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Hip Fracture Pain Management

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – When it comes to the best way to manage pain due to hip fracture, data are sparse but nerve blockade may have the edge over other modalities, a Canadian group reports.

Pain control is an integral part of hip fracture management, given that greater pain is associated with increased risk of delirium, slower mobilization, longer hospital stays and poorer quality of life, the researchers point out in their report in the Annals of Internal Medicine online May 17.

Since there are no guidelines on pain management in hip fracture, Dr. Ahmed M. Abou-Setta, at the University of Alberta in Edmonton, and colleagues conducted a systematic review of evidence on the effectiveness and safety of pharmacologic and nonpharmacologic strategies in this setting.

The team identified a total of 83 relevant trials and cohort studies covering nerve blockade, spinal anesthesia, systemic analgesia, traction, multimodal pain management, neurostimulation, rehabilitation, and complementary and alternative medicine.

The mean age of study participants ranged from 59 to 86 years. No study examined pain beyond 30 days, and 31 of the studies excluded patients with cognitive impairment or delirium, according to the report.

“The strength of evidence was low to moderate for some interventions in alleviating acute pain, preventing delirium, and decreasing the 30-day mortality rate,” the researchers found. “The strength of evidence for the remaining outcomes was insufficient because of inadequate numbers of studies and study power.”

Overall, nerve blockade appeared to be more effective than standard care. The authors comment: “Nerve blockade is within the repertoire of most practicing anesthesiologists, but many clinicians do not perform them routinely because they believe the additional time, effort, and supervision required may outweigh the benefits. On the contrary, the evidence would suggest that blockade may be beneficial.”

On the other hand, spinal anesthesia, while effective and safe, did not differ from general anesthesia in terms of mortality, delirium or other complications, the data indicate.

“Surprisingly few studies focused on systemic analgesics, opiates, or traditional NSAIDs,” the investigators note. As for nonpharmacologic therapies, the limited evidence available indicated that acupressure, relaxation therapy, TENS, and physical therapy were safe and may produce clinically meaningful reductions in pain.

Summing up, Dr. Abou-Setta and colleagues write: “Nerve blockade seems effective in reducing acute pain after hip fracture. Sparse data preclude firm conclusions about the relative benefits or harms of many other pain management interventions for patients with hip fracture.”

Ann intern Med 2011.