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Three Part Question

[In Adult patients with painful Hip/Femur Fracture] can [Fascia Iliaca Compartment Block] be used to [ achieve sufficient pain control]

Clinical Scenario

An elderly lady presented in severe pain with shorted and externally rotated leg in keeping with a NOF fracture. You are worried about giving her iv Morphine. In your anaesthetic secondment you observed a Fascia iliaca Block being used for post operative pain control and you wonder whether you can do the same.

Search Strategy

Ovid MEDLINER 1950-March 2010
EMBASE 1980-2010 week 11 using multifile searching

[(fractured and neck and femur) or (femur and fracture) or fractured neck of femur or hip or hips or femur or hip fracture or hip injury or femur neck fracture or femur fracture] AND [(fascia and iliaca and block) or (fascia and iliaca and compartment) or fascia] Limit to adults, humans, English Language. Duplicates removed.

Search Outcome

255 papers were found. All abstracts were reviewed and only 6 papers were selected as they are pertaining to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Sandrine L, Gros T et al 2003 France	27 patients with a suspected Femur fracture based on History and clinical findings. Mean age 26 y. Excluded <18 years, GCS<15.	Prospective observational study.	Pain score prior to Block, at 10 minutes and on arrival to Trauma centre.	The pain score decreased 10 minutes after the block as well as on arrival to trauma centre (45 minutes median time) P= .000001. Only 1 patient required supplemental analgesia. No adverse complications.	Technique performed by Anaesthesists experienced in regional blocks. No Comparison group available to confirm the superiority of the FIB.
Candal-Couto J, McVie J et al. 2004 UK	30 consecutive patients with NOF fracture including those with dementia (12 patients). Mean age 77.	Prospective consecutive observational study.	Pain assessed in the form of a Sitting Scale and Pain-free passive flexion of the hip. Also used 10-point visual analogue scale (VAS). Measurements were done pre- and 1h post block.	Post block 24 patients managed a Sitting Score of >2 (Semirecumbant using >2 pillows) as compared to none prior to block. Flexion improved by mean 44 degree post block. VAS improved from 7.2 to 3.2 post block. P-value < .001 for all findings.	The lack of blinding and of a control group can enforce a placebo effect. The objective assessment of pain was open to bias as patients were examined by the investigators.
Monzon G and Iserton K et al 2006 Argentina	63 adult patients mean age 73.5 with confirmed NOF fracture on X-Ray. A FIB was administered by ED Physician.	Prospective consecutive observational study.	Pain relief as measured on VAS at 15 min, 2h, 8h. Also subjectively assessed sensory loss over the affected skin dermatomes.	Significant decrease in the level of pain from 15 min to 8 h post Block.	No information available to who measured the pain scores and how. Few elderly patients with NOF fracture will have dementia that will render any pain assessment almost impossible.
Foss N, Kristensen B et al 2007 Denmark	24 patients in FIB group vs. 24 in Morphine group	RCT. Double-blinded setup	Pain at rest and on movements at 30, 60 and 180 minutes post analgesia measured using a verbal ranking scale (VRS).	FIB provided superior pain relief to im Morphine both at rest and on 15 degree lift. Patients in the Morphine group were more sedated. No adverse incidents in the FIB group.	Randomization did not fully succeed as there was higher proportion of male patients in the FIB group. The gold standard for Opioids analgesia is an iv titrated regime whereas the control group in the study received im morphine.
Obideyi A, 2008, UK	35 Patients, aged 62-102 with NOF Fracture evident on X-Rays. Exclusion criteria included dementia and gross obesity as both impeded the assessment of the pain and the execution of the block respectively.	Prospective observational study	Pain assessed at presentation and 15 min, 2h, 8h and 24h post block using VA scale.	Pain score at presentation 8-10. 54% had pain score of 4 or less 15 min post block, 72% and 77% had pain score of 4 or less 2 and 4 h post block respectively. No reported complication.	Pain score assessed by the operators, who were 2 trained pain specialist nurses, who also performed the block. Pain score of 4 or less in 16 patients at 24h. Bupivacaine duration of action up to 20h.
Yun MJ, 2009, Korea	40 patients aged 26-88 divided in tow groups: the FICB vs. IV Fentanyl group. The intervention happened just prior to placing the patients for their spinal block.	Prospective randomised clinical study	Pain score assessed on VAS prior to block, 20 min post block and during handling the patient into the lateral decubitus position. Patients with block failure excluded. Pain score in the Fentanyl group noted at presentation, 2min post analgesia and during positioning	VAS scores at 20 min post FICB and 2 min post iv Fentanyl were no different but decreased from the base line score in both groups.. The main VAS score during positioning and 6 h post surgery was lower in the FICB than the iv group. (2 vs 4/ 2.9 vs 3.6). No additional analgesia needed in the FICB.	Blocks performed by senior anaesthetist. There was no documentation of analgesia prior to intervention. Recording the scores of pain couldn’t be blinded when a patient is obviously under Fentanyl influence.

Comment(s)

Regional anaesthesia with local anaesthetics has been associated with improved dynamic pain relief as compared to systemic opioids. Nerve blocks have been used to treat hip fracture pain. However they are usually placed near vital neurovascular structures and may require the use of a nerve stimulator for a precise application of the block. The FICB although gaining acceptance among Anaesthesists, it has probably not yet been widely advocated among ED physicians.

Editor Comment

CF

Clinical Bottom Line

Current Data support the use of FICB in the acute management of hip fracture as it seems effective, low-tech, low risk, easy to learn procedure with no reported adverse incidents. It has the potential to reduce the reliance on opioids and their side effects in a fragile group of patients.

References

1. Sandrine Lopez Fascia Iliaca Compartment Block for femoral bone fractures in prehospital care. Regional Anaesthesia and Pain Medicine Vol 28, No3, 2003: pp 203-207.
2. Candal-Couto J Pre-operative analgesia for patients with femoral neck fractures using a modified fascia ilica block technique Injury, Int. J. Care injured (2005) 36, 505-510.
3. Monzon D Single Fascia iliaca compartment block for post-hip fracture pain relief. The J of Emergency Medicine, Vol 32, No 3, pp:257-262, 2007.
4. Foss N Fascia liaca compartment blockade for acute pain control in hip fracture patients Anaesthesiology V 106, No 4, Apr 2007, pp 773-8.
5. Ayodele Obideyi. Nurse administered FICB for pre-operative pain relief in adult fractured neck of femur. Acute Pain 2008 10,145-149.
6. M J Yun. Analgesia before a spinal block for femorak neck fracture: Fascia iliaca compartment block. Acta anaesthesiology scand 2009; 53: 1282-1287.