Strong evidence supports regional analgesia to improve preoperative pain control in patients with hip fracture.

Rationale
Six high strength studies (Fletcher et al 10, Foss et al 11, Haddad et al 12, Monzon et al 13, Mouzopoulos et al 14, and Yun et al 15) and one moderate strength study (Matot, 2003 16) showed beneficial outcomes. Six studies inclusive of 593 patients used a prospective randomized clinical trial design to assess the effect of regional analgesia in reducing preoperative pain after hip fracture upon presentation to the emergency department (Fletcher et al 10, Foss et al 11, Haddad et al 12, Monzon et al 13, Mouzopoulos et al, and Yun et al 15).  These studies all used a technique of administration of a local anesthetic that results in temporary loss of nerve function in the fascia iliaca or femoral compartment of the injured hip.  In each study the patients who received this agent reported significant reduction in reported preoperative pain on a visual analog scale.  One of these studies reported improved reported pain at time of administering spinal anesthesia.
 
The administration of regional analgesia in these six studies was performed by a different group of providers in each study including: emergency physicians, anesthesiologists, and orthopaedic surgeons (Fletcher et al 10, Foss et al 11, Haddad et al 12, Monzon et al 13, Mouzopoulos et al 14, and Yun et al 15).  All the providers who were administering the analgesia were trained in performance of the specific technique before the study began.  One study found the technique for this type of regional analgesia administration can be successfully taught to medical providers who were inexperienced in these skills (Fletcher et al 10). 
 
In all of these trials pain recorded with a visual analog score is a reported outcome (Fletcher et al 10, Foss et al 11, Haddad et al 12, Matot, et al 16, Monzon et al 13, Mouzopoulos et al 14, and Yun et al 15).  Reported outcomes in five of the trials were limited to the preoperative episode of care for the studies patients (Fletcher et al 10, Foss et al 11, Haddad et al 12, Monzon et al 13, and Yun et al15). 
 
Two trials reported effects beyond this initial preoperative period.   One trial reported a reduction in the incidence of postoperative delirium in addition to a reduction in preoperative pain levels in the population who received regional analgesia. Incidence of delirium with the regional analgesia group was 11% (11/102) and 24% (25/105) in the control group [relative risk 0.45, 95% CI 0.23-0.87] (Mouzopoulos et al 14).   The seventh study reported the use of epidural anesthesia administered preoperatively in hip fracture patients with known cardiac disease or who were at high risk for cardiac disease was associated with reduction of preoperative myocardial ischemia events; Adverse preoperative cardiac events occurred in 7 of 34 patients in the control group and 0 of 34 patients in the treatment group [p = 0.01] (Matot et al 16).  
 
No complications were reported in these studies using a technique of administration of a numbing agent that results in temporary loss of nerve function in the femoral compartment of the injured hip. However, the consideration of standard risks and benefits of these techniques should be considered when implementing this recommendation.

Risks and Harms of Implementing this Recommendation
Risks are equal to those of any regional anesthesia technique.

Future Research
The studies available to date report improved pain scores preoperatively.  Future research should focus on the impact of early regional analgesic technique on patient outcome.  Several important outcomes need to be studied: assessment of total opioid usage pre- and post-op, incidence of delirium during hospital stay, and length of stay; There may be others.  

 
  1. (10) Fletcher AK, Rigby AS, Heyes FL. Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med 2003;41(2):227-233.
  2. (11) Foss NB, Kristensen BB, Bundgaard M et al. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anesthesiology 2007;106(4):773-778.
  3. (12) Haddad FS, Williams RL. Femoral nerve block in extracapsular femoral neck fractures. J Bone Joint Surg Br 1995;77(6):922-923.
  4. (13) Monzon DG, Vazquez J, Jauregui JR, Iserson KV. Pain treatment in post-traumatic hip fracture in the elderly: regional block vs. systemic non-steroidal analgesics. Int J Emerg Med 2010;3(4):321-325.
  5. (14) Mouzopoulos G, Vasiliadis G, Lasanianos N, Nikolaras G, Morakis E, Kaminaris M. Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study. J Orthop Traumatol 2009;10(3):127-133.
  6. (15) Yun MJ, Kim YH, Han MK, Kim JH, Hwang JW, Do SH. Analgesia before a spinal block for femoral neck fracture: fascia iliaca compartment block. Acta Anaesthesiol Scand 2009;53(10):1282-1287.
  7. (16) Matot I, Oppenheim-Eden A, Ratrot R et al. Preoperative cardiac events in elderly patients with hip fracture randomized to epidural or conventional analgesia. Anesthesiology 2003;98(1):156-163.