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Femoral Nerve Block for Diaphyseal and Distal Femoral Fractures in the Emergency Department
Christopher E. Mutty, MD1; Erik J. Jensen, MD2; Michael A. MankaJr., MD2; Mark J. Anders, MD2; Lawrence B. Bone, MD2
1 Department of Orthopaedic Surgery, Wake Forest University Health Sciences, Medical Center Boulevard, Winston-Salem, NC 27157. E-mail address: cmutty@buffalo.edu
2 Departments of Anesthesiology (E.J.J.), Emergency Medicine (M.A.M.), and Orthopaedic Surgery (M.J.A. and L.B.B.), Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at Erie County Medical Center, an affiliate of the State University of New York at Buffalo, Buffalo, New York

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2007 Dec 01;89(12):2599-2603. doi: 10.2106/JBJS.G.00413
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: Diaphyseal and distal femoral fractures are painful injuries that are frequently seen in patients requiring a trauma work-up in the hospital emergency department prior to definitive management. The purpose of this study was to determine whether a femoral nerve block administered in the emergency department could provide better pain relief for patients with femoral fractures than currently used pain management practices.

Methods: Patients who presented with an acute diaphyseal or distal femoral fracture were identified as potential candidates for this study. Eligible patients were randomized by medical record number to receive either (a) the femoral nerve block (20 mL of 0.5% bupivacaine) along with standard pain management or (b) standard pain management alone (typically intravenous narcotics). The pain was assessed with use of a visual analog scale at the initial evaluation and at five, fifteen, thirty, sixty, and ninety minutes following the initial evaluation. Fifty-four patients were enrolled in the study from April 2005 to May 2006. Thirty-one patients received a femoral nerve block, and twenty-three patients received standard pain management alone.

Results: Baseline scores on the visual analog pain scale did not differ between the groups at the initial evaluation. The patients who received a femoral nerve block (along with standard pain management) had significantly lower pain scores at five, fifteen, thirty, sixty, and ninety minutes following the block than did the patients who received standard pain management alone (p < 0.001). The score on the visual analog pain scale across these time-points was an average of 3.6 points less (on a 10-point scale) for those who received the block. There were no infections, paresthesias, or other complications related to the femoral nerve block.

Conclusions: The acute pain of a diaphyseal or distal femoral fracture can be significantly decreased through the use of a femoral nerve block which can be administered safely in the hospital emergency department.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Christopher E Mutty, M.D.
    Posted on March 19, 2008
    Dr. Mutty responds to Dr. Rogers, et al.
    Wake Forest University Health Sciences, Winston-Salem, NC

    Drs. Rogers and Rang bring up several points in their letter regarding our study(1) that I would like to address.

    The first and most pointed question raised by Drs. Rogers and Rang is whether we should be doing nerve blocks at all in acute lower extremity injuries. The risk-benefit ratio for femoral nerve block for femur fracture pain was carefully examined prior to the start of the study(1). Trauma patients in the emergency department are in a unique category. These patients often have severe, multiple injuries. To adequately manage the pain of a fractured femur would require a level of IV opioid analgesia that could alter subtle clues to the trauma team that additional, potentially life threatening conditions may be present or developing in the patient. Perhaps an improved protocol for systemic analgesia can be designed which does not diminish the trauma team's ability to monitor the patient.

    In the meantime, we should evaluate all of the tools currently available for improving inadequately managed fracture pain. The femoral nerve block has shown itself to be a very effective method for controlling femur fracture pain. Use of the block does require an increased awareness for the development of compartment syndrome and, as stated in the article, we do not recommend use of the block in patients at increased risk for this complication. 21 of the 31 patients in the study who received a block sustained their fracture through a high energy mechanism (most commonly a motor vehicle accident). These fractures were AO-OTA type 32 (diaphyseal) and 33 (distal) fractures. The majority of the diaphyseal fractures were subtypes A (simple) and B (wedge), but there were several subtype C (complex) patterns. The distal fractures were either subtype A (extra-articular) or C (complete articular) and some degree of comminution was present in both subtypes. No patient in the study developed a compartment syndrome and all patients were followed around the clock by orthopaedic house staff. While important for helping to indicate the degree of energy imparted to the soft tissues, it appears that fracture pattern should not serve as a sole determinant in deciding which patients are appropriate candidates for the block.

    We used a threshold minimum nerve stimulation current of 0.8 mA to produce a quadriceps muscle twitch. Experience demonstrated that this current level provided a reliable patellar twitch. Optimizing needle placement by adjusting current downward to less than 0.5 mA while maintaining patellar twitch may have resulted in improved pain scores in the few patients who received the block but continued to report high pain levels (as suggested by Drs. Rogers and Rang). Ultrasound is being increasingly used for nerve localization in peripheral nerve blocks and is available in our emergency department. The peripheral nerve stimulator technique for nerve localization was quickly mastered by the orthopaedic house staff and could be performed efficiently in the trauma setting. However, as more experience is gained with ultrasound techniques, its use for this indication will be evaluated and the results compared to those achieved with the stimulator technique. While cardiotoxicity has not been reported with the use of our femoral nerve block protocol, this remains a concern as there is a risk of intravascular injection with improper technique. Levobupivacaine and ropivacaine are prepared in an almost pure L-isomer form whereas bupivacaine is a racemic mixture of the D and L isomers. Levobupivacaine and ropivacaine have reportedly less cardiotoxicity than bupivacaine because they contain almost none of the D-isomer form. Levobupivacaine is 5 times more expensive, and ropivacaine 8 times more expensive, than bupivacaine(2). The real world difference in cost is ~$10 for our application and I agree either of these agents is probably a better choice given their improved side effect profile.

    Finally, the importance of explaining the risks and benefits of any procedure cannot be understated. Obtaining informed consent in the acute trauma setting is a significant challenge but must be done appropriately before proceeding with any intervention.

    References:

    1. Mutty CE, Jensen EJ, Manka MA, Anders MJ, Bone LB. Femoral nerve block for diaphyseal and distal femoral fractures i the emergency department. J Bone Joint Surg Am. 2007;89:2599-2603.

    2. Panni M, Segal S. New local anesthetics – Are they worth the cost? Anesthesiology Clin N Am. 2003; 21:19-38.

    Christopher E Mutty, M.D.
    Posted on March 18, 2008
    Dr. Mutty Responds to Dr. Singisetti
    Wake Forest University Health Sciences, Winston-Salem, NC

    Dr. Singisetti's letter regarding our study(1) is comprehensive and I agree with many of his points. I would like to address several of the issues he raised.

    ATLS protocol must be followed for any patient arriving at the emergency department with injuries (including femur fractures) or a mechanism of injury that warrants this approach. Our femoral nerve block protocol and how the block was integrated into ATLS protocol will be more fully described in an upcoming Surgical Techniques Supplement of the Journal. In brief, we typically administered the block shortly after the secondary survey was completed.

    A complete neurological evaluation of every trauma patient must be performed and, as stated in the article, the block is contraindicated in any patient with an abnormal neurovascular exam of the injured lower extremity.

    Dr. Singisetti appropriately states that technique is important in avoiding both intravascular and intraneural injection. As these patients are receiving the injection in the emergency department, they are, by definition, receiving the block where resuscitation facilities are at hand. More important than readily available resuscitation facilities is the ability of those administering the block to recognize signs of cardiotoxicity related to the anesthetic. Although cardiotoxicity secondary to intravascular injection has not been previously reported using our femoral nerve block protocol, it remains a potential complication, and users of the technique must be able to recognize its signs and be prepared to treat it appropriately. A more detailed discussion of this issue will be available in the upcoming Surgical Techniques article.

    We dedicated a substantial portion of our Discussion to the topic of compartment syndrome of the thigh. Dr. Singisetti references an article(2) in which a leg (not thigh) compartment syndrome was missed in a patient who underwent intramedullary nailing of a tibial fracture and who received a "3 in 1" nerve block postoperatively(this is a modification of the femoral nerve block and provides a more complete block of the lower extremity). As stated in the article, for patients receiving the femoral nerve block for a femur fracture, a higher level of vigilance for the development of compartment syndrome is warranted.

    Finally, a "3 in 1" nerve block may be more effective than an isolated femoral nerve block in providing relief of the pain associated with a femur fracture. However, this technique typically requires an injection more proximal than that for an isolated femoral nerve block and is, therefore, more difficult to perform. Our results showed that the isolated femoral nerve block can be safely administered by orthopaedic house staff and that it is effective in providing pain relief in this setting.

    References:

    1. Mutty CE, Jensen EJ, Manka MA, Anders MJ, bone LB. Femoral nerve block for diaphyseal and distal femoral fractures in the emergency department. J Bone Joint Surg Am. 2007;89:2599-2603.

    2. Hyder N, Kessler S, Jennings AG, De Boer PG. Compartment syndrome in tibial shaft fracture missed because of a local nerve block. J Bone Joint Surg [Br] 1996;78-B:499-500.

    Kiran K Singisetti
    Posted on February 15, 2008
    Precautions in use of femoral nerve block for diaphyseal and distal femoral fractures
    Queen Elizabeth Hospital, Gateshead

    To The Editor:

    I read with interest the article by Mutty et al.[1] regarding use of femoral nerve block for diaphyseal and distal femoral fractures.

    The authors are aware of the possibility for bias due to randomisation methods used, but we should appreciate the difficulty of randomization in an emergency care setting. Regional nerve blocks are effective in pain control and have sustained effects with less systemic problems when used appropriately. The use of femoral nerve block has been well described for femoral neck fractures[2,3]. I have the following comments about the procedure.

    The timing of these procedures was not clearly stated in the article. The authors state that the mechanism of injury in many of the patients with femoral fractures was motor vehicle accidents. It is vital therefore, to follow an ATLS[4] protocol when such patients arive at the emergency department. All attempts to diagnose and treat life and limb threatening injuries should be made from the outset.

    Complete neurological examination should be made before performing any nerve block because this may mask any signs of neurological injuries such as those following thoraco-lumbar spine fractures, peripheral nerve injuries, etc.

    Intravascular and intraneural injection of local anaesthetic can be avoided by careful technique. It is best to perform such procedures with resuscitation facilities at hand because of the potential cardio toxicity related to bupivacaine.

    Though the authors rightly mention the risk of compartment syndrome of the thigh. Missed compartment syndrome of the leg has been described due to nerve block[5].

    A history of bleeding diathesis would be a relative contraindication for any nerve block.

    A triple or three in one nerve block (femoral, lateral cutaneous, and obturator nerves) would logically give more pain relief compared to isolated femoral nerve block.

    The author did not receive any outside funding or grants in support of his/her research for or preparation of this work. Neither he/she nor a member of his/her immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his/her immediate family, is affiliated or associated .

    References:

    1. Mutty CE, Jensen EJ, Manka MA, Jr., Anders MJ, Bone LB. Femoral nerve block for diaphyseal and distal femoral fractures in the emergency department. J.Bone Joint Surg.Am 2007; 89:2599-2603

    2. Parker MJ, Griffiths R, Appadu BN. Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures. In: The Cochrane Library, Issue 1, 2006. Chichester, UK: John Wiley & Sons, Ltd. Search date 2001.

    3. Kullenberg B, Ysberg B, Heilman M, et al. Femoral nerve block as pain relief in hip fracture. A good alternative in perioperative treatment proved by a prospective study. Lakartidningen 2004;101:2104–2107. [In Swedish] [PubMed]

    4. Advanced Trauma Life Support – Student Course Manual, 7th Edition. 2004. American College of Surgeons.

    5. Hyder N, Kessler S, Jennings AG, De Boer PG. Compartment syndrome in tibial shaft fracture missed because of a local nerve block. J Bone Joint Surg [Br] 1996;78-B:499-500.

    Benedict A Rogers, MA, MSc, MRCGP, MRCS
    Posted on January 07, 2008
    Femoral Nerve Block for Diaphyseal and Distal Femoral Fractures in the Emergency Department
    St Peter's Hospital, Chertsey, UK

    To The Editor:

    We read with interest the paper by Mutty et al.(1) and we would like to make the following points:

    The authors make reference in the Methods section to the risk of compartment syndrome as an exclusion criterion for the study. However, compartment syndrome is a serious complication of lower limb trauma that has a poor outcome(2), necessitates rapid treatment(3), and its diagnosis can be problematic(4). Should we risk reducing its detection with the nerve block or would an improved protocol for IV opioid analgesia be safer?

    The study details fracture location, but omits any description of fracture comminution. Fracture comminution correlates to the amount of energy that is dissipated and to the degree of soft tissue damage, inceasing the risk of compartment syndrome. In contrast, low energy fractures have different specific morphological features(5).

    In their description of peripheral nerve stimulation methods, the authors did not specify the threshold minimum nerve stimulation current to produce a quadriceps twitch that was accepted before injection of local anaesthetic. If this threshold was greater than 0.5mA, there would be a risk that the needle tip was too distant from the nerve, and the infiltrated local anaesthetic would be ineffective(6). Failure to achieve a successful block by this mechanism may explain the few patients who had a block, but continued to have high pain scores throughout the study period.

    The study utilises peripheral nerve stimulation for femoral nerve localisation. Ultrasound has been increasingly used as an alternative to peripheral nerve stimulation, allowing identification of the femoral nerve, artery and vein and enabling accurate deposition of local anaesthetic around the nerve. An ultrasound-guided technique may decrease onset time, improve quality, reduce failure rate, and permit a lower dose of local anaesthetic(7). Ultrasound is often readily available in emergency departments and emergency physicians may already be experienced in their use.

    The use of 0.5% bupivacaine risks cardiotoxicity and cardiac arrest following intravascular injection. Levobupivacaine has been shown to have a superior side effect profile(8) with less cardiotoxicity. This may be a more suitable choice of local anaesthetic for a femoral nerve block in the emergency department setting.

    Gaining informed consent from patients with severe pain is challenging(9), especially in an acute trauma setting. It is important to explain the potential benefits and risks of femoral nerve block and to ascertain that the risks have been understood and accepted before proceeding.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. Mutty, Jensen EJ, Manka MA, Jr., Anders MJ, Bone LB. Femoral nerve block for diaphyseal and distal femoral fractures in the emergency department. J.Bone Joint Surg.Am 2007; 89:2599-2603

    2. Gulli, Templeman D. Compartment syndrome of the lower extremity. Orthop Clin North Am 1994; 25:677-684

    3. Cascio, Pateder DB, Wilckens JH, Frassica FJ. Compartment syndrome: time from diagnosis to fasciotomy. J.Surg.Orthop Adv. 2005; 14:117-121

    4. Swain, Ross D. Lower extremity compartment syndrome. When to suspect acute or chronic pressure buildup. Postgrad.Med. 1999; 105:159-62, 165, 168

    5. Salminen, Pihlajamaki H, Avikainen V, Kyro A, Bostman O. Specific features associated with femoral shaft fractures caused by low-energy trauma. J.Trauma 1997; 43:117-122

    6. Gurnaney, Ganesh A, Cucchiaro G. The relationship between current intensity for nerve stimulation and success of peripheral nerve blocks performed in pediatric patients under general anesthesia. Anesth.Analg. 2007; 105:1605-9, table

    7. Marhofer, Schrogendorfer K, Wallner T, Koinig H, Mayer N, Kapral S. Ultrasonographic guidance reduces the amount of local anesthetic for 3- in-1 blocks. Reg Anesth.Pain Med. 1998; 23:584-588

    8. Gristwood. Cardiac and CNS toxicity of levobupivacaine: strengths of evidence for advantage over bupivacaine. Drug Saf 2002; 25:153-163

    9. Williams, French JK, White HD. Informed consent during the clinical emergency of acute myocardial infarction (HERO-2 consent substudy): a prospective observational study. Lancet 2003; 361:918-922

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