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Three Part Question

In [fracture neck of femur] is [IV opioid better than fermoral block] in [alleviating pain and distress]

Search Strategy

MEDLINE 1966-11/04 using the OVID interface.
[hip fracture.mp. or exp hip fracture/ OR exp femoral neck fractures/ or femoral neck.mp. or exp Femur Neck/] AND [femoral nerve.mp. or exp Femoral Nerve/ OR nerve block.mp. or exp nerve block/ OR exp LIDOCAINE/ OR exp BUPIVACAINE/ OR exp Anesthetics, Local/ OR local anaesthetic$.mp. OR exp Anesthesia, Local/ OR exp Nerve Block/] LIMIT to HUMAN AND ENGLISH

Search Outcome

Altogether 65 papers found of which 8 were relevant to the study question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Fletcher AK, Rigby AS and Heyes FLP, 2003 UK	50 patients age range 63-89 with fracture neck of femur 3-in-1 femoral nerve block (with 20 mL of 0.5% bupivacaine) vs systemic analgesia alone	RCT	Mean pain score using 0-3 scale	Greater reduction in nerve block group with mean difference [95% CI]: -0.78 [-1.02 to -0.54]	Small numbers Method of radonmisation unclear
			Time to best response	Mean difference [95% CI]: -2.93 [-5.48 to -0.38h]
			analgesic requirements	Reduced in 24 hours from admission in nerve block group
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
			Analgesic requirements	Reduced in the 24 hours from admission in nerve block group
			Incidence of complications	Significantly reduced in nerve block group

Comment(s)

The above studies suggest some benefit for the use of nerve block in fracture neck of femur in the pre-operative setting, in an emergency department. However the studies are small and have important weaknesses.

Clinical Bottom Line

In patients with suspected fracture neck of femur, regional nerve block may benefit in reducing parentral analgesic requirements and in achieving pain relief faster.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Alan K.Fletcher, Alann S. Rigby, Francis L.P.Heyes three-in-one femoral Nerve block as Analgesia for fracture neck of Femur in the Emergency Department: A Randomized, Controlled Trial Annals of Emergency Medicine febuary 2003 41:2 227-233
2. Haddad FS, Williams RL. Femoral nerve block in extracapsular femoral neck fractures. J Bone Joint Surg Br 1995;77(6):922-3.