Original contribution
Single Fascia Iliaca Compartment Block for Post-Hip Fracture Pain Relief

Presented at the Society for Academic Emergency Medicine Annual Meeting (Poster presentation), New York, NY, May 25, 2005; First International Interdisciplinary Conference on Emergencies (IICE), Montreal, Canada, June 2005; First Inter-American Congress of Emergency Medicine, Buenos Aires, Argentina, April 20, 2006.
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Abstract

Hip fractures can cause considerable pain when untreated or under-treated. To enhance pain relief and diminish the risk of delirium from typically administered parenteral analgesics and continued pain, we tested the efficacy of using fascia-iliaca blocks (FICB), administered by one of four attending physicians working in the emergency department (ED), with commonly available ED equipment. After informed consent, a physician administered one FICB to 63 sequential adult ED patients (43 women, 20 men; ages 37–96 years, mean 73.5 years) with radiographically diagnosed hip fractures. Under aseptic conditions, a 21 g, 2-inch IM injection needle was inserted perpendicularly to the skin 1 cm below the juncture of the lateral and medial two-thirds of a line that joins the pubic tubercle to the anterior superior iliac spine. The needle was inserted until a loss of resistance was felt twice (fascia lata and fascia iliaca), at which point 0.3 mL/kg of 0.25 bupivacaine was infused. The physician tested the block’s efficacy by assessing sensory loss. Pain assessments were done using a 10-point Likert Visual Analog Scale (VAS) before, and at 15 min, 2 h, and 8 h post-block. Block failure was having the same level of pain as before the block. Oral analgesics were administered as needed. The IRB approved this study. Post-procedure pain was reduced in all patients, but not completely abolished in any. Before the FICB, the pain ranged from 2 to 10 points (average 8.5) using the VAS; at 15 min post-injection, it ranged from 1 to 7 points (average 2.9); at 2 h post-injection, it ranged from 2 to 6 points (average 2.3); at 8 h post-injection, it ranged from 4 to 7 points (average 4.4). Analgesic requests in the first 24 h after admission averaged 1.2 doses (range 1 to 4 doses) of diclofenac 75 mg. There were no systemic complications and only two local hematomas. Resident physicians learned the procedure and could perform it successfully with less than 5 min instruction. Physicians rarely use the FICB in EDs, although the technique is simple to learn and use. This rapid, effective, and safe method of achieving excellent pain control in ED patients with hip fractures can be performed using standard ED equipment.

Introduction

More than 500,000 hip fractures occur annually in the United States (1). About 80% of the fall-related fractures occur in elderly women with osteoporosis (2, 3). The mechanisms underlying hip fracture in the elderly are complex and multifactorial, involving an interaction between risks for falling and an age-associated decline in bone and muscle mass (possibly related to increased intake of animal proteins), and impairment of neuromuscular function (4, 5).

Hip fractures usually cause considerable pain. Untreated or under-treated pain and potent systemic analgesics can increase the risk of delirium, especially in elderly patients (6). The relationship of pain relief to decreased morbidity and mortality remains controversial (7, 8). The benefits of the acute analgesia play an important role in patient comfort. It permits clinicians to take a more accurate history and do a better physical examination, improves systemic vital signs, and avoids the intense use of non-steroidal analgesics (with the accompanying risk of epigastric pain and coagulation abnormalities), or opioids (altering the sensorium). Therefore, the physician’s goal to relieve pain whenever possible in the most rapid and least damaging manner suggests that a safe and easily performed regional block, rather than mind-altering systemic analgesics, may be a very effective tool.

Pain control is often not a high priority and systemic analgesics can cause or complicate problems, especially in the elderly population most susceptible to hip fractures. Elderly patients (50 years or older) with hip fractures report a 50% to 70% incidence of “severe to very severe” pain in the first 24 h post-injury (7). Although narcotics continue to be the mainstay for pre- and post-operative pain relief, in this patient group, avoiding or using very low doses of opioids to treat pain significantly decreases the risk to them of developing delirium (6).

In this prospective study, we evaluated the feasibility, ease of use, and efficacy of using standard emergency department (ED) equipment to perform a single fascia iliaca compartment block (FICB) for pain relief after a hip fracture.

Section snippets

Materials and Methods

This study was prospective, interventional, and uncontrolled.

After informed consent, 63 sequential adult patients presenting to the ED and diagnosed with hip fracture radiographically were included in this study. Each received a single FICB from one of four attending physicians working in the ED.

A standardized FICB technique was used for all patients (Figure 1). No premedication or sedation was used. The patient was placed in supine position, the inguinal ligament was identified and the femoral

Demographic Characteristics

Sixty-three sequential patients were included in this study (43 women, 20 men), with ages ranging from 37 to 96 (mean 73.5) years. Thirty-nine had fractures on the right side and 24 on the left. Significant concomitant medical diseases included 9 patients with diabetes, 17 with hypertension, and 6 with both. One had a history of angina pectoris, 2 had undergone valve replacements, 5 had suffered contralateral hip fractures, and another had a laparotomy within the prior 2 months for colon

Discussion

Dalens used the relatively recent anatomical description of the iliaca fascial compartment (IFC) to first describe the FICB procedure in 1989 (9, 10). This closely followed the publication of the procedure accidentally being done while trying to block the lateral femoral cutaneous nerve (11). Dalens described the procedure in contrast to the similar “3-in-1” block as being more successful (>90%), not requiring expensive equipment such as a neurostimulator, and being safer, because it was

Conclusions

The FICB is a rapid, effective, safe and easily performed method of achieving excellent pain control in ED patients with hip fractures. Emergency physicians can perform the FICB with standard ED equipment and the procedure is easy to learn.

Based on extensive literature that demonstrates its utility, future studies will explore the efficacy of using the FICB for knee and femoral shaft fractures in adults and children. A particular group that might benefit from FICB use is multiple trauma

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