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Three Part Question

In [patients with suspected neck of femur fracture] is [regional nerve block better than intravenous analgesia] at [providing and maintaining analgesia]?

Clinical Scenario

A 73 year old lady, who is usually fit and well, is brought to the emergency department following a fall. She is complaining of severe pain in her left groin. Examination shows that her left leg is shortened and externally rotated. You make a clinical diagnosis of fractured neck of femur (which is later confirmed radiologically). You wonder whether regional nerve block is better than intravenous analgesia for pain relief.

Search Strategy

Medline 1966-12/01 using the OVID interface.
(exp femoral neck fractures OR exp hip fractures) AND (exp analgesia OR analgesia.mp) AND (exp nerve block OR nerve block.mp OR exp anesthesia, local OR exp anesthetics, local OR regional anaesthesia.mp OR regional anesthesia.mp)

Search Outcome

21 papers found. Of these only four were relevant to the pre-operative setting.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Finlayson BJ and Underhill TJ, 1988, UK	36 patients age range 31 - 95 with fractured neck of femur. Intracapsular (16) and extracapsular (20) Femoral nerve block (10ml 0.5% bupivocaine)	Cohort Study	Subjective Assessment	26 patients had reduced pain (14 intracapsular, 12 extracapsular), 4 had no pain (all extracapsular), 6 had no change (all intracapsular)	No control group Statistical significance not assessed Heterogenous group of patients (2 young patients, 1 with multiple injuries)
			Objective Assessment	29 had reduced sensation. 7 no change (6 intracapsular, 1 extracapsular)
			Complications	None found
Haddad FS and Williams RL, 1995, UK	50 patients with extracapsular fractures of the femoral neck, age range 68 - 89 Femoral nerve block (0.3 ml/kg 0.25% bupivicaine) vs systemic analgesia alone	RCT	Mean pain score using VAS	Greater reduction in nerve block group - statistically significant at 15 mins and 2 hours	Small number of patients Only extracapsular fractures included ? Optimal analgesia given to control group
			Incidence of complications	Significantly reduced in nerve block group
			Analgesic requirements	Reduced in the 24 hours from admission in nerve block group
Chudinov A et al, 1999, Israel	40 consecutive patients age 67 - 96 years with fractured neck of femur undergoing surgery. Continuous psoas compartment block (2mg/kg/ of 0.25% bupivocaine with 0.8ml/kg adrenaline) vs analgesia	RCT	Complication Rate	3 cases of local erythema in psoas group	Method of randomisation unclear Small numbers of patients Unblinded Unclear whether optimal analgesia given to control group Type of block not typically used in emergency setting
			Pain relief (VAS)	Significant difference in psoas block group at 8 and 16 hours pre-operatively and 16, 24 and 32 hours post-operatively
Parker MJ et al, 2000, UK	269 patients from 7 randomised or quasi - randomised trials with fractured neck of femur - analgesia/anaesthesia given pre-operatively in 2 of these trials. Patients given either regional block or intravenous analgesia.	Systematic Review	Pain Levels	Reduction in mean pain score in nerve block group	Heterogenous group of patients Trials involving both pre and post operative patients were assessed together Different forms of block used in different trials Small numbers in contributing studies Unclear if amount of parenteral analgesia given was optimal
			Analgesic Requirements	Reduced analgesic requirements in nerve block group
			Complication Rate	No difference

Comment(s)

The above studies suggest some benefit for the use of nerve block in fractured neck of femur in the pre-operative setting, most notably in extracapsular fractures. However, the studies are small and have important weaknesses.

Editor Comment

This BET is currently being updated by Dr F. Siddiqui. 06/03/09 KW

Clinical Bottom Line

In patients with suspected fractured neck of femur, regional nerve block may be of benefit in reducing parenteral analgesic requirements.

References

1. Finlayson BJ, Underhill TJ. Femoral nerve block for analgesia in fractures of the femoral neck. Archives of Emergency Medicine 1988;5(3):173-6.
2. Haddad FS, Williams RL. Femoral nerve block in extracapsular femoral neck fractures. J Bone Joint Surg Br 1995;77(6):922-3.
3. Chudinov A, Berkenstadt H, Salai M, et al. Continuous psoas compartment block for anesthesia and perioperative analgesia in patients with hip fractures. Regional Anesthesia & Pain Medicine 1999;24(6):563-8.
4. Parker MJ, Griffiths R, Appadu BN. Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures (Cochrane Review). Cochrane Database of Systematic Reviews [computer file] (2):CD001159, 2000.