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Regional Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review

  • Brandon Ritcey (a1), Paul Pageau (a1), Michael Y. Woo (a1) (a2) and Jeffrey J. Perry (a1) (a2)
Abstract
AbstractObjectives

Hip and femoral neck fractures are common in elderly patients, who are at an increased risk of complications if their pain is suboptimally managed. This systematic review seeks to determine if regional nerve blocks reduce pain, reduce the need for parenteral opiates, and reduce complications, compared to standard pain management with opiates, acetaminophen, or NSAIDs.

Data sources

Systematic review of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials found 401 articles, of which nine were selected for inclusion.

Study selection

Randomized controlled trials including adult patients with a hip or femoral neck fracture (Population) who had a 3-in-1 femoral nerve block, traditional femoral nerve block, or fascia iliaca compartment block performed preoperatively (Intervention). Comparison must have been made with standard pain management with opiates, acetaminophen, or NSAIDs (Comparison) and outcomes must have included pain score reduction (Outcome).

Data synthesis

Eight out of nine studies concluded pain scores were improved with the regional nerve block compared to standard pain management. A significant reduction in parenteral opiate use was seen in five out of six studies. No patients suffered life-threatening complications related to the nerve block; however, more minor complications were under-reported. Most of the studies were at a moderate to high risk of bias.

Conclusions

Regional nerve blocks for hip and femoral neck fractures have a benefit in reducing pain and the need for IV opiates. The use of these blocks can be recommended for these patients. Further high-quality randomized controlled trials are required.

RÉSUMÉObjectifs

Les fractures de la hanche et du col du fémur sont fréquentes chez les personnes âgées, qui connaissent un risque accru de complications si le soulagement de la douleur n’est pas suffisant. La revue systématique présentée ici visait à déterminer si l’analgésie régionale par blocage nerveux permettait d’atténuer la douleur, de réduire la nécessité d’administrer des opiacés par voie parentérale et de diminuer le risque de complications comparativement au traitement habituel de la douleur par les opiacés, l’acétaminophène ou les anti-inflammatoires non stéroïdiens (AINS).

Sources de données

Une revue systématique effectuée dans les bases de données MEDLINE, EMBASE, CINAHL et Cochrane Central Register of Controlled Trials a permis de relever 401 articles, dont 9 ont été retenus pour l’étude.

Sélection des études

Il s’agissait d’essais comparatifs à répartition aléatoire, menés chez des adultes qui avaient subi une fracture de la hanche ou du col du fémur (population) et qui avaient été traités par un bloc fémoral « 3 en 1 », un bloc fémoral classique ou un bloc de la loge du fascia iliaque en phase préopératoire (intervention). Les comparaisons devaient avoir été établies avec le traitement habituel de la douleur par les opiacés, l’acétaminophène ou les AINS (comparaison) et les résultats devaient faire état d’une réduction du score de la douleur (résultats [outcome]).

Synthèse des données

Dans huit études sur neuf, on a noté une réduction des scores de la douleur, liée à l’analgésie régionale par blocage nerveux comparativement au traitement habituel de la douleur. Une diminution importante de l’utilisation des opiacés par voie parentérale a été constatée dans cinq études sur six. Aucune complication potentiellement mortelle n’a été observée en lien avec l’analgésie régionale; toutefois, des complications bénignes ont été sous-déclarées. La plupart des études comportaient un risque moyen ou élevé de biais.

Conclusions

L’analgésie régionale par blocage nerveux pour les fractures de la hanche ou du col du fémur soulage efficacement la douleur tout en diminuant la nécessité d’administrer des opiacés par voie intraveineuse. Le recours à ce type d’analgésie est donc recommandable chez ces patients. Il faudrait toutefois mener d’autres essais comparatifs, à répartition aléatoire, de qualité.

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Copyright
Corresponding author
Correspondence to: Dr. Brandon Ritcey, Department of Emergency Medicine, The Ottawa Hospital - Civic Campus, 1053 Carling Ave., E-Main Room EM-206, Box 227, Ottawa, ON K1Y 4E9; Email: britcey@toh.on.ca
Linked references
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1. RS Morrison , J Magaziner , M Gilbert , et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003;58(1):76-81.

2. AP Winnie , S Ramamurthy , Z Durrani . The inguinal paravascular technic of lumbar plexus anesthesia: the “3-in-1 block”. Anesth Analg 1973;52(6):989-996.

3. B Dalens , G Vanneuville , A. Tanguy Comparison of the fascia iliaca compartment block with the 3-in-1 block in children. Anesth Analg 1989;69(6):705-713.

6. JP Higgins , DG Altman , PC Gøtzsche , et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928.

10. FL Beaudoin , JP Haran , O Liebmann . A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial. Acad Emerg Med 2013;20(6):584-591.

11. AK Fletcher , AS Rigby , FL Heyes . 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;41(2):227-233.

14. NB Foss , BB Kristensen , M Bundgaard , et al. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anesthesiology 2007;106(4):773-778.

16. DG Monzón , J Vazquez , JR Jauregui , et al. Pain treatment in post-traumatic hip fracture in the elderly: regional block vs. systemic non-steroidal analgesics. Int J Emerg Med 2010;3(4):321-325.

18. A Abou-Setta , LA Beaupre , S Rashiq , et al. Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Ann Intern Med 2011;155(4):234-245.

20. G Mouzopoulos , G Vasiliadis , N Lasanianos , et al. Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study. J Orthop Traumatol 2009;10(3):127-133.

21. P Marhofer , K Schrögendorfer , H Koinig , et al. Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anesth Analg 1997;85(4):854-857.

22. P Marhofer , K Schrögendorfer , T Wallner , et al. Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks. Reg Anesth Pain Med 1998;23(6):584-588.

23. J Dolan , A Williams , E Murney , et al. Ultrasound guided fascia iliaca block: a comparison with the loss of resistance technique. Reg Anesth Pain Med 2008;33(6):526-531.

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Canadian Journal of Emergency Medicine
  • ISSN: -
  • EISSN: 1481-8035
  • URL: /core/journals/canadian-journal-of-emergency-medicine
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