Anaesthesia 2021 doi:10.1111/anae.

15504

Guidelines

Regional analgesia for lower leg trauma and the risk of

acute compartment syndrome
Guideline from the Association of Anaesthetists

M. H. Nathanson,1 W. Harrop-Griffiths,2 D. J. Aldington,3 D. Forward,4 S. Mannion,5

R. G. M. Kinnear-Mellor,6 K. L. Miller,7 B. Ratnayake,8 M. D. Wiles9 and M. R. Wolmarans10

1 Consultant, Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK; President,
Association of Anaesthetists (Co-Chair)
2 Professor, Imperial College, London, UK; Vice President, Royal College of Anaesthetists (Co-Chair)
3 Consultant, Hampshire Hospitals NHS Trust, Hampshire, UK; British Pain Society
4 Consultant, Department of Trauma and Orthopaedic Surgery, Nottingham University Hospitals NHS Trust, Nottingham,
UK
5 Consultant, Department of Anaesthesiology, South Infirmary Victoria University Hospital, Cork, Ireland; Irish Standing
Committee, Association of Anaesthetists
6 Consultant, Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK and Surgeon
Commander, Royal Navy; Chair, Defence Medical Services Military Pain Special Interest Group
7 Consultant, Department of Paediatric Anaesthesia, Birmingham Women’s and Children’s NHS Foundation Trust,
Birmingham, UK; Trainee Committee, Association of Anaesthetists
8 Consultant, Department of Anaesthesia, Kingston Hospital NHS Trust, Kingston-upon-Thames, UK; Immediate Past
President, British Society of Orthopaedic Anaesthetists
9 Consultant, Department of Anaesthesia and Operating Services, Sheffield Teaching Hospitals NHS Foundation Trust,
Sheffield, UK
10 Consultant, Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK;
Past-President, Regional Anaesthesia UK (RA-UK)

Summary
Pain resulting from lower leg injuries and consequent surgery can be severe. There is a range of opinion on the
use of regional analgesia and its capacity to obscure the symptoms and signs of acute compartment syndrome.
We offer a multi-professional, consensus opinion based on an objective review of case reports and case series.
The available literature suggested that the use of neuraxial or peripheral regional techniques that result in dense
blocks of long duration that significantly exceed the duration of surgery should be avoided. The literature
review also suggested that single-shot or continuous peripheral nerve blocks using lower concentrations of
local anaesthetic drugs without adjuncts are not associated with delays in diagnosis provided post-injury and
postoperative surveillance is appropriate and effective. Post-injury and postoperative ward observations and
surveillance should be able to identify the signs and symptoms of acute compartment syndrome. These
observations should be made at set frequencies by healthcare staff trained in the pathology and recognition of
acute compartment syndrome. The use of objective scoring charts is recommended by the Working Party.
Where possible, patients at risk of acute compartment syndrome should be given a full explanation of the
choice of analgesic techniques and should provide verbal consent to their chosen technique, which should be
documented. Although the patient has the right to refuse any form of treatment, such as the analgesic technique
offered or the surgical procedure proposed, neither the surgeon nor the anaesthetist has the right to veto a
treatment recommended by the other.

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© 2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists. 1
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and
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Anaesthesia 2021 Nathanson et al. | Analgesia and compartment syndrome

Correspondence to: M. H. Nathanson

Email: mike.nathanson@nuh.nhs.uk
Accepted: 16 April 2021
Keywords: acute compartment syndrome; analgesia; trauma
Twitter: @Assoc_Anaes; @mikenathanson61; @STHJournalClub
This is a consensus document produced by expert members of a Working Party established by the Association of Anaesthetists
of Great Britain and Ireland. It has been seen and approved by the Board of Directors of the Association of Anaesthetists. It has
been endorsed by the Royal College of Anaesthetists, the British Pain Society, the British Society of Orthopaedic Anaesthetists
and Regional Anaesthesia UK.

Recommendations express to the patient the concerns voiced by the

1 Patients at risk of acute compartment syndrome (ACS) surgeon.
should be identified on admission to hospital or at the 7 The available literature suggests that the use of
time of surgery, and should be managed within agreed, neuraxial or peripheral regional techniques that result in
multidisciplinary protocols. dense blocks of long duration, that is, significantly
2 Post-injury and postoperative ward observations and exceeding the duration of surgery, should be avoided.
surveillance should be able to identify the signs and 8 The available literature suggests that single-shot or
symptoms of ACS; these observations should be made continuous peripheral nerve blocks using lower
at set frequencies by healthcare staff trained in the concentrations of local anaesthetic drugs without
pathology and recognition of ACS. The use of objective adjuncts are not associated with delays in diagnosis
scoring charts is recommended. provided post-injury and postoperative surveillance is
3 The equipment necessary to measure appropriate and effective.
intracompartmental pressure should be available on 9 Given the lack of reliable, published data on the safety
wards caring for patients at risk of ACS. Staff should and efficacy of analgesia in patients at risk of ACS, the
be trained in its use and there should be standard Working Party recommends that studies that address
operating procedures available and implemented the use of low-dose regional analgesia, spinal opioid
that address the performance of such measurements, analgesia and wound infusion with local anaesthetic
and the urgent steps to be taken if measurements are drugs for patients undergoing surgery for tibial fractures
abnormal. be conducted as a matter of urgency. The low incidence
4 All patients who have suffered trauma or who have of ACS means that prospective, randomised trials would
undergone surgery should be offered effective need to be large, and the conduct of prospective audit
analgesia. should therefore be encouraged
5 Where possible, patients at risk of ACS should be given
a full explanation of the choice of analgesic techniques What other guideline statements are
and should provide verbal consent to their chosen available on this topic?
technique, which should be documented. There are no other guidelines currently available.
6 Although the patient has the right to refuse any form of
treatment, such as the analgesic technique offered or Why were these guidelines developed?
the surgical procedure proposed, neither the surgeon Pain resulting from lower leg injuries and consequent
nor the anaesthetist has the right to veto a treatment surgery can be severe. There is a range of opinion on the
recommended by the other. Ideally, consensus should use of regional analgesia and its capacity to obscure the
be achieved but, if consensus is not achievable, the role symptoms and signs of ACS. However, a systematic review
of the anaesthetist as the expert on pain relief should be of the available literature is absent. We offer a multi-
respected. It is, therefore, the anaesthetist who has the professional, consensus opinion based on an objective
right to offer the patient the range of what they consider review of case reports and case series. We aimed to provide
to be acceptable analgesic techniques provided they pragmatic guidance to enable optimal analgesia and to

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Nathanson et al. | Analgesia and compartment syndrome Anaesthesia 2021

highlight the need for careful observation for ACS in any overall incidence in children is lower [1]. Acute
patient at risk (irrespective of the mode of analgesia). compartment syndrome is a recognised side-effect of intra
osseous access [1]. Acute compartment syndrome can
How and why does this statement differ occur in the absence of a fracture if there is soft tissue
from existing guidelines? damage.
Opinion on the optimal choice of anaesthesia and analgesia Additional risk-factors in developing ACS after lower
is often based on a single case or a small case series in which limb trauma include: open fracture; intramedullary nailing;
the impact of the mode of analgesia was poorly understood. anticoagulation; high energy injury; penetrating trauma;
Other evidence is often anecdotal. In the absence of high- vascular injury; burns; the use of tourniquets; and
quality trials, consensus opinion offers the next best haemophilia [1].
guidance and should supplant personal opinion.
Pathophysiology
Introduction Acute compartment syndrome is the result of an increased
Few topics divide orthopaedic surgeons and anaesthetists pressure in a closed, relatively inelastic osteofascial
quite so quickly and reliably as the question of whether compartment [7]. There is then a spiralling action that results
regional techniques should be used for analgesia during in a rapid increase in pressure requiring early action (Fig. 1)
and after surgery for lower leg trauma. This is in large part [8]. The increasing pressure reduces the capillary and
because of the well-recognised association between lower venous blood flow, and the resulting tissue ischaemia
limb fracture and acute compartment syndrome (ACS), the results in more oedema and release of vaso-active
potentially life-changing complications of ACS, and the mediators, further increasing the pressure in the
assumption made by many that effective analgesia can compartment.
mask pain as one of the cardinal symptoms of this The above describes the arteriovenous gradient
syndrome. hypothesis. However, there is an alternative hypothesis: the
This guidance document aims to provide a brief review ischaemic-reperfusion mechanism [9]. Within both
of ACS and an appraisal of the literature available on the hypotheses, there is increased pressure resulting in
subject. It also aims to present the current consensus view of decreased capillary blood flow, decreased oxygen delivery
a group of experts brought together by the Association of to the tissues and a resulting metabolic deficit. However, the
Anaesthetists with the purpose of providing pragmatic latter hypothesis focuses on free radicals, calcium and
guidance to those managing these potentially challenging vasoactive substrates released under ischaemic conditions
cases. resulting in the increased vessel permeability and
This document will limit itself to trauma to the lower leg, subsequent increase in extravascular fluid and pressure. In
while accepting that ACS is by no means restricted to this both, the pressure cannot be relieved until the inability of
area of the body, in order to provide an exemplar of the the compartment to expand has been resolved.
management of similar clinical situations for which there is
less supporting information.

Fracture associated with

Pathology and diagnosis soft tissue injury

Incidence Intracompartmental
swelling
Acute compartment syndrome has a reported incidence of
3.1 per 100,000 [1], with a range of 1–7.3 per 100,000 [2]. It Vessel collapse
Tissue pressure > venous pressure
has an incidence in men of 10 times that in women, at 7.3
per 100,000 [2], although this difference is accentuated in Decreased tissue
blood flow
those who suffer ACS that is associated with fractures, for
Tissue
which the male to female ratio is 13:1 [3]. Fractures account hypoxia

for 69% of all ACS cases [4]. Up to 40% of all ACS episodes
Oedema
involve a tibial shaft fracture, and approximately 4–5% of all
tibial fractures result in ACS [5]. There is an increased risk in
young men aged < 35 y with tibial fractures [1, 4, 6].
Children are at a theoretically increased risk due to the Figure 1 Pathophysiology of acute compartment
higher pre-existing compartment pressures. However, the syndrome (adapted from [8]).

© 2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists. 3
Anaesthesia 2021 Nathanson et al. | Analgesia and compartment syndrome

Diagnosis The use of scoring charts such as that provided by the

The diagnosis of ACS remains a controversial area. UK’s Royal College of Nursing [18] is recommended. While
Historically, it was regarded as a clinical diagnosis, with clinical signs are not completely reliable, their recording will
compartment pressure measurement reserved for cases in help maintain a heightened sense of awareness of this
which the diagnosis remained unclear after clinical condition among the healthcare workers caring for at-risk
examination. However, several studies have cast doubt on patients.
the reliability of diagnosing ACS on clinical signs alone. This
uncertainty in diagnostic criteria may lead to a significant Measurement of compartment pressure
variation in rates of fasciotomy between surgeons [10]. The diagnosis of ACS can be especially challenging in
Classically, six clinical signs or symptoms are attributed obtunded, confused or unco-operative patients, in whom
to ACS: pain; cold; paraesthesia; paralysis; pulselessness; clinical signs may be impossible to elicit. Direct
and pallor [11]. As perfusion to the affected compartment measurement of intracompartmental pressure is indicated
decreases, the lack of oxygen and the accumulation of in those cases in which the diagnosis remains in doubt.
metabolic waste products cause nerve and muscle Direct compartment pressures can be obtained using a
ischaemia and irritation, resulting in pain and decreased variety of equipment and techniques. Described methods
peripheral sensation. Pain out of proportion to the injury or include traditional needle manometry, multiparameter
clinical situation is often reported as being the earliest sign monitors usually used to monitor arterial blood pressure
of developing ACS. Pain on passive stretch of the affected and dedicated transducer-tipped intracompartmental
muscle compartment is regarded by some as the most pressure monitors [19]. The obtained compartment
sensitive early sign. The affected compartment may also pressure may be affected by the technique and equipment
physically swell and become increasingly firm as used. The use of an 18-G needle may lead to an
intracompartmental pressure rises. The loss of a pulse, overestimation of compartment pressure by up to
paralysis, pallor and decreased temperature are late signs, 18 mmHg when compared with a slit catheter or side-
indicating significant disruption to the vascularity and ported needle [20]. Whatever equipment is used, pressure
viability of the affected limb. As diagnosis should be made should be measured in the relevant compartments in the
before the onset of muscle ischaemia, these signs are not affected limb.
useful in the early diagnosis of ACS. Single or continuous pressure monitoring may be
There is a paucity of published evidence to allow the performed. Continuous compartment pressure monitoring
calculation of the sensitivity and specificity of individual has been suggested in high-risk, obtunded patients. There
clinical signs. The information available from published is little evidence that continuous monitoring reduces the risk
prospective studies suggests the sensitivity and positive of missed ACS compared with serial examination in the alert
predictive value of clinical signs are low, whereas the and co-operative patient [21].
specificity and negative predictive value are high [12–15].
Palpation of the suspected compartment has been shown to Pressure threshold for fasciotomy
be unreliable in isolation, with a sensitivity and specificity of Traditionally, an absolute compartment pressure of
54% and 76% respectively in predicting an increased ≥ 30 mmHg has been regarded as a diagnostic cut-off for
compartment pressure in children [16]. In isolation, severe ACS requiring fasciotomy [14, 22]. When taken in isolation
pain gave around only a 25% chance of a correct diagnosis without other clinical suggestions of ACS, this may lead to a
of ACS. However, as the number of clinical signs increases, rate of fasciotomy of up to 29% after tibial surgery [23].
the likelihood of a positive diagnosis of ACS increases [17]. Higher thresholds of up to 45 mmHg have been suggested
The presence of both severe pain and pain on passive [24], although these too may over-diagnose ACS when
stretch of the affected muscle compartment gives a positive taken in isolation [13]. The differential pressure threshold is
predictive value of 68%. A predictive value of 93% is found if the most recognised cut-off for intervention in current use
pain, pain on passive stretch and paralysis are present. [25]. Tissue perfusion is affected both by the patient’s
However, as paralysis is a late clinical sign, it is likely that by diastolic blood pressure and intracompartmental pressure.
this stage the patient would have experienced irreversible Patients with an increased diastolic blood pressure can
muscle ischaemia. The absence of clinical signs is therefore tolerate a greater increase in compartment pressure without
arguably more accurate in excluding ACS than their muscle or nerve ischaemia from hypoperfusion when
presence is in making the diagnosis. compared with patients who are hypotensive. Fasciotomy

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Nathanson et al. | Analgesia and compartment syndrome Anaesthesia 2021

should usually be performed when the tissue pressure physiology. Younger children may have difficulty
increases to within 10–30 mmHg of the diastolic pressure in articulating symptoms such as pain and paraesthesia, which
a patient with any of the other signs or symptoms of ACS. are the common symptoms alerting one to possible ACS.
When combined with the differential pressure threshold, One group has suggested the use of ‘three As’ to diagnose
continuous pressure monitoring in patients after tibial shaft ACS in children: anxiety; agitation; analgesic requirement
fracture has been reported to have a sensitivity of up to 94%, [27].
with an estimated specificity of 98% [26]. Unfortunately, by A recent study found an incidence of ACS after
definition, even this approach may miss some cases of ACS. paediatric trauma of 0.02% [28]. This study included
There is insufficient prospective evidence for any single 18-year-olds and found 24 cases of ACS in > 144,000
sign or investigation that is guaranteed to diagnose or trauma admissions (21 male patients). The mean (range)
exclude ACS. Despite clinical signs frequently being relied age was 13 (2–18) years. Over the age of 14 y, all cases were
on in clinical practice, the literature suggests that the men with long bone fractures but with similarly increased
predictive value of these signs is relatively low. Based on compartment pressures at diagnosis (25–90 mmHg vs.
limited prospective evidence, measurement of 30–75 mmHg in those aged ≤ 14 years); the cut-off of
intracompartmental pressures can be regarded as the gold 14 years was chosen because the epiphyseal plates close at
standard diagnostic investigation but only when other around that age. Age is an important predictor for the
clinical features suggesting ACS are present. When the development of ACS; children aged 12–19 years have a
diagnosis is in doubt or a patient is considered high-risk, high prevalence of ACS after tibial fracture [29]. As in adults,
and serial examination is not reliable, continuous pressure most cases of ACS in children occur after tibial or forearm
monitoring may be the safest diagnostic investigation to fractures [30]. In a study of 978 children with upper limb
avoid a missed case of ACS. fractures, the incidence of ACS was 0.6% for humeral and
0.7% for forearm fractures [31].
Publications on analgesia and acute Normal leg compartment pressures in children are
compartment syndrome higher than those found in adults (13–16 mmHg vs. 0–
The available literature on ACS is marked by the complete 10 mmHg) [32]. This difference has been postulated to be
absence of reports of the results of prospective, the result of muscle hypertrophy related to growth. Some
randomised, controlled studies and, therefore, of authors have suggested that these higher compartment
informative meta-analyses. There exist a large number of pressures combined with lower normal diastolic blood
case reports and case series that are often interpreted in pressure predispose children to ACS [32]. The threshold
accordance with their authors’ inherent bias. We have intracompartmental pressure used clinically is usually the
highlighted selected publications that shed some light on same as for adults at 30 mmHg by direct measurement, or a
the occurrence of ACS and on the interpretation of how difference between diastolic blood pressure and
analgesic techniques may affect diagnosis in online intracompartmental pressure of ≤ 30 mmHg. Higher
Supporting Information (Appendix S1). baseline intracompartmental pressures and
Our summary of the available, and admittedly not high communication difficulties have led some to recommend
quality, literature is as follows: dense neuraxial or peripheral the measurement of compartment pressures in all children
nerve blockade may be associated with a delay in the [33, 34]. Others have argued against this for children aged
diagnosis of ACS if extended into the postoperative period; < 12 y with minimally displaced tibial fractures [35]. There
there is no convincing evidence of the potential for the use were no cases of ACS in 159 children with these fractures
of single-shot or continuous peripheral nerve blocks with whose pain was well controlled and who mobilised in a
low concentrations of local anaesthetic to mask the back slab, with early follow-up following Emergency
symptoms of ACS or delay the diagnosis of ACS; and some Department discharge [35]. Near infra-red spectroscopy
surgeons continue to be concerned about the use of has also been used successfully in young children to
regional analgesia in patients undergoing surgery diagnose ACS [36]. However, there is currently no
associated with a significant incidence of ACS. agreement on what method of monitoring is best: clinical;
intracompartmental pressure measurement; near infra-red
Special circumstances: children spectroscopy; or a combination of these. Complications
Children present unique challenges in the diagnosis and after ACS in children are rare. One study found a
management of ACS. They constitute a heterogeneous complication rate of 4.2%, with 87.5% of children who
group, ranging from a neonate to a 17-year-old with adult underwent fasciotomy having a secondary closure

© 2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists. 5
Anaesthesia 2021 Nathanson et al. | Analgesia and compartment syndrome

of skin and only 12.5% requiring split skin grafting. Mean Defence Medical Services approach to injuries at risk of
time from admission to fasciotomy was just under 28 h and ACS. As such, military surgeons perform early fasciotomies
ranged from 2.5 h to 99 h [28]. as part of the initial management of those casualties with
Debate continues regarding the use of regional either clinical suspicion or at high risk of developing ACS
anaesthesia and patient/nurse-controlled analgesia in [43]. It is accepted that limb fasciotomies are not a benign
children at risk of ACS. Paediatric regional anaesthetists’ surgical intervention, with risks including haemorrhage,
desire to prove the safety of low-dose peripheral nerve nerve damage, infection, difficult wound closure and poor
blockade and the absence of convincing case reports cosmetic result. However, these risks should be balanced
linking regional analgesia in children to diagnosis delays against the risk of not performing fasciotomy, namely
led the European Society of Regional Anaesthesia and Pain development of ACS and subsequent potential limb loss. It
Therapy (ESRA) and the American Society of Regional is worth noting that during operations in Afghanistan, those
Anesthesia and Pain Medicine (ASRA) to conclude in casualties at high risk of ACS underwent fasciotomies
guidance published in 2015 [37] that: “there is no current irrespective of whether or not they were going to receive
evidence that the use of regional anaesthetics increases the regional nerve blockade [44].
risk for ACS or delays its diagnosis in children” and to Battlefield injuries are high-energy penetrating injuries
recommend that after discussion with the child, parents and involving bone and soft tissue and may involve traumatic
surgical team, low concentrations of local anaesthetic amputation. Such high-energy injuries are at high risk of
(bupivacaine or ropivacaine 0.1–0.25% for single shot and ACS. Similar high-energy injuries are also seen during
0.1% for continuous nerve blocks) can be used safely for peacetime in civilians as a result of gunshot wounds or
single-shot and continuous nerve blocks for surgery terror-related bombings. The anaesthetic care of patients
associated with an increased risk of ACS. The guidelines with these injuries no longer remains the preserve of military
recommended cautious use of adjuncts to local anaesthetists. However, their experience of successfully
anaesthetics, as these can increase the density and duration using regional anaesthesia in these patient groups has an
of blocks. An acute pain service should also be in place and increased civilian relevance. The UK Defence Medical
rapid provision of intracompartmental pressure monitoring Services have successfully used continuous peripheral
should be available. nerve analgesia using low-dose local anaesthetic solutions
Since the ESRA/ASRA guidelines were published in in those with high-energy injuries at risk of ACS. This
2015, there have been no cases reported of ACS in children provides analgesia with some preservation of sensory and
associated with regional analgesia or anaesthesia. There are motor function, thereby allowing identification of
increasing numbers of case reports and series of successful breakthrough pain, which is considered a cardinal feature of
diagnosis of ACS in children receiving regional anaesthesia, ACS, although it should be noted that this may not always
including continuous upper and lower limb blocks [38–40]. be a feature of the syndrome [8, 45, 46].
Definitive studies have not been performed, with no One factor that may have contributed to the low
randomised trials or cohort studies investigating a possible incidences of ACS during recent conflicts is the format of a
association. Proper systems should be in place to recognise consultant-led and delivered service within deployed
ACS occurring in children after trauma and allow clinicians secondary care coupled with a familiarity among nursing
to react promptly and provide appropriate management staff on the wards with dealing with high-energy injuries at
[41]. risk of ACS. UK military experience from combat operations
suggests that the majority of cases of ACS have been
Special circumstances: military injuries recognised and managed during initial management at in-
The management of an ACS in a military environment may country surgical centres. An unpublished review of > 100
come with additional layers of complexity due to variable UK casualties with significant limb injuries identified only
access to surgical services in the area of operations and two casualties who required fasciotomies after evacuation
prolonged repatriation times. While military casualties from from theatre, that is, country of wounding. Both cases were
recent conflicts in Iraq and Afghanistan often underwent late presentations of ACS rather than a ‘missed’ event
repatriation soon after their injury and initial surgery, the during initial management [43].
repatriation journey itself can take many hours. A Education of medical teams on the pattern of injuries
compartment syndrome developing during this repatriation likely to be encountered on military operations and their
process would have been catastrophic without urgent subsequent management may play a part in the UK Defence
fasciotomy [42]. These factors have influenced the UK Medical Services’ experiences regarding the use of regional

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Nathanson et al. | Analgesia and compartment syndrome Anaesthesia 2021

anaesthesia in those with high-energy injuries. The military is not possible to seek consent from a parent or other adult
surgical teams train together on the Military Operational with the legal right to take decisions on behalf of the patient,
Surgical Team Training (MOSTT) course and again before is it reasonable for the anaesthetist and surgeon to take on
deployment on a ‘whole-hospital’ simulation exercise. This the responsibility of determining which form of analgesia
education and training support teamworking assists will be used.
situational clinical decision-making with the aim of reducing
adverse events such as ACS [47]. Conclusion
There is anecdotal evidence of poor analgesia in patients
Pain relief after lower leg trauma with lower leg injuries that may, in part, be the result of
The Declaration of Montreal underscores the widespread concerns about the risk of ACS. Good analgesia is, however,
view that pain relief is a fundamental human right, and the a basic human right. The Working Party members believe
provision of effective analgesia for patients suffering any that the use of single-shot or continuous peripheral nerve
form of trauma should therefore be a priority [48]. If the blocks using lower concentrations of local anaesthetic drugs
injury suffered is one that is associated with a significant without adjuncts are not associated with delays in diagnosis,
incidence of ACS, this human right is not affected, and the provided appropriate post-injury and postoperative
provision of pain relief should remain central to the medical surveillance is used. The use of such techniques, including
management of the patient. their risks and benefits, should be discussed with the patient
Regional analgesia is not the only form of pain relief as part of shared decision-making.
available to patients who suffer lower limb trauma, and
multimodal analgesia that includes paracetamol, non- Acknowledgements
steroidal anti-inflammatory drugs (if not contraindicated), MN is Chair of the Editorial Board and MW is an editor of
opioids and other adjuncts can be effective. Regional Anaesthesia. No other competing interests declared.
analgesia without the use of local anaesthetic drugs has
been used in the past (discussed earlier) and there is now
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