Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial

Abstract

Objectives: To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture.

Design: Multisite randomized controlled trial from April 2009 to March 2013.

Setting: Three New York hospitals.

Participants: Individuals with hip fracture (N = 161).

Intervention: Participants were randomized to receive an ultrasound-guided, single-injection, femoral nerve block administered by emergency physicians at emergency department (ED) admission followed by placement of a continuous fascia iliaca block by anesthesiologists within 24 hours (n = 79) or conventional analgesics (n = 82).

Measurements: Pain (0-10 scale), distance walked on Postoperative Day (POD) 3, walking ability 6 weeks after discharge, opioid side effects.

Results: Pain scores 2 hours after ED presentation favored the intervention group over controls (3.5 vs 5.3, P = .002). Pain scores on POD 3 were significantly better for the intervention than the control group for pain at rest (2.9 vs 3.8, P = .005), with transfers out of bed (4.7 vs 5.9, P = .005), and with walking (4.1 vs 4.8, P = .002). Intervention participants walked significantly further than controls in 2 minutes on POD 3 (170.6 feet, 95% confidence interval (CI) = 109.3-232 vs 100.0 feet, 95% CI = 65.1-134.9; P = .04). At 6 weeks, intervention participants reported better walking and stair climbing ability (mean Functional Independence Measure locomotion score of 10.3 (95% CI = 9.6-11.0) vs 9.1 (95% CI = 8.2-10.0), P = .04). Intervention participants were significantly less likely to report opioid side effects (3% vs 12.4%, P = .03) and required 33% to 40% fewer parenteral morphine sulfate equivalents.

Conclusion: Femoral nerve blocks performed by emergency physicians followed by continuous fascia iliaca blocks placed by anesthesiologists are feasible and result in superior outcomes.

Keywords: functional recovery; hip fracture; pain.

© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

Figures

Figure 1. CONSORT Diagram

Figure 1 details enrollment statistics and intervention protocols. Patients were eligible for inclusion if they were aged 60 years or older with a radiographically confirmed hip fracture (femoral neck, intertrochanteric, or peri-capsular). We excluded patients: with multiple trauma, cancer-related fractures, bilateral hip fractures, or previous fracture or surgery at the currently fractured site; transferred from another hospital; presenting greater than 48 hours after fracture; with a history of substance abuse as evidenced by an affirmative response to either of the first two items on the Drug Abuse Screening Test or documentation of a history of substance abuse in the medical record; who were delirious as determined by the Confusion Assessment Method (CAM); who did not speak English, Spanish, or Russian; with a history of an allergy or adverse reaction to bupivacaine/ropivicaine; with an allergy to opioid analgesics; with a bleeding diatheses, unable to self-report their pain, or with moderate cognitive impairment as documented by a score of 3 or less on the Callahan six item screener. Details regarding the 1004 excluded patients are as follows: Advanced dementia - 390, ruled out for hip fracture - 86, presented after study hours - 102, under age 60 - 168, language barrier - 72, pathologic fracture - 68, over 48 hours at home before presenting to ED - 45, decision for non-operative management - 29, bilateral fracture - 17, substance abuse - 15, transferred from another hospital - 12. Following enrollment, subjects were randomized to FNB or conventional care using a stratified blocked randomization list with stratification by site. The block size for the randomization was randomly chosen for each block as either 2, 4 or 6 patients.33.

Figure 2. Emergency Department Pain

Mean pain scores with standard errors for pain at ED admission (baseline) and subsequently at 1 and 2 hours following ED admission for control patients (solid lines) and intervention patients (dashed lines). Pain was rated on numeric rating scales from 0-10.

Figure 3. Post-Operative Pain Outcomes

Mean pain scores for pain at rest, pain with transfers out of bed, and pain with walking with standard error bars for control patients (shaded) and intervention patients (hashed) for post-operative days 3. Pain was rated on numeric rating scales from 0-10.