Elsevier

Injury

Volume 36, Issue 4, April 2005, Pages 505-510
Injury

Pre-operative analgesia for patients with femoral neck fractures using a modified fascia iliaca block technique

https://doi.org/10.1016/j.injury.2004.10.015Get rights and content

Summary

Adequate pre-operative analgesia for elderly patients with femoral neck fractures is difficult to assess and is often an overseen aspect of their care. We aimed to assess the efficacy of fascia iliaca blocks inserted via plexus blockade catheters in the pre-operative period. Our simple technique allowed the block to be administered safely without the need for a nerve stimulator. We assessed the effectiveness of the block with a novel objective sitting score and by assessing the degree of passive hip flexion that could be achieved comfortably. Visual analogue scores were also used. We studied 30 consecutive patients, regardless of their mental state. One hour following the block, there was a significant improvement in the sitting scores as well as the passive hip flexion (mean increase 44°). Visual analogue scores also score improved significantly from 7.2 to 4.6 (S.D. 2.4) in the 18 patients without cognitive impairment. We conclude that fascia iliaca blocks can provide significant benefit in the pre-operative period and allow patients to sit up more comfortably while they await surgery.

Introduction

Fractures of the femoral neck in the elderly represent a major part of the workload in UK trauma departments.1, 5 Surgery is very often delayed for more than 24 h for a variety of reasons.1 Providing satisfactory analgesia is a major challenge while patients wait for surgery. Many studies suggest that peripheral nerve blocks may have a role to play in the perioperative management of pain, but little is known about their specific value in the pre-operative period.2, 4, 7, 8, 9, 11, 12, 13, 14, 15 The needs for a nerve stimulator or a cooperative patient have made some published techniques unattractive in this setting. Furthermore, the difficulties of assessing analgesia in this elderly population have also been highlighted.6 We have observed difficulties with nursing patients waiting for surgery because they are unable to sit up comfortably largely limited by pain in the injured hip. Using this observation, we have developed a new method of assessing the effectiveness of a simple modification of the fascia iliaca lumbar plexus block that could be provided at the bedside without the need for a nerve stimulator.

Section snippets

Patients and method

We recruited 30 consecutive patients with low-energy femoral neck fractures. Patients with significant coagulopathy, allergy to local anaesthetics or other concomitant lower limb injuries were excluded. However, because we were using an objective assessment of pain, patients with impaired cognition or dementia were included in the study. Baseline demographic data was collected and a modified Blessed Mental State Questionnaire (MSQ) was completed for each patient.10, 17 The fractures were

Results

We studied 30 consecutive admissions to the department of Trauma and Orthopaedics. There were 21 female patients and 9 male with a mean age of 77.7 years (12.1). Nineteen fractures were extracapsular and 11 were intracapsular. Eighteen patients had a Mental Score of 10 or above (max 13) while 12 had variable degrees of cognitive impairment. Four patients had a score of 3 or less. No patients required any further analgesia between the insertion of the block and the 1-h assessment. Seventeen

Discussion

Our results suggest that a fascia iliaca block performed via a plexus blockade catheter provides significant benefit to elderly patients with hip fractures. We performed the study as a prospective case series as we were particularly keen to include equally patients with and without cognitive impairment. Randomisation of an unproven technique or the use of placebo in demented patients was deemed unacceptable for this patient subgroup.

The Visual analogue scores improved significantly in patients

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