Pre-operative analgesia for patients with femoral neck fractures using a modified fascia iliaca block technique
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
References (17)
- et al.
Analgesia requirements following hip fracture in the cognitively impaired
Injury
(2000) - Audit Commission. United They Stand; Co-ordinating Care for Elderly Patients with Hip Fracture. A national Report....
- et al.
Psoas Block for surgical repair of hip fracture: a case report and description of a catheter technique
Anaesth Analg
(1990) - et al.
Comparison of the three-in-one and Fascia Iliaca compartment blocks in adults
Anaesth Analg
(1998) Post-operative analgesia following femoral neck surgery—a comparison between 3-in-1 femoral nerve block and lateral cutaneous nerve block
Eur J Anaesthesiol
(1991)- et al.
Femoral nerve block in extracapsular femoral neck fractures
J Bone Joint Surg [Br]
(1995) - et al.
Postoperative analgesia after triple nerve block for fractured neck of femur
Anaesthesia
(1991)
Cited by (53)
A review of evidence-based clinical practice on fascia iliaca compartment block for lower limb injury
2021, Annals of Medicine and SurgeryEvaluation of the intensity and management of pain before arrival in hospital among patients with suspected hip fractures
2020, International Emergency NursingCitation Excerpt :The patients in this study are representative of the Swedish population of patients with hip fractures, since the distribution of age and gender in our study was similar to the distribution in the Swedish National Registry of hip fracture patient care [4]. Other studies that start pain recording and management after admission to hospital report similar numerical pain scores ranging from 7 to 9 before treatment, when using scales that grade the severity of pain from 0 to 10 [20,47–50]. This implies that pain at baseline may be valid for patients in an international setting, as the demographics (i.e. age and gender proportions) of the patients in this study correspond to those of an international population [51,52].
Pre-operative pain management with nerve block in patients with hip fractures: a randomized, controlled trial
2019, International Journal of Orthopaedic and Trauma NursingCitation Excerpt :Sample size calculation was performed using data from Candal-Couto (Candal-Couto et al. 2005). It was proposed that, using a Visual Analogue Scale (VAS), the pain score on movement would be reduced from 7.2 (SD 1.8) prior to injection to 3.6 (SD 2.4) 1 h after the injection (Candal-Couto et al. 2005). In the control group, we expected a reduction in pain score on movement from 7.2 (SD1.8) to 5.5 (SD2.4) using a VAS.
Systematic review of the effects of fascia iliaca compartment block on hip fracture patients before operation
2018, British Journal of AnaesthesiaPatients with suspected hip fracture in the chain of emergency care: An integrative review of the literature
2018, International Journal of Orthopaedic and Trauma NursingCitation Excerpt :Alternative methods such as nerve block as preoperative pain relief were highlighted by randomised controlled studies (RCT) (Foss et al., 2007; Godoy Monzon, Vazquez, Jauregui et al., 2010). Eleven other quantitative studies also showed benefits of nerve blocks for patients with hip fractures (Beaudoin et al., 2013; Candal-Couto et al., 2005; Dochez et al., 2014; Fletcher et al., 2003; Godoy Monzon et al., 2007; Hanna et al., 2014; Høgh et al., 2008; Lees et al., 2016; McRae et al., 2015; Newman et al., 2013; Williams et al., 2016). One study was critical to single-shot nerve blocks because the duration of effect is shorter than waiting time to operation.