Original contributionSingle Fascia Iliaca Compartment Block for Post-Hip Fracture Pain Relief
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
References (32)
- et al.
Broader strategies for hip fracture prevention
Am J Med
(2004) - et al.
Comparison of continuous 3-in-1 and fascia iliaca compartment blocks for postoperative analgesia: feasibility, catheter migration, distribution of sensory block, and analgesic efficacy
Reg Anesth Pain Med
(2003) - et al.
Comparison of patient-controlled analgesia and continuous lumbar plexus block after anterior cruciate ligament reconstruction
Arthroscopy
(1993) - et al.
Bilateral fascia iliaca catheters for postoperative pain control after bilateral total knee arthroplasty: a case report and description of a catheter technique
Reg Anesth
(1997) - et al.
Fascia iliaca compartment block for femoral bone fractures in prehospital care
Reg Anesth Pain Med
(2003) - et al.
Bloc iliofascial en médecine préhospitalière
Annales françaises danesthèsie et de rèanimation
(1999) - et al.
Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial
Ann Emerg Med
(2003) - et al.
Delayed retroperitoneal haematoma after failed lumbar plexus block
Br J Anaesthesia
(2004) - et al.
The “3 in1” block: myth or reality?
Ann Fr Anesth Reanim
(1989) - Centers for Disease Control and Prevention. Falls and hip fractures among older adults. Available at:...