Three Part Question
In [fracture neck of femur] is [IV opioid better than fermoral block] in [alleviating pain and distress]
MEDLINE 1966-11/04 using the OVID interface.
[hip fracture.mp. or exp hip fracture/ OR exp femoral neck fractures/ or femoral neck.mp. or exp Femur Neck/] AND [femoral nerve.mp. or exp Femoral Nerve/ OR nerve block.mp. or exp nerve block/ OR exp LIDOCAINE/ OR exp BUPIVACAINE/ OR exp Anesthetics, Local/ OR local anaesthetic$.mp. OR exp Anesthesia, Local/ OR exp Nerve Block/] LIMIT to HUMAN AND ENGLISH
Altogether 65 papers found of which 8 were relevant to the study question.
|Author, date and country
||Study type (level of evidence)
|Fletcher AK, Rigby AS and Heyes FLP,|
|50 patients age range 63-89 with fracture neck of femur
3-in-1 femoral nerve block (with 20 mL of 0.5% bupivacaine) vs systemic analgesia alone||RCT||Mean pain score using 0-3 scale||Greater reduction in nerve block group with mean difference [95% CI]: -0.78 [-1.02 to -0.54]||Small numbers
Method of radonmisation unclear|
|Time to best response||Mean difference [95% CI]: -2.93 [-5.48 to -0.38h]|
|analgesic requirements||Reduced in 24 hours from admission in nerve block group|
|Haddad FS and Williams RL,|
|50 patients with extracapsular fractures of the femoral neck, age range 68 - 89 Femoral nerve block (0.3 ml/kg 0.25% bupivicaine) vs systemic analgesia alone||RCT||Mean pain score using VAS||Greater reduction in nerve block group - statistically significant at 15 mins and 2 hours||Small number of patients
Only extracapsular fractures included
? Optimal analgesia given to control group|
|Analgesic requirements||Reduced in the 24 hours from admission in nerve block group|
|Incidence of complications||Significantly reduced in nerve block group|
The above studies suggest some benefit for the use of nerve block in fracture neck of femur in the pre-operative setting, in an emergency department. However the studies are small and have important weaknesses.
Clinical Bottom Line
In patients with suspected fracture neck of femur, regional nerve block may benefit in reducing parentral analgesic requirements and in achieving pain relief faster.
Level of Evidence
Level 2 - Studies considered were neither 1 or 3.
- Alan K.Fletcher, Alann S. Rigby, Francis L.P.Heyes three-in-one femoral Nerve block as Analgesia for fracture neck of Femur in the Emergency Department: A Randomized, Controlled Trial Annals of Emergency Medicine febuary 2003 41:2 227-233
- Haddad FS, Williams RL. Femoral nerve block in extracapsular femoral neck fractures. J Bone Joint Surg Br 1995;77(6):922-3.