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Three Part Question

[In children with fractured femus] are [fascia iliaca blocks as effective as femoral nerve blocks or traditional systemic analgesia] at [decreasing pain]

Clinical Scenario

A 9 year old boy with osteogenesis imperfecta is admitted having fallen out of bed and sustaining a left fractured femur. He is in considerable pain. He is given intranasal diamorphine and cannulated to be given systemic analgesia. You are aware that it is recommended that femoral nerve blocks should be performed with ultrasound guidance and that you are not competent to perform this procedure. You are competent to perform a fascia iliaca blocks and wonder if this would give adequate analgesia.

Search Strategy

Medline 1950-present using the interface MESZ Ovid MEDLINE.
("child"[MeSH Terms] OR "child"[All Fields] OR "children"[All Fields]) AND (("fractures, bone"[MeSH Terms] OR ("fractures"[All Fields] AND "bone"[All Fields]) OR "bone fractures"[All Fields] OR "fractured"[All Fields]) AND ("femur"[MeSH Terms] OR "femur"[All Fields])) AND (("fascia"[MeSH Terms] OR "fascia"[All Fields]) AND iliaca[All Fields] AND block[All Fields]) AND ("humans"[MeSH Terms] AND English[lang] AND ("infant"[MeSH Terms] OR "child"[MeSH Terms] OR "adolescent"[MeSH Terms]))

Search Outcome

1 paper was found and this was reviewed. This paper compared fascia iliaca blocks with systemic analgesia. There were no papers found which compared femoral nerve blocks and fascia iliaca blocks in children with femur fractures.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Wathen JE et al. Aug 2007 USA	Children aged 15 months to 18 years with acute femur fractures, presenting to a free-standing, tertiary care children's hospital.Fifty-five patients, 26 in the fascia iliaca group and 29 in the morphine sulfate group, ranged in age from 16 months to 15 years (median 5.7 years).	Prospective, randomized, unblinded, controlled trial	Primary outcome measured was pain scores; a difference of 15% in scores assessed at 30 minutes from the study's baseline pain management was considered clinically meaningful.	Mean pain scores at 30 minutes after initial treatment were 5.87 for fascia iliaca compartment nerve block and 7.54 for morphine sulfate, with a difference of 1.67, which corresponds to an 18% (95% confidence interval [CI] 8% to 27%) difference in pain reduction between the 2 groups, according to the average baseline score of 9.45.	There was no blinding of the pain assessors

Comment(s)

There are no papers which compare fascia iliaca compartment block with femoral nerve block in children. The fascia iliaca block is easy to learn and does not require ultrasound guidance, it is effective in reducing pain and is shown to give longer duration of analgesia compared to systemic opiate analgesia.

Clinical Bottom Line

Fascia iliaca block is shown to give better and longer analgesia than systemic opiates and should be considered as an alternative.

References

1. Wathen JE, Gao D, Merritt G, Georgopoulos G, Battan FK. A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Ann Emerg Med. 2007 Aug;50(2):162-71, 171.e1. Epub 2007 Jan 8.