Regional Nerve Block in Fractured Neck of Femur
Date First Published:
August 15, 2001
Last Updated:
March 21, 2002
Report by:
Bruce Martin, Specialist Registrar (Manchester Royal Infirmary)
Search checked by:
Baha Ali, Manchester Royal Infirmary
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.
Search Details:
(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)
Outcome:
21 papers found. Of these only four were relevant to the pre-operative setting.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Femoral nerve block for analgesia in fractures of the femoral neck. Finlayson BJ, 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 | ||||
| Femoral nerve block in extracapsular femoral neck fractures. Haddad FS, 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 | ||||
| Continuous psoas compartment block for anesthesia and perioperative analgesia in patients with hip fractures. Chudinov A, Berkenstadt H, Salai M, 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 | ||||
| Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures (Cochrane Review). Parker MJ, Griffiths R, Appadu BN. 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 |
Author Commentary:
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.
Bottom Line:
In patients with suspected fractured neck of femur, regional nerve block may be of benefit in reducing parenteral analgesic requirements.
References:
- Finlayson BJ, Underhill TJ.. Femoral nerve block for analgesia in fractures of the femoral neck.
- Haddad FS, Williams RL.. Femoral nerve block in extracapsular femoral neck fractures.
- Chudinov A, Berkenstadt H, Salai M, et al.. Continuous psoas compartment block for anesthesia and perioperative analgesia in patients with hip fractures.
- Parker MJ, Griffiths R, Appadu BN.. Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures (Cochrane Review).