3 in 1 W Fascia Iliaca in Children

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ANESTH ANALG 7051989:69 7 5 1

Comparison of the Fascia Iliaca Compartment Block with the 3-in-1Block in Children

Bernard Dalens, MD, Guy Vanneuville, MD, and Alain Tanguy, MD

DALENS B, VANNEUVILLE G, TANGUY A. Comparisonof t he fascia iliaca compartment block with the 3-in-1 blockin children. Anesth Analg 1989;69705-13.

A new single injection procedure, the fascia iliaca compart-ment block, is described for blocking the femoral, lateralcutaneous, and obturator nerves. The technique consists ofinjecting a local anesthetic immediately behind the fasciailiaca at the uni on of the lateral wit h the tw o medial thirdsof the inguinal ligament, and forcing it upward by fingercompression. This block was prospectively evaluated in60pediatric patients aged 0.7 to 7 years undergoing surgeryof the lower limb, and then compared witha similar groupof 60 children give n a 3-in-1 block. Adequate analgesia wasonly obtained in 20 of the patients given 3-in -1 blocks(group I , whereas the fascia iliaca compartment blockproved to be easy, free of com plicat ions, and effective inmore than 90 of patients (group 2) . Such a high failure

rate n group 1 was not d ue to misplaceme nt of the needlesince a femoral nerve block developed in all patients.Therefore it s unlik ely that the local anesf hetic can spreadrostrally towards the lumbar plexus then return peripher-ally along the issuing nerves, and this was, indeed, notconfirmed by radiological find ing s.In the authors opinion,a multieffective block can only develop when the localanesf hetic is introduced behind the fascia iliaca, whichcircumscribes a potential space where the femoral, lateralcutaneous, and obturator nerves run for a considerable partof their course. This report shows that deliberately inject ingthis space almost always results in an easy and effectiveblock of these three nerves . The fascia iliaca compartme ntblock can be recommended for use n children.

Key Words: ANESTHETIC TECHNIQUES,REGIONAL-lumbar plexus block, femoral nerveblock. ANESTHESIA, PEDIATRIC.

The intraoperative and postoperative courses of nu-merous operations on the upper extremity are im-proved by using regional anesthetic techniques, es-pecially axillary and supraclavicular brachial plexusblocks. The same improvements can be expected foroperations on the lower extremity. However, due tothe complexity of the sensory supply to the lowerlimb, either a central block or multiple peripheralblocks are necessary for providing adequate anesthe-sia. On the one hand, epidural or spinal anesthesiasare unnecessary and even undesirable for unilateraloperations; on the other, the performance of several

peripheral blocks is time-consuming and increasesthe dangers of inaccura te injection and systemictoxicity.

Winnie et al. 1) renewed general interest in re-gional anesthesia for operations on the lower extrem-ity by describing a multieffective block of the lumbar

Received from the Department of Anesthesiology and theDepart ment of Pediatric Surgery, HBtel-Dieu Hospital, Clermont-Ferrand, France. Accepted for publication June 8, 1989.

Address correspondence to Dr. Dalens, Pavillon Gosselin,HBtel-Dieu 8 . 69, 63003 Clermont-Ferrand, France.

plexus nerves supplying the thigh with a singleinjection of reasonable am oun ts of local anesthetic,the 3-in-1 block. In a number of patients, however,the block fails to provide adequate anesthesia in areassupplied by the lateral cutaneous nerve of the thighand the obturator nerve. Furthermore, this blockprocedure has not gained wide acceptance in pediat-rics, since most children are unable to grasp theconcept of paresthesia. We expected tha t the use ofelectrical stimulation and insulated needles mightallow the application of the 3-in-1 block procedure inchildren, and even with improved results, but this

was not confirmed by our clinical experience.We then reevaluated the gross anatomy of thelumbar plexus nerves and fascias of the groin andthigh in children. Our anatomical findings supportedthe hypothesis that sufficient amounts of a solutioninjected immediately posterior to the fascia iliacacould spread a t the inne r surface of this fascia andcontact the femoral, lateral cutaneous, genitofemoral,and obturator nerves that run, at least in part, imme-diately posterior to the fascia. We then developed anew blocking procedure, referred to as the fascia

1989 by the Int ernat ional Anesthesia Research Society


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706 ANESTH ANALG1989;69:705-13

DALENS ET AL.

Figure 1 . Gross anatomy of the lumbar plexus nerves supplyingthe lower extremity.

1. Psoas muscle 5 . Femoral vessels (within2. Lateral cutaneous nerve their specific sheath )

6. Obturator nerve3. Femoral nerve 7. Genitofemoral nerve4 Inguinal ligament 8. Iliac vessels

of the thigh

iliaca compartment block. The present study wasdesigned to evaluate prospectively the efficacy andreliability of this new technique an d to compare itwith the 3-in-1 block procedure in 120 pediatricpatients. The study protocol received institutionalapproval as well as informed consent from parents.To reduce interindividual factors, all blocks wereperformed by the same anesthesiologist.

Material and MethodsAna tornic Considerations

The lower extremity is supplied by three nervesoriginating from the lumbar plexus which lies in thepsoas compartment 3), within the substance of thepsoas muscle. The lateral cutaneous nerve of the thigh (asensory nerve) emerges at the upper part of thelateral border of the psoas muscle (Figure 1). Itobliquely crosses the iliacus muscle, immediatelyposterior to the fascia iliaca, passes behind (orthrough) the inguinal ligament, and then divides intotwo terminal branches, which supply sensory inner-

vation to the lateral aspect of the thigh. The femoralnerve (a mixed nerve) also emerges at the lateralborder of the p ioa s muscle, runs posterior to thefascia iliaca in the groove formed by the psoas withthe iliacus muscles, passes behind the inguinal liga-ment, and then enters the groin in the femoraltriangle lateral to the femoral vessels (Figure 1). It

supplies both sensory innervation to the ventralaspect of the thigh and the periosteum of th e femurand motor innervation to the muscles of the front ofthe thigh. The obturafor nerve (mixed, but mainly amotor nerve) emerges at the medial border of thepsoas muscle (Figure l ) , behind the common iliacvessels, from which it is separated by the fascia iliaca.It then reaches the obturator foramen, where it di-vides into two terminal branches that are then dis-tributed to the thigh. An accessory obturator nervemay occasionally accompany the obturator nerve.

Two other lumbar plexus nerves also contribute

sensory fibers to the upper part of the anterior aspectof the thigh: 1) he ilioinguinal nerve, which emerges atthe lateral border of the psoas muscle, then crossesthe quadratus lumbarum muscle obliquely, immedi-ately posterior to its covering fascia until it reachesthe iliac crest, where it pierces the transversus abdo-minis and the oblique muscles in the direction of thespermatic cord (in the male) or the round ligament ofthe uterus (in the female); and 2) the genitofemoralnerve, which perforates the psoas muscle, then runson its anterior aspect (Figure l), posterior to the fascia


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FASCIA ILIACA COMPARTMENT BLOCK ANESTH ANALG 7071989;6970513

iliaca, in the direction of the inguinal ligament, whereit divides in two terminal branches, genital andfemoral, the latter supplying sensory innervation tothe skin covering Scarpas triangle.

Thus, the femoral, lateral cutaneous, obturator,

and genitofemoral nerves run a considerable part oftheir course close to the inner aspect of the fasciailiaca. This complex fascia (3) is attached medially tothe vertebral column and the upper part of thesacrum (Figure 2). Rostrally, it covers the psoasmuscle and blends laterally with the fascia coveringthe quadratus lumbarum muscle. Caudally, it coversthe iliacus muscle and is tightly attached to the innerlip of the iliac crest, and , medially, to the pelvic brim.The external iliac vessels are anterior to it, whereasthe lumbar plexus nerves are posterior to it. At thegroin, the fascia iliaca is continuous with the poste-rior margin of the inguinal ligament. Medially, itpasses behind the femoral vessels (which are en-closed in a common sheath limiting a perivascularyspace often referred to as the lacuna uaso~um) ndblends with the pectineal fascia which attaches to thepecten pubis (Figure 3 . At this level, it also derivesfibers towards the capsule of the hip: these fibersform a septum, usually incomplete, which reinforcesthe division between the femoral nerve (wrapped inits specific sheath) and the lacuna vasorum withinwhich run the femoral vessels.

More caudally, at the level of the femoral trianglethe fascia iliaca becomes narrow. Laterally, it attaches

to the anterior superior iliac spine and then blendswith the fascia covering the sartorius muscle. Medi-ally, it is continuous with the pectineal fascia. It iscovered by the fascia lata and it forms the roof of afat-filled space, sometimes referred to as the lacunamusculorum (adjacent to the lacuna vasorum).

Finally, the fascia iliaca delimits a potential space,the fascia iliaca compartment, triangular in shape(Figure 2). The limits of this compartment are:

1) anteriorly, the inner aspect of the fascia iliaca,which covers the iliacus muscle and reflects medi-

ally, thus covering the dorsal, then lateral, thenventral, and then medial aspects of the psoasmuscle;

2) posteriorly, the outer aspect of the iliacus muscle;3 medially, the vertebral column and the upper part

of the sacrum; and4) rostrally and laterally, the inner lip of the iliac crest

to which the fascia is tightly attached (rostrally andmedially, the space is continuous with that com-prised between the quadratus lumbarum muscleand its covering fascia).

Below the inguinal ligament this space is continuouswith the lacuna musculorum, covered by the fasciailiaca, the fascia lata, and then the skin covering thefemoral triangle. Injecting a sufficient amount of asolution in the lacuna musculorum and favoring its

upward migration towards the iliacus muscle shouldresult in a spread of the solution within the entirefascia iliaca compartment, thus allowing all the struc-tures (especially the nerves) traversing this space tobe contacted by the solution.

Pat iez sOne hundred twenty patients, 78 males and 42 fe-males, were included in this study after informedconsent had been obtained from parents and , a s oftenas possible, from the children themselves. The pa-tients ranged in age from 0.7 to 17 years and inweight from 7.3 to 79 kg. They all underwent surgeryof the lower extremity, including 43 emergency pro-cedures (Table 1). They were randomly allocated toone of two equal groups differing from one another inthe blocking procedure used: 3-in-1 block in the 60patients of group 1, and fascia iliaca compartmentblock in the 60 patients of group 2.

Methods

Anesthetic methods. All procedures were carried outin operating rooms after insertion of a peripheralvenous line. Twenty-six patients were kept alert andwere given no drugs other than local anesthetics.Children given general anesthesia in addition toregional anesthesia were given 0.02 mg/kg atropineand 0.1 mg/kg diazepam; as usual in our pediatricunit (4,5), anesthesia was then induced using eitherhalothane in 35 02/65 N,O or intravenous thio-pental (4 mg/kg) as preferred by the patients, andmaintained using halothane 0.25 to 0.5 in 35

Two needles connected to a plastic extension cath-eter (immobile needles [6]) were used: 1) 50-mm-long 22-gauge insulated needles (Top needles) ingroup 1, and 2) 50-mm-long 24-gauge short bevelneedles (Plexufix from Braun) in group 2. A nervestimulator (Myotest from Datex), adjusted to deliver 1mA impulses every second, was used in all patientsin group 1 . All patients were given the same anes-thetic solution consisting of a mixture of 1 idocainewith 0.5 bupivacaine, both with 1:200,000 epineph-rine. The volumes of local anesthetic injected were

02165 NZO.


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ANESTH ANALG1989:69:70513

708 DALENS ET AL.

Figure 2. Diagrammatic representation of the fasciailiaca. (Note the reflection of the fascia close to thevertebral column.)

1. Quadratus lumbarum muscle2. Psoas muscle3. Iliacus muscle4 Lateral cutane ous nerve of the thigh5. Inguinal ligament6. Femoral nerve7. Sartorius muscle8. Obturator nerve9. Genitofemoral nerve

10. Medial attachment of the fasia iliaca to the verte-bral column and upper part of the sacrum


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FASCIA ILIACA COM PARTMEN T BLOCK ANESTH ANALG 7091989;69705 13

Figure 3 . Transverse section at the root of thigh.1. Division branches

of the obturatornerve

2. Pectineal muscle3. Femoral vein4 Femoral artery5. Fascia lata6. Lacuna vasorum

7. Division branchesof the lateralcutaneous nerveof the thigh

8. Femoral nerve9. Psoas muscle

10. Lacuna musculo-rum

Table 1. Surgcal Indications in Two Groups of PatientsAnesthetized by 3-in4 Block Group 1) or Fascia IliacaCompartment Block (Group 2)

~~ ~

Indication Group 1 Group 2

Fracture of the femur 19 17Surface operations of the thigh 11 9

Removal of implants an d biopsies of 15 10

Operations necessitating the placement 11 21

Slipped capital femoral epiphysis 4 3

wounds, skin grafts, abscesses)

the femur

of a tourniquet at the thigh

calculated on weight basis in both groups: 0.7 mL/kgfor children weighing less than 20 kg, 15 mL for thoseweighing 20 to 30 kg, 20 mL for 30 to 40 kg children,25 mL for those 40 to 50 kg in weight, and 27.5 mL forthose weighing over 50 kg.

BZocking procedures. A modification of the 3-in-1block (1) using electrical stimulation for precise nerve

location was used in group 1. With the patients in thesupine position, the site of puncture was marked onthe skin 0.5 to cm below the inguinal ligament andlateral to the femoral artery. The block needle wasadvanced in a sagittal plane at a 30 angle to skin,pointing rostrally, until muscle twitches were elicitedin the quadriceps femoris muscle. Then finger pres-sure was applied gently but firmly just distal to theneedle (1) before injection, to force the anesthetic

upwards. After the needle had been w ithdrawn, thefinger pressure was maintained for a few minuteswhile the area was massaged to favor upward diffu-sion.

The technique of the fascia iliaca compartmentblock used the same dorsal recumbent position forthe patients. A projection of the inguinal ligamentwas drawn on the skin from the pubic tubercle to theanterior superior iliac spine and divided in threeequal parts. The site of puncture was marked 0.5 cmcaudal to the point where the lateral joined the two


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Table 2. Distribution of Anesthesia

Anesthesia

CompleteSensoryMotor

IncompleteSensoryMotor

SensoryMotor

Absent

Femoral nerve

Group 1 Group 2

60 608 1

0 039 22b

0 013 37b

Lateral cutaneousnerve Obturator nerve

Group 1 Group 2 Group 1 Group 2

9 55b 8 53bc d d

3 4 1 5c d

48 l b 51 bc d d

Genitofemoral nervea

Group 1 Group 2

10 55

1 2

49 3

~~ ~~

Femoral branch of the genitofemoral nerve providing sens ory supply to Scarpas triangle.bSignificant difference when compared to group 1.T h e lateral cutaneous nerve of the thigh is a sensory nerve.dThe clinical test used for testing motor blockade did not allow definitive conclusions regarding the obt urator nerve

medial thirds of this line. The needle was inserted at

a right angle to the skin while gentle pressure wasexerted on the barrel of a syringe filled with the localanesthetic and connected to the block needle. A firstgive followed by a loss of resistance was felt as thetip crossed the fascia lata. The needle was advancedfurther until another give and another loss ofresistance was felt as the fascia iliaca was pierced: theanesthetic solution was then injected, at the sametime exerting a firm compression immediately caudalto the needle to favor the upward spread of theanesthetic. After the needle had been withdrawn, theswelling in the groin was firmly massaged to improverostra1 diffusion of the local anesthetic within thefascia iliaca compartment.

Monitoring procedures and evaluationof anesthesia.Electrocardiogram tracings, respiratory rate, andblood pressure (Dinamap) were monitored during allprocedures. Tidal volume, end-tidal CO,, and halo-thane concentration were continuously monitored inpatients given general anesthesia.

The blocking procedure was considered successfulwhen the lateral, ventral, and medial aspects of thethigh were anesthetized permitting the scheduledsurgical procedure to be completed on a motionlesspatient without any additional treatment. The extent

of analgesia was evaluated in both groups at the endof the surgical procedure by skin pinching. Anesthe-sia was considered complete when no reaction orcomplaints of pain occurred during application of thenociceptive stimulus. It was considered incomplete ifthe patient either complained a little of pain or hadmotor responses not observed after pinching of adja-cent areas.

Motor blockade was evaluated a t the end of theoperation in both groups, either by asking the patientto move his or her leg and/or by applying nociceptive

stimuli aimed at eliciting withdrawal movements.

(This crude evaluation was suitable for testing thequadriceps femoris muscle, supplied by the femoralnerve, but it did not permit conclusions regarding thefunction of the adductors of the thigh, supplied bythe obturator nerve.)

The duration of the sensory block was measured asthe time between injection and the first evidence ofpain (complaints of pain; crying; grimacing; restless-ness; or autonomic responses such as tachycardia,hypertension, or sweating) occurring either sponta-neously or with hourly assessments using skin pinch-ing of the ventral aspect of t he thigh (supplied by thefemoral nerve).

Statistical methods. Data from the two groups werecompared using both parametric (Students t-test)and nonparametric (Mann-Whitney test) tests. Qual-itative parameters were evaluated using chi-squaretest. Differences were considered statistically signifi-cant at level P < 0.05.

ResultsPatients in the two groups d id not differ significantly

with regard to age, weight, surgical indications, orgender. The same 2:l predominance of males wasseen in both groups.

Group 3-in-1 Block

The femoral nerve was located in every case on thefirst attempt in 51 procedures. In nine patients, asecond attempt had to be made due to reflux of bloodinto the syringe (arterial in three, venous in two)


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FASCIA ILIACA COMPARTMENT BLOCK ANESTH ANALG 71 11989 ;6970513

Figure 4 Spread of a solution containing contras t media (data frompatients not included in t he stu dy protocol). A) 3-in-1 block. Note thatthe solution does not reach the psoas compartment where the lumbarplexus lies. B) Fascia iliaca compartment block. Note the spread of thesolution along the anterior aspect of the iliacus muscle and the medialincrease in opacity, probably due to superimposition resulting fromthe reflection of the fascia iliaca compartment covering successively: 1)the anterior aspect of the iliacus muscle, then 2 the posterior, and 3)the anterior aspects of the psoas muscle.

upon initial insertion of the needle or misplacementof the needle (absence of muscle twitches in four).During injection, swelling in the groin occurred in 11

patients. All patients developed a femoral block, butthe procedure was totally successful only in 12 chil-dren, including the 11 individuals who developed


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DALENS ET AL.

swelling in the groin. The spread of the anestheticsolution when no swelling had occurred is shown inFigure 4A. The distribution of sensory and motorblockades is shown in Table 2. There were no com-plications, and postoperative pain relief lasted 6.2 ?

1.4 hours.

Group 2 Fascia lliaca Compartment Block)The two characteristic gives resulting from thecrossing of the needle through the fascia lata andthen through the fascia iliaca were felt on the firstattempt in 59 patients, and on the second attempt inone child. Swelling in the groin occurred in 59 pa-tients, and the block procedure was successful in 55.The spread of the local anesthetic is shown in Figure4B The one patient who did not show any swelling in

the groin developed a femoral nerve block only. Thedistribution of anesthesia is shown in Table 2: motorblockade of the femoral nerve developed less often ingroup 2 than in group 1 (a statistically significantdifference [ P < 0.05]), whereas sensory blockade ofthe lateral cutaneous, obturator, and the femoralbranch of the genitofemoral nerves occurred moreoften (also statistically significant [ P < 0.051). Nocomplications were observed and postoperative painrelief lasted 5.0 * 1.3 h (significantly less than ingroup 1 [ P < 0.051).

DiscussionThe fascia iliaca compartment block proved to be easyand free of adverse effects. The technique resulted inblocking the three main lumbar plexus nerves sup-plying the thigh in more than 90 of procedures anddid not require expensive materials or unusual skills.On the other hand, the use of a nerve stimulator didnot improve, and even worsened, the results of the3-in-1 block procedure (1). These poor results werenot du e to misplacement of the needle since a femoralblock developed in all patients, as confirmed by the

spread of the local anesthetic within the perifemoralnerve sheath (Figure 4A) . While suspecting the im-portance of the fascia iliaca, Winnie et al. (1) sug-gested that the local anesthetic injected within thefemoral nerve sheath could spread upward, thusreaching the lumbar plexus, within the psoas com-partment, and then spreading backward along thelateral cutaneous and obturator nerves. In their pa-per, the authors included radiographs taken after theinjection of contrast material, but as seen in Figure4A, the local anesthe tic does not extend out of the

pelvis and does not reach the psoas compartment.Furthermore, in our experience of lumbar plexusblocks 7), we did not observe any spread of anes-thetic solution from within the psoas compartment,where the solution was directly introduced, towards

either the femoral, lateral cutaneous, or obturatornerve. Thus, the hypothesis of Winnie et al. (1) s notsupported even by their own data, and anotherexplanation has to be found to explain why, in anumber of patients, three separate nerves can beblocked by a single injection of a local anesthe tic. Inour group 1, 11 of the 12 patients with a block of thelateral cutaneous nerve developed swelling in thegroin during injection. Our hypothesis is that thesepatients were, in fact, actually given a fascia iliacacompartment block and we think that at least in mostcases, the 3-in-1 block is successful when the tip ofthe needle does not lie within the perifemoral nerveshea th, but outside of it (even if still very close to it),within the fascia iliaca compartment. Confirmation ofthis hypothesis can be found in the development ofinadver tent 3-in-1 blocks following various peripheralnerve blocks at the thigh, such as lateral cutaneousnerve blocks 8,9). Since using a nerve stimulatorimproves the accuracy of the location of the femoralnerve, it may be expected that the tip of the blockneedle is inserted in and stays within the perifemoralnerve space (limited by the femoral nerve sheath)more often than after a blocking procedure elicitingparesthesias only. This may explain why the use of a

nerve stimulator did not improve the distribution ofanesthesia in group 2 but even worsened it.

Whereas the distribution of analgesia was signifi-cantly improved by using the fascia iliaca compart-ment block technique, the durat ion of postoperativepain relief was significantly reduced (by approxi-mately 1 h). This may be due to the more extendedspread of t he local anesthetic to the vicinity of highlyvascularized tissues (especially the iliacus muscle) ascompared to the spread following a 3-in-1 blockwithin the perifemoral nerve space, a space with arelatively poor venous drainage. Thus, the probably

higher vascular uptake after fascia iliaca compartmentblocks may account for the decrease in duration ofpostoperative analgesia.

In conclusion, the fascia iliaca compartment blocktechnique is easy, reliable, and provides a high de-gree of sensory blockade of the lumbar plexus nervesthat supply the thigh using reasonable amounts oflocal anesthetic. This technique requires neither un-usual skills nor expensive devices, and it does notthreaten any vital organ. We believe that this tech-nique can be recommended for use in children.


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FASCIA ILIACA CO MPARTM ENT BLOCK ANESTH ANALG 7131989;69:70513

We thank Professor Ven Murthy, Lava1 University, Quebec, Can-ada, for considerable help in reviewing the manuscript, and J.P.Monnet and Y. Harman d for technical assistance in the preparationof illustrations.

References1. Winnie AP, Ramamurthy S, Durrani Z. The inguinal paravas-

cular technic of lumbar plexus anesthesia : the 3-in-I block.Anesth Analg 1973;52:989-96.

2. Chayen D, Nathan H, Chayen M. The psoas compartmentblock. Anesthesiology 1976;45:9>9.

3. Williams PL, Wanvick R. Fasciae an d muscles of the lower limb.In: Williams PL, Wanvick R, eds. Grays Anatomy, 36th ed.Philadelphia: WB Saunders, 1980:593-621.

4. Dalens B, Vanneuville G, Tanguy A. A new parascalene ap-proach to the brachial plexus in children: comparison with thesupraclavicular approach. Anesth Analg 1987;66:1264-71.

5 . Dalens B, Hasnaoui A. Caudal anesthesia in pediatric surgery:success rate and adverse effects in 750 consecutive patients.Anesth Analg 1989;68:83-9.

6. Winnie AP. An immobile needle for nerve blocks. Anesthe-siology 1969;31:577-8.

7. Dalens B, Tanguy A, Vanneuville G. Lumbar plexus block inchildren: a comparison of two proced ures in 50 patients. AnesthAnalg 1988;6775C-S.

8. Sharrock NE. Inadvertent 3-in-1 block following injection ofthe lateral cutaneous nerve of the thigh. Anesth Analg 1980;59:887-8.

9. Lonsdale M. 3-in-1 block: confirmation of Winnies anatomicalhypothesis. Anesth Analg 1988;67:601-2.

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3 in 1 W Fascia Iliaca in Children