Patients with a fracture may require surgery to reposition or restructure their bones, and spinal anesthesia is an excellent tool for pain management in many orthopedic surgeries. However, positioning these patients for the administration of spinal anesthesia presents unique clinical challenges due to the pain and physical limitations resulting from their broken bone(s). Effective positioning is critical for the safe and successful administration of spinal anesthesia, particularly in orthopedic surgeries such as femoral fracture repairs. The ideal position facilitates access to the subarachnoid space while minimizing discomfort and the risk of exacerbating the injury.
Patients with long bone fractures, especially of the femur or hip, experience significant pain during positioning for spinal anesthesia. To address this, several analgesic strategies have been proposed to improve tolerability. A systematic review and meta-analysis confirmed that femoral nerve blocks (FNB) are effective in reducing pain and improving patient cooperation during spinal anesthesia positioning. Compared to intravenous opioids like fentanyl, FNBs resulted in more favorable pain scores and allowed for better positioning outcomes in the lateral or sitting positions (1).
The sitting position is frequently preferred due to improved landmark identification, especially in obese or elderly patients. However, it can cause severe discomfort in patients with a broken femur bone and prevent anesthesiologists from being able to administer spinal anesthesia successfully. Studies suggest that combining regional analgesia with sedatives, such as dexmedetomidine and ketamine, can enhance patient tolerance to the sitting posture (2).
Another effective technique is the fascia iliaca compartment block (FICB), which provides broader nerve coverage than FNB, including the lateral femoral cutaneous and obturator nerves. In a randomized controlled trial, patients receiving FICB reported significantly better positioning tolerance and analgesia compared to those receiving intravenous fentanyl or FNB alone. These results suggest that FICB may be particularly advantageous in managing patients with complex or proximal femoral fractures where nerve distribution is more diffuse (3).
Regardless of the analgesic technique employed, patient safety during positioning is paramount. Excessive manipulation or incorrect alignment can lead to further displacement of fracture fragments or compromise of neurovascular structures. A study by Sia et al. emphasized that spinal anesthesia should be delayed until adequate analgesia is ensured, preferably using regional blocks, to avoid sudden patient movements that can jeopardize both the spinal procedure and fracture stability (4).
In cases involving multiple trauma or spinal instability, lateral positioning is preferable because it allows for spinal anesthesia without requiring the patient to sit up. This is particularly valuable in patients with unstable hemodynamics or concurrent spinal injury. Coordination with orthopedic and trauma teams is essential in these scenarios to ensure that alignment precautions are observed. Some literature suggests that lateral positioning may reduce the risk of vasovagal responses during neuraxial anesthesia, particularly in elderly patients with impaired venous return (5).
Positioning patients with broken bones for spinal anesthesia requires a tailored, multidisciplinary approach that integrates analgesia, anatomical considerations, and perioperative support. Regional techniques such as FNB and FICB, often augmented with sedatives, represent effective solutions to minimize pain and optimize positioning. These strategies not only improve the patient experience but also enhance the success rate and safety of spinal anesthesia. Further exploration of individualized pain management protocols and biomechanical aids that support safer, more efficient positioning practices is warranted.
References
- Hsu YP, Hsu CW, Chu KCW, et al. Efficacy and safety of femoral nerve block for the positioning of femur fracture patients before a spinal block – A systematic review and meta-analysis. PLoS One. 2019;14(5):e0216337. Published 2019 May 2. doi:10.1371/journal.pone.0216337
- Lee KH, Lee SJ, Park JH, et al. Analgesia for spinal anesthesia positioning in elderly patients with proximal femoral fractures: Dexmedetomidine-ketamine versus dexmedetomidine-fentanyl. Medicine (Baltimore). 2020;99(20):e20001. doi:10.1097/MD.0000000000020001
- Bantie M, Mola S, Girma T, Aweke Z, Neme D, Zemedkun A. Comparing Analgesic Effect of Intravenous Fentanyl, Femoral Nerve Block and Fascia Iliaca Block During Spinal Anesthesia Positioning in Elective Adult Patients Undergoing Femoral Fracture Surgery: a Randomized Controlled Trial. J Pain Res. 2020;13:3139-3146. Published 2020 Nov 26. doi:10.2147/JPR.S282462
- Sia S, Pelusio F, Barbagli R, Rivituso C. Analgesia before performing a spinal block in the sitting position in patients with femoral shaft fracture: a comparison between femoral nerve block and intravenous fentanyl. Anesth Analg. 2004;99(4):1221-1224. doi:10.1213/01.ANE.0000134812.00471.44
- Madabushi R, Rajappa GC, Thammanna PP, Iyer SS. Fascia iliaca block vs intravenous fentanyl as an analgesic technique before positioning for spinal anesthesia in patients undergoing surgery for femur fractures-a randomized trial. J Clin Anesth. 2016;35:398-403. doi:10.1016/j.jclinane.2016.09.014