Anaesthesia, 2011, 66, pages 300–305 doi:10.1111/j.1365-2044.2011.06628.

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ORIGINAL ARTICLE
Ultrasound-guided supra-inguinal fascia iliaca block: a
cadaveric evaluation of a novel approach
P. Hebbard,1 J. Ivanusic2 and S. Sha3
1 Clinical Associate Professor, Anaesthesia and Pain Management Unit, Department of Pharmacology, University of
Melbourne, Melbourne, Vic., Australia
2 Lecturer, Department of Anatomy and Cell Biology, University of Melbourne, Melbourne, Vic., Australia
3 Anaesthetics Registrar, Northeast Health Wangaratta, Wangaratta, Vic., Australia

Summary
Existing descriptions of ultrasound-guided fascia iliaca block focus on injection of local anaesthetic
inferior to the inguinal ligament, relying on supra-inguinal spread to block the lateral femoral
cutaneous nerve in the iliac fossa. In this study, we explored injectate spread and nerve involvement
in a cadaveric dye-injection model, using a supra-inguinal ultrasound-guided technique that places
local anaesthetic directly into the iliac fossa. Bilateral injections of 20 ml 0.25% aniline blue dye
were made in six unembalmed cadavers. The femoral nerve was stained by the dye in all twelve
injections. The lateral femoral cutaneous nerve was stained bilaterally in five cadavers, but the nerve
was absent on both sides in the sixth cadaver. The ilio-inguinal nerve passed into the iliac fossa over
the iliacus muscle in eight of the hemi-pelvi and was stained in seven of these occasions. We have
performed more than 150 blocks in patients using this approach without complications.
Injection using this technique in cadavers leads to extensive fluid spread throughout the iliac
fossa. In patients this approach may allow a lower volume block of the femoral nerve and lateral
femoral cutaneous nerve while still injecting at a distance from the femoral nerve.
. ......................................................................................................
Correspondence to: Peter Hebbard
Email: p.hebbard@bigpond.com
Accepted: 26 November 2010

Fascia iliaca block places local anaesthetic in the plane technique demonstrated radio-opaque dye spread into
containing the femoral nerve and lateral femoral the iliac fossa, which is the target area for the block [3,
cutaneous nerve (LFCN) between the fascia iliaca 4]. Ultrasound-guided fascia iliaca block in the infra-
and the underlying iliacus muscle. It is used for inguinal area has been described previously [5, 6].
anaesthesia and analgesia of the hip, knee and thigh We have used a supra-inguinal approach to the fascia
[1, 2]. Success rates vary between 67% in junior trainee iliaca block under ultrasound guidance over a period of
anaesthetists [2], to over 90% for experienced anaes- three years in over 150 patients. Local anaesthetic is
thetists [3–5]. Fascia iliaca block does not directly target placed directly into the iliac fossa by advancing a needle
the femoral nerve, thereby reducing the risk of needle beneath the fascia iliaca from below the inguinal
injury, and it has a higher rate of simultaneous block of ligament, so that the needle tip lies superior to the
the femoral and LFCN than perivascular femoral nerve ligament. This may be advantageous as the LFCN
block [3, 5]. leaves the fascia iliaca plane at the inguinal ligament,
Dalens et al. first described a landmark approach to and branches of the femoral nerve to the iliacus muscle
fascia iliaca block in 1989 [4] using a skin entry point in and acetabulum leave the nerve proximal to the
the thigh. A ‘2-pop’ technique identifies the fascia lata inguinal ligament [7]. An infra-inguinal local anaes-
and fascia iliaca. Early investigators using the landmark thetic injection must pass superiorly from the thigh to

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300 Anaesthesia  2011 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2011, 66, pages 300–305 P. Hebbard et al. Æ Ultrasound-guided supra-inguinal fascia iliaca block
. ....................................................................................................................................................................................................................

block these nerves and may therefore require a greater

volume of injectate. In addition, the proximal LFCN
and femoral nerve lie close together in the iliac fossa
and may be blocked simultaneously by a smaller
volume injection. A previously described landmark
approach to supra-inguinal fascia iliaca block involves
insertion of the needle inferiorly to the inguinal
ligament and then advancing it superiorly [8] and
utilising a ‘2-pop’ approach similar to the infra-
inguinal, landmark-based fascia iliaca block [4]. Unfor-
tunately, bladder perforation has now been described
using this (superior needle advancement) technique [9].
Ultrasound may reduce the risk of unintended punc- Figure 1 Probe and needle position and diagram of dissected
ture of the bladder and other structures in this area, iliac fossa showing anatomy for the supra-inguinal fascia iliaca
including the deep circumflex iliac artery, inferior block. Iliacus muscle (IM), psoas muscle (PM), femoral nerve
epigastric artery, external iliac artery, spermatic cord (FN), femoral artery (FA), femoral vein (FV), anterior
and hernia contents. superior iliac spine (ASIS), umbilicus (U).
Herein we describe an ultrasound-guided supra-
inguinal approach to the fascia iliaca block in a series of (a)
dye injections in cadavers, in order to explore the
extent of nerve involvement and injectate spread as a
prelude to further clinical investigation.

Methods
This block is performed with a high frequency linear
ultrasound transducer (probe) imaging to approxi-
mately 4 cm depth, or a lower frequency curvi-linear
probe (allowing deeper penetration in obese patients).
(b) (c)
A sterile cover is applied to the probe, the hip is
extended by laying the patient flat and the anterior
superior iliac spine palpated. The probe is placed over
the inguinal ligament, close to the anterior superior
iliac spine, and orientated in the para-sagittal plane
(Fig. 1). In obese patients, an assistant may retract the
abdominal wall. Initially, the thick white line of the Figure 2 Diagram of anatomical section in the parasagittal
ilium and then the more superficial, dark (echolucent) plane of the supra-inguinal fascia iliaca block (a) and
iliacus muscle with the fascia iliaca covering its surface composite sonograms (b) and (c). Iliacus muscle (IM), fascia
are identified (Fig. 2). Imaging of the fascia iliaca can iliaca (FI), psoas muscle (PM), sartorius muscle (S), tensor
fascia lata muscle (TFL), ilium (I), deep circumflex iliac
be enhanced by tilting the transducer so that the beam artery (DCIA), subcutaneous tissue (SCT). Inferior (INF),
is directed more laterally to orientate the fascia more superior (SUP). The fascia iliaca, anterior inferior iliac spine
perpendicular to the beam. The probe is then moved (AIIS) and fascia over sartorius are highlighted in sonogram (b).
infero-medially, along the line of the inguinal ligament,
until the femoral artery is imaged. Moving supero- the block. If the fascia iliaca is not well imaged at this
laterally back along the inguinal ligament the anterior point the probe may be moved more laterally to obtain
inferior iliac spine is imaged. The anterior inferior iliac a clearer image. The deep circumflex iliac artery should
spine forms the attachment of the rectus femoris muscle be identified superficial to the fascia iliaca 1–2 cm
and is identified by the sudden rising of the ilium superior to the inguinal ligament, as it forms a
towards the transducer as the probe is moved laterally. landmark for the needle placement.
In this position the probe is found lateral to the femoral The needle is introduced through the skin, parallel
nerve and this is the recommended starting point for to the probe, in-plane (with respect to the ultrasound

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Anaesthesia  2011 The Association of Anaesthetists of Great Britain and Ireland 301
P. Hebbard et al. Æ Ultrasound-guided supra-inguinal fascia iliaca block Anaesthesia, 2011, 66, pages 300–305
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beam), approximately 2–4 cm inferior to the inguinal rotated to the transverse position to image the distri-
ligament, and is advanced through the fascia iliaca at bution of fluid that usually passes medially, deep to
the level of the inguinal ligament. The depth of the tip fascia iliaca and superficial to the femoral nerve
of the needle relative to the skin entry point is (Fig. 4). The needle alignment is suitable for a catheter
approximately 2–4 cm. placement.
There is usually a ‘pop’ as the needle passes through In the present study, we report a series of cadaveric
the fascia iliaca and into the iliacus muscle. The needle dye-injections to simulate this ultrasound-guided
is withdrawn to the fascia and the position confirmed supra-inguinal fascia iliaca block and subsequent
by an injection of 1 ml of local anaesthetic, which, if dissections to explore the extent of dye spread and
correctly placed, forms a lens deep to the fascia (Fig. 3). nerve involvement. The cadaver dye injections were
There is no distinct fascial line between the local performed in the Department of Anatomy at the
anaesthetic lens and the dark iliacus muscle in this University of Melbourne following institutional review
position. The needle is advanced into the lens and committee approval.
further local anaesthetic is injected. Through this We used six unembalmed, frozen ⁄ thawed cadavers.
process of hydro-dissection the needle is passed supe- We performed bilateral ultrasound-guided supra-
riorly, deep to the fascia iliaca and into the iliac fossa, inguinal injections (as described above) of 20 ml
moving only into the space created by the distending aniline blue dye (0.25% in water), giving a total of 12
fluid. The fluid must spread freely across the surface of injections. We could not determine the position of the
the muscle, separated from the deep circumflex iliac femoral artery as readily as in the living due to the
artery by the fascia iliaca. The end-point is reached absence of arterial flow and we gave precedence in
when the local anaesthetic passes freely superiorly, over the injection to finding a site with good imaging of the
the iliacus muscle and into the iliac fossa. A total of fascia iliaca. We used a 19-G 100-mm facet tip needle
20 ml ropivacaine 0.5–0.75% is injected slowly at this and 20-G catheter set (PlexoLong Nanoline facet;
position. Imaging during the entire injection is Pajunk GmbH Medizintechnologie, Geisingen Ger-
recommended to confirm that the local anaesthetic is many). After the dye injection we introduced the
not being injected intravascularly. The probe may be catheter through the needle, to pass 2–3 cm beyond
the tip of the needle.
We commenced the dissection by reflecting the skin
of the upper thigh and abdominal wall, taking care not
to disturb the catheter. We performed deep dissection

Figure 3 Sonograms during hydro-dissection (left image)

and towards conclusion of block (right image) showing the Figure 4 Transverse scan at the conclusion of supra-inguinal
lens of local anaesthetic (LA) beneath the fascia iliaca (black fascia iliaca block. The needle (N) is lateral to the femoral
arrows) with the needle advanced through it. Iliacus muscle nerve (FN) which has local anaesthetic (LA) passing over the
(IM), ilium (I) subcutaneous tissue (SC), abdominal muscles superficial surface deep to the fascia iliaca (FI). Femoral artery
(A). Inferior (INF), superior (SUP). (FA), iliacus muscle (IM). Medial (MED), lateral (LAT).

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302 Anaesthesia  2011 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2011, 66, pages 300–305 P. Hebbard et al. Æ Ultrasound-guided supra-inguinal fascia iliaca block
. ....................................................................................................................................................................................................................

near the anterior superior iliac spine to identify the

LFCN emerging through the inguinal ligament and
passing superficially to the sartorius muscle. We
identified the femoral nerve and femoral artery medi-
ally, deep to the inguinal ligament. We traced both the
femoral and LFCNs proximally, to their emergence
from the lateral edge of the psoas muscle. We identified
the ilio-inguinal nerve either at the iliac crest, or just
medial to it in the iliac fossa. The identity of the nerves
was confirmed independently by the two dissectors
(PH and JI). We measured the extent of dye spread in
the superior-inferior and medial–lateral directions and
we then noted the proximity of the dye to the anterior
superior iliac spine and the femoral artery. We
documented the nerves stained by the dye and then Figure 5 Photograph of right-sided dissection specimen.
determined the distance from the catheter to the The dye (outline by dashed line) fills the iliac fossa (X). The
femoral nerve and LFCN at the levels of the catheter femoral nerve (FN) (lifted by forceps), lateral femoral
tip and the inguinal ligament. cutaneous nerve (LFCN) and ilio-inguinal nerve (IIN) all
pass through the dye. Note that the LFCN and femoral nerve
are in close proximity deep in the iliac fossa. Femoral artery
Results (FA), iliac crest (IC), anterior rectus sheath (ARS). Inferior
(INF), superior (SUP), medial (MED), lateral (LAT).
There was extensive dye spread within the iliac fossa,
and in 10 of the 12 injections dye also spread into the
thigh along the femoral nerve, the superior to inferior but remained unstained when it did not pass into the
spread (mean (SD)) measured 183 (36) mm and medial iliac fossa.
to lateral spread 75 (46) mm. The spread inferior to the Three of the catheters were displaced during the
inguinal ligament, along the course of the femoral dissection; the position of the remaining nine catheters
nerve, was for a mean (SD) distance of 70 (46) mm. was assessed. At the inguinal ligament the catheter
The dye also spread laterally to reach the anterior entered the fascia iliaca at a mean (SD) of 27 (14) mm
superior iliac spine in nine specimens and within lateral to the femoral artery, 17 (13) mm lateral to the
15 mm of it in the other three specimens. Medially, the femoral nerve and 25 (19) mm medial to the LFCN.
dye spread deep to the femoral artery to a distance of The catheter tip was found to be a mean (SD) of 14
3 (8 mm) and a maximum of 25 mm medial to the (14) mm lateral to the femoral nerve and 9 (15) mm
lateral wall of the femoral artery. In one specimen the medial to the LFCN.
dye stopped 8 mm lateral to the femoral artery. There
was no spread of dye superior to the iliac crest.
Discussion
We identified the femoral nerve bilaterally in all six
cadavers and noted it was surrounded by dye in all Our cadaveric dye-injection study confirms that the
cases. We identified the LFCN bilaterally in five ultrasound-guided supra-inguinal approach results in
cadavers, but noted it was absent bilaterally in one significant spread of injectate with simultaneous
cadaver. The LFCN was surrounded by dye in all cases involvement of both the femoral nerve and LFCN,
it was present (Fig. 5), but in the one cadaver where in the iliac fossa, in all the cadavers in which we
we failed to identify the nerve in the iliac fossa, there identified these nerves by dissection. The extent of
was staining in its normal location. We identified the femoral nerve involvement was particularly significant,
ilio-inguinal nerve bilaterally in all six cadavers. In and extended between 50 and 140 mm into the thigh
eight hemi-pelvi it passed over the iliac crest onto the in ten of the twelve injections. Our clinical experience,
iliacus muscle and re-emerged into the muscular in over 150 cases of reliable simultaneous block of the
abdominal wall anteriorly. In the other four hemi- femoral nerve and LFCN using 20 ml of local anaes-
pelvi the nerve remained in the muscular abdominal thetic, is consistent with these findings. In addition, we
wall. The ilio-inguinal nerve was stained in seven of have placed catheters without difficulty in over fifty
the eight specimens when it passed over the iliac crest, patients, using either the same catheter system as in

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Anaesthesia  2011 The Association of Anaesthetists of Great Britain and Ireland 303
P. Hebbard et al. Æ Ultrasound-guided supra-inguinal fascia iliaca block Anaesthesia, 2011, 66, pages 300–305
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these cadavers or alternatively 10.8-cm arterial cathe- fluid in the correct plane is important to allow adequate
ters (Arrow International Inc., Reading, PA, USA). spread to the target nerves, and if local anaesthetic is
No short-term complications have been noted in any deposited within the iliacus muscle it is usually
patient. Three previous reports by Capdevila et al., apparent on ultrasound imaging and accompanied by
Dolan et al. and Morau et al. [3, 5, 10] have found a some reflux of fluid back to the correct plane. Fluid
high rate of combined LFCN and femoral nerve injected within the abdominal musculature or into the
blockade with fascia iliaca block although they used fat between the fascia iliaca and peritoneum does not
larger volumes, either 30 ml of an equal volume mix of flow into the correct compartment along the iliacus
lidocaine 2% and bupivacaine 0.5% or an average of muscle, deep to the deep circumflex iliac artery and
36 ml (0.5 ml.kg)1) ropivacaine 0.5%. Notably, Lopez into the iliac fossa.
et al. used 20 ml lidocaine 1.5% and found only a 50% During performance of the block the abdominal wall
rate of simultaneous block of the two nerves using a is compressed on to the fascia iliaca by the ultrasound
landmark infra-inguinal technique [11]. probe, thereby excluding any intra-peritoneal organs.
The bilateral absence of the LFCN in one cadaver The peritoneum can potentially lie between the
was an unexpected finding. This variation has been abdominal wall and the fascia iliaca, although it does
described previously (7.3% of 200 cadavers) [12] and it not stand out on the ultrasound image. Needle
is suggested that when the LFCN is absent, the skin misplacement into the extraperitoneal fat superficial
over the lateral aspect of the thigh is supplied by the to the fascia iliaca, the abdominal wall or the perito-
femoral or iliohypogastric nerves instead. In most cases neum is possible. However, the technique we
the intra-abdominal course of the LFCN is relatively described involves piercing the fascia iliaca in the
constant and the variation is in its distal course through proximal thigh superficial to the anterior inferior iliac
or inferior to the inguinal ligament [13]. spine, with subsequent advancement into the hydro-
The ilio-inguinal nerve was also involved in the dissected space deep to the fascia iliaca. We have
injectate in seven of the eight specimens in which it experienced cases where the needle needs to be
passed through the iliac fossa. The passage of the ilio- advanced a few millimetres beyond the hydro-
inguinal nerve across the iliac crest and deep to fascia dissection before the local anaesthetic passes freely into
iliaca is well recognised although the incidence is not the iliac fossa. In these instances the operator must be
well described. Some investigators describe the nerve as confident that the needle is deep to the fascia iliaca
remaining above the iliac crest [14, 15], whereas others before advancing. The deep circumflex iliac artery
have found the incidence of the ilio-inguinal nerves should be specifically sought, as it provides a landmark
passing below the iliac crest to be 25–32% [16, 17], superficial to the correct plane and could be damaged
while Gray’s Anatomy [7] simply describes it passing on by incorrect needle advancement. Rotation of the
to the iliacus muscle, as we observed in four of our six probe to a transverse alignment after the injection, and
cadavers. Recognition of block of the ilio-inguinal the imaging of the local anaesthetic passing superficial
nerve is unlikely to be clinically important when or deep to the femoral nerve, confirms correct
performing fascia iliaca block; however, staining of this placement.
nerve with dye in our cadaveric study suggests that it One catheter in the cadaver study entered the fascia
passes through the same plane as the LFCN, deep to iliaca very close to the femoral nerve, passing
fascia iliaca, when it passes through the iliac fossa. superficial to it to lie in a medial position. One
The cadaveric injections and our clinical experience catheter entered the fascia iliaca lateral to the LFCN
confirm the feasibility of ultrasound-guided supra- and remained in this position after advancement. In
inguinal approach to the fascia iliaca block; however, a this case, the injected dye still spread extensively along
number of technical considerations warrant discussion. the femoral nerve in the iliac fossa, passing 60 mm
Positioning of the patient with extension of the hip is along the nerve into the thigh. A medial entry point
desirable as hip flexion may make the approach or a medial direction of the needle will make
difficult. Other difficulties that we have encountered positioning close to the femoral nerve more likely.
include poor imaging of the fascia iliaca (usually To reduce the chance of puncturing the femoral
corrected by medial to lateral angulation of the probe) nerve we recommend imaging the femoral artery and
and associated imprecision identifying the endpoint then moving several centimetres laterally until the
(fluid spreading under the fascia iliaca). Free spread of anterior inferior iliac spine is imaged.

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304 Anaesthesia  2011 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2011, 66, pages 300–305 P. Hebbard et al. Æ Ultrasound-guided supra-inguinal fascia iliaca block
. ....................................................................................................................................................................................................................

Our description of ultrasound-guided supra-inguinal 7 Standring S, Editor. Gray’s Anatomy, 40th edn. Missouri,
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and Pain Medicine 2003; 28: 309–14.
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declared. Fascia iliaca compartment block for femoral bone frac-
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