleolar fracture. The patient was scheduled for the removal of an external fixator, followed by open reduction and internal fixation (ORIF) in the prone position. Importantly, the patient expressed a preference to avoid general anesthesia.

Anesthesia plan

Given the patient’s preference and medical history, the anesthesia team opted for a combination of spinal anesthesia and a peripheral nerve block. Initially, spinal anesthesia was administered using 10 mg (2 mL) of isobaric bupivacaine 0.5%. Subsequently, once the patient was positioned prone in the operating room, a popliteal block was performed using 15 mL of ropivacaine 0.5%. This approach was chosen to provide both intraoperative anesthesia and postoperative pain relief. A tourniquet was placed above the knee to facilitate the surgical procedure.

Reverse Ultrasound Anatomy for a popliteal block with needle insertion out-of-plane. The local anesthetic spread is shown in blue. TN, tibial nerve; CPN, common peroneal nerve; PA, popliteal artery; PV; popliteal vein; SmM, semimembranosus muscle; BFM, biceps femoris muscle.

Patient outcome

The combination of spinal anesthesia and popliteal block was successful in providing adequate anesthesia for the duration of the surgery. The patient reported minimal discomfort and remained hemodynamically stable throughout the procedure. Postoperatively, the patient experienced effective pain relief from the popliteal block.

This case highlights the effectiveness of combining spinal anesthesia with a peripheral nerve block in patients where general anesthesia is either contraindicated or not preferred. It also demonstrates the importance of individualizing anesthesia plans to cater to patient preferences and specific health conditions.

For more case studies like these and the complete guide to the 60 most frequently used nerve blocks, download the Nerve Blocks App HERE. Don’t miss the chance to get the bestselling NYSORA Nerve Blocks App also in book format – the perfect study companion with the Nerve Blocks app!