Pain Management
Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: A randomized, controlled trial*

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Abstract

Study objective: We determine whether 3-in-1 femoral nerve block is effective as analgesia for fractured neck of femur when administered by emergency physicians. Methods: This was a prospective, randomized controlled trial with blinded assessors conducted in a district general hospital emergency department in the United Kingdom. Over a 6-month period, all patients with fractured neck of femur were considered for study. Patients were randomly assigned to receive 3-in-1 nerve block with bupivacaine plus intravenous morphine or intravenous morphine. An accreditation package for all ED medical staff was devised to ensure competence in the technique of 3-in-1 nerve block. Pain scores were recorded on arrival and at intervals up to 24 hours after admission. Morphine consumption in the first 24 hours was recorded. Results: Ninety-four patients sustained fractured neck of femur during the study period; 50 were studied. Of 44 not studied, 42 were confused, 1 did not consent, and 1 was overlooked. Patients receiving 3-in-1 nerve blocks recorded a faster time to reach the lowest pain score: 2.88 hours for patients with nerve block and 5.81 hours for control patients (mean difference −2.93 h; 95% confidence interval [CI] −5.48 to −0.38 h). Nerve block recipients required significantly less morphine per hour than control patients (mean of 0.49 mg/h versus 1.17 mg/h; mean difference −0.68 mg/h; 95% CI −1.23 to −0.12 mg/h). Conclusion: Three-in-one femoral nerve block is an effective method of providing analgesia to patients with fractured neck of femur in the ED. All grades of medical staff were able to apply and consolidate this skill. [Ann Emerg Med. 2003;41:227–233.]

Introduction

Fractured neck of femur causes significant mortality and morbidity in elderly patients. Even with optimum so-called fast tracking of these patients through hospital admission, surgery, and rehabilitation, mortality rates of 18% at 90 days can be anticipated.1 Patients with fractured neck of femur are often in considerable pain, and minimizing this has important implications for patient comfort and reduction of morbidity and mortality.2 The 3-in-1 femoral nerve block is a safe and widely practiced local anesthetic technique used to supplement anesthesia and provide postoperative analgesia after hip surgery.3 Local anesthetic infiltrates the femoral nerve sheath and tracks cranially and laterally to anesthetize the femoral and obturator nerves, the lower cords of the lumbar plexus, and the lateral cutaneous nerve of the thigh (Figure 1).Two previous studies4, 5 have shown that femoral nerve block provides effective analgesia for patients with fractured neck of femur in the emergency department, but each relied on one practitioner's expertise for block administration and might consequently have been relatively selective in patients recruited. One of these studies5 did not have a control group. Another recent study6 has successfully used 3-in-1 femoral nerve block for fractures of the upper femur, but the study population was not clearly described, had no control group, and once again relied on expert block administration.

This study was conducted to assess whether 3-in-1 femoral nerve block is effective when taught to and implemented by ED medical staff. Our study was powered to detect a 40% reduction in pain scores in those given a nerve block. The applicability of the technique has been evaluated in a United Kingdom district general hospital ED setting.

Section snippets

Materials and methods

The study was conducted in the ED of our medium-sized district general hospital in the United Kingdom. The ED handles 65,000 new attendances per year. Local research ethical committee approval for the study was obtained. Patients were recruited during a 6-month period, from February until August, coinciding with senior house officer (intern) posts. Two consultants, 4 middle-grade physicians, and 7 senior house officers staff our ED. An accreditation package was developed for all ED medical

Results

The characteristics of the 2 patient groups are given in Table 1.

. Patient characteristics.

VariableStudy Patients (N=24)Control Group (N=26)
Mean age, y (SD)76 (13)80 (9)
Female sex, No. (%)17 (71)18 (69)
Intertrochanteric, No. (%)15 (63)15 (58)
Subcapital-transcervical, No. (%)9 (37)11 (42)
Mean time to surgery, h (SD)29.3 (20.8)27.4 (16.5)
Mean pain score on arrival (SD)2.8 (0.4)2.7 (0.6)
All but 1 (consultant) of the 14 ED medical staff performed nerve blocks. No one physician or grade performed more

Discussion

We show that 3-in-1 femoral nerve block is effective in producing analgesia in the ED for patients with fractured femoral neck. Analgesia is achieved substantially quicker in patients receiving the nerve blocks, and these patients require less morphine, reproducing the findings of other studies. This has many potential advantages for patient care, and above all, our data show that the 3-in-1 nerve block technique can be generally applicable. The frequency of admissions of patients with

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*

Address for reprints: Alan Fletcher, MRCP(UK), Department of Emergency Medicine, Northern General Hospital, Herries Road, Sheffield, United Kingdom S5 7AU; +44 0114 2714741, fax +44 0114 2560472; E-mail [email protected].

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