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The Journal of Emergency Medicine, Vol. 32, No. 3, pp. 257–262, 2007Copyright © 2007 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/07 $–see front matter

doi:10.1016/j.jemermed.2006.08.011

OriginalContributions

SINGLE FASCIA ILIACA COMPARTMENT BLOCK FOR POST-HIP FRACTUREPAIN RELIEF

Daniel Godoy Monzon, MD,* Kenneth V. Iserson, MD, MBA, FACEP, FAAEM,† and Jorge A. Vazquez, MD‡

*Servicio de Ortopedia y Traumatologia, Instituto Carlos E. Ottolenghi, Hospital Italiano, Buenos Aires, Argentina, †Department ofEmergency Medicine, University of Arizona College of Medicine, Tucson, Arizona, and ‡Central de Emergencias, Hospital Italiano,

Buenos Aires, ArgentinaReprint Address: Kenneth V. Iserson, MD, Department of Emergency Medicine, University of Arizona College of Medicine,

PO Box 24-5057, 1501 N. Campbell Avenue, Tucson, AZ 85724

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Abstract—Hip fractures can cause considerable painhen untreated or under-treated. To enhance pain reliefnd diminish the risk of delirium from typically adminis-ered parenteral analgesics and continued pain, we testedhe efficacy of using fascia-iliaca blocks (FICB), adminis-ered by one of four attending physicians working in themergency department (ED), with commonly available EDquipment. After informed consent, a physician adminis-ered one FICB to 63 sequential adult ED patients (43omen, 20 men; ages 37–96 years, mean 73.5 years) with

adiographically diagnosed hip fractures. Under asepticonditions, a 21 g, 2-inch IM injection needle was insertederpendicularly to the skin 1 cm below the juncture of the

ateral and medial two-thirds of a line that joins the pubicubercle to the anterior superior iliac spine. The needle wasnserted until a loss of resistance was felt twice (fascia lata andascia iliaca), at which point 0.3 mL/kg of 0.25 bupivacaineas infused. The physician tested the block’s efficacy by as-

essing sensory loss. Pain assessments were done using a0-point Likert Visual Analog Scale (VAS) before, and at 15in, 2 h, and 8 h post-block. Block failure was having the

ame level of pain as before the block. Oral analgesics weredministered as needed. The IRB approved this study. Post-

Presented at the Society for Academic Emergency Medi-ine Annual Meeting (Poster presentation), New York, NY,ay 25, 2005; First International Interdisciplinary Confer-

nce on Emergencies (IICE), Montreal, Canada, June 2005;irst Inter-American Congress of Emergency Medicine,uenos Aires, Argentina, April 20, 2006.

ECEIVED: 22 April 2005; FINAL SUBMISSION RECEIVED: 23

CCEPTED: 28 August 2006

257

rocedure pain was reduced in all patients, but not com-letely abolished in any. Before the FICB, the pain rangedrom 2 to 10 points (average 8.5) using the VAS; at 15 minost-injection, it ranged from 1 to 7 points (average 2.9); ath post-injection, it ranged from 2 to 6 points (average 2.3);t 8 h post-injection, it ranged from 4 to 7 points (average.4). Analgesic requests in the first 24 h after admissionveraged 1.2 doses (range 1 to 4 doses) of diclofenac 75 mg.here were no systemic complications and only two localematomas. Resident physicians learned the procedure andould perform it successfully with less than 5 min instruc-ion. Physicians rarely use the FICB in EDs, although theechnique is simple to learn and use. This rapid, effective,nd safe method of achieving excellent pain control in EDatients with hip fractures can be performed using stan-ard ED equipment. © 2007 Elsevier Inc.

Keywords—regional anesthesia; hip fracture; analgesia;mergency medicine; geriatrics

INTRODUCTION

ore than 500,000 hip fractures occur annually in thenited States (1). About 80% of the fall-related fracturesccur in elderly women with osteoporosis (2,3). Theechanisms underlying hip fracture in the elderly are

omplex and multifactorial, involving an interactionetween risks for falling and an age-associated decline in

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one and muscle mass (possibly related to increasedntake of animal proteins), and impairment of neuromus-ular function (4,5).

Hip fractures usually cause considerable pain. Un-reated or under-treated pain and potent systemic anal-esics can increase the risk of delirium, especially inlderly patients (6). The relationship of pain relief toecreased morbidity and mortality remains controversial7,8). The benefits of the acute analgesia play an impor-ant role in patient comfort. It permits clinicians to takemore accurate history and do a better physical exami-

ation, improves systemic vital signs, and avoids thentense use of non-steroidal analgesics (with the accom-anying risk of epigastric pain and coagulation abnor-alities), or opioids (altering the sensorium). Therefore,

he physician’s goal to relieve pain whenever possible inhe most rapid and least damaging manner suggests that

safe and easily performed regional block, rather thanind-altering systemic analgesics, may be a very effec-

ive tool.Pain control is often not a high priority and systemic

nalgesics can cause or complicate problems, especiallyn the elderly population most susceptible to hip frac-ures. Elderly patients (50 years or older) with hip frac-ures report a 50% to 70% incidence of “severe to veryevere” pain in the first 24 h post-injury (7). Althougharcotics continue to be the mainstay for pre- and post-perative pain relief, in this patient group, avoiding orsing very low doses of opioids to treat pain significantlyecreases the risk to them of developing delirium (6).

In this prospective study, we evaluated the feasibility,ase of use, and efficacy of using standard emergencyepartment (ED) equipment to perform a single fascia

igure 1. Fascia iliaca block technique. A) The fascia iliaca cocm caudal to the inguinal ligament at the junction of the latepine (1) to the anterior superior iliac spine (2). B) Transversertery; (5) femoral nerve; (6) needle insertion for a femoral or

nsertion for a fascia iliaca compartment block; (10) lateral femnesthesiology 2001;94:534–6. Diagram “A,” “B,” with permission

liaca compartment block (FICB) for pain relief after aip fracture.

MATERIALS AND METHODS

his study was prospective, interventional, andncontrolled.

After informed consent, 63 sequential adult patientsresenting to the ED and diagnosed with hip fractureadiographically were included in this study. Each re-eived a single FICB from one of four attending physi-ians working in the ED.

A standardized FICB technique was used for all pa-ients (Figure 1). No premedication or sedation was used.he patient was placed in supine position, the inguinal

igament was identified and the femoral artery was pal-ated. The skin was cleaned with iodopovidone and therea was isolated using sterile drapes. A 21 g, 2-inchntramuscular injection needle (Terumo; Leuven, Bel-ium) was inserted perpendicular to the skin at a point 1m below the juncture of the lateral and medial two-hirds of a line that joins the pubic tubercle to the anterioruperior iliac spine. The needle was inserted until a lossf resistance was felt as the fascia lata was passed, andurther advanced until a second loss of resistance oc-urred when the fascia iliaca was pierced (often de-cribed as two “pops”). With an attached syringe, we firsterformed aspiration to exclude intravascular injection,fter which we injected approximately 0.3 mL/Kg of.25 bupivacaine. The block was never re-administered.

The physician tested the block’s efficacy both subjec-ively and objectively by assessing sensory loss. Sensa-

ment block. The needle is inserted perpendicular to the skin,-third and the medial two-thirds of a line that joins the pubict the midinguinal ligament level. (3) Femoral vein; (4) femoralin-one nerve block; (7) fascia lata; (8) fascia iliaca; (9) needle

mpartral oneview athree-

oral cutaneous nerve. (From: Atchabahian A, Brown AR.).

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ion was tested by palpating the skin over the affectedip. Subjective pain assessment was performed using a0-point Likert Visual Analog Scale (VAS). This assess-ent was performed before block, at 15 min, 2 h, and 8 h

fter the block. Patients’ heart rate (HR), respiratory rateRR), and mean arterial pressure (MAP) were assessed athe same intervals. Block failure was defined as the sameevel of pain and discomfort as before the block. Preop-ratively, no patient was placed in traction. Postopera-ively, an abduction pillow was used.

No regular parenteral analgesia was prescribed, butral analgesics, usually diclofenac 75 mg (Voltaren De-ayed Release), were administered as needed. All pa-ients had surgery within 48 h of admission.

Other data collected included limited patient demo-raphics, type of fracture, duration of analgesia, and theeed for additional analgesics. Statistical analysis waserformed for patients’ pain assessments correspondingo time zero (before application of the anesthetic block),nd 15 min, 2 h, and 8 h after performing the block. Eachroup’s average and range of scores were determined, asas the standard deviation and the 95% confidence in-

erval. The results using the VAS in the pre-block groupere then compared for significance with those in thether groups using the Student’s t-test.

RESULTS

emographic Characteristics

ixty-three sequential patients were included in thistudy (43 women, 20 men), with ages ranging from 37 to6 (mean 73.5) years. Thirty-nine had fractures on theight side and 24 on the left. Significant concomitantedical diseases included 9 patients with diabetes, 17ith hypertension, and 6 with both. One had a history of

ngina pectoris, 2 had undergone valve replacements, 5ad suffered contralateral hip fractures, and another hadlaparotomy within the prior 2 months for colon cancer.hese patients went on to have 25 total hip replacements,1 dynamic hip screws, and 17 cephalic screws. Totalip replacement was performed in medial hip fracture

able 1. Patients’ Vital Signs, Including Pain (VAS) Evaluatio

Time post-block 0 15 m

AS (95% CI) 8.5 � 0.72 (6.89–9.71) 2.9 � 0.16Value – �0AP 133.3 � 15.1 139.2 �R 148.5 � 15.7 151.2 �R 23 � 4.1 22.4 �

AS � visual analog scale; MAP � mean arterial pressure; HR

ith displacement (Garden grade 3 and 4). Screws were t

sed in cases with little or no displacement (Gardenrade 1 and 2), and dynamic hip screws were used inateral fractures (Evans classification). With dynamic hipcrews, postoperative analgesia is very important, be-ause rehabilitation is begun immediately.

valuation of the Block

ignificant differences (all with p � 0.05) were noted inhe level of pain experienced by patients from 15 min to

h after the block (Table 1). The objective pain scores,lso on a 1 to 10 scale, were almost identical to those ofhe VAS. The first post-block pain assessments wereone 15 min after administration, so it is unclear howuch faster the block may have begun decreasing pain in

ome patients. Because these patients with hip fracturesid not ambulate before surgery, the only movement washen patients who had surgery within 8 h of block

dministration had their legs prepped and positioned forurgery. All of those patients allowed that positioning with-ut significant pain or the need for additional analgesics.lthough all study patients experienced pain relief post-lock, some did not get as much relief as expected.

During the 8-h observation period, there was a gradualrend toward normalization of vital signs and no changen their Glasgow Coma Scale scores. These patients’nalgesic requirements during the first 24 h after thentrance into the study averaged 1.2 doses (range 1 to 4)f 75 mg diclofenac.

There were no systemic complications of the FICB andnly two local hematomas at the injection site that resolvedithout additional interventions. Post-procedure, there wassubjective and objective reduction of pain in all pa-

ients, although it was not completely abolished in anyatient.

DISCUSSION

alens used the relatively recent anatomical descriptionf the iliaca fascial compartment (IFC) to first describe

2 hours 8 hours

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110.2 � 10.8 120.5 � 12.582.4 � 10.3 85.3 � 11.120.8 � 3.2 20.5 � 2.1

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owed the publication of the procedure accidentally be-ng done while trying to block the lateral femoral cuta-eous nerve (11). Dalens described the procedure inontrast to the similar “3-in-1” block as being moreuccessful (�90%), not requiring expensive equipmentuch as a neurostimulator, and being safer, because itas distant from the femoral neurovascular elements (9).ecent studies have found that the FICB is easier toerform, less costly, and has a more rapid onset than the-in-1 block (12).

The widely used 3-in-1 block, first described by Win-ie et al. in 1973, is designed to block, with one injectiont the inguinal ligament, the femoral nerve, lateral cuta-eous nerve of the thigh and the obturator nerve, all ofhich stem from the lumbar plexus. Success results from

he proximal spread of local anesthetic injected aroundhe femoral nerve to the other two nerves. Physiciansenerally use a nerve stimulator to locate the femoralerve and to avoid some complications (13).

Subsequently, the FICB primarily has been used, of-en as a continuous infusion through an indwelling cath-ter, for control of postoperative pain after hip, femoralhaft, thigh, patellar, and knee surgeries, both in adultsnd children. The FICB provides superior analgesia tohat provided by the use of systemic morphine (14–16).t also has been used in multi-trauma patients to decreasehe need for systemic morphine and, barring other systemeasons, reduce the time patients must remain intubatednd artificially ventilated (17). It also has been success-ully used bilaterally (18). Although prior studies haveemonstrated the success of single-injection FICBs, theyave rarely been used in Emergency Medicine and pre-ospital care (and then only on anesthesiologist-staffedmbulances) (19,20).

Other blocks at the inguinal ligament have been usedo treat hip fracture pain. The 3-in-1 block using aeurostimulator has also been occasionally used in EDs,specially in Europe (21). One ED study demonstratedhe efficacy of ED use of 3-in-1 blocks without using aeural stimulator, although it required producing pares-hesias to ascertain correct needle positioning (problem-tic in those elderly patients with diminished mentalapacity), and it took 2.88 h post-block to reach theatient’s lowest pain score (22). Similarly, femoral nervelocks have also been occasionally used for pain controln ED patients after hip fractures (23,24). Both of theselocks are performed near vital neurovascular structures.

Although quickly gaining acceptance among anesthe-iologists, the FICB has probably not yet been widelydopted in Emergency Medicine because it is relativelyew and has been described only in the anesthesia liter-ture. The more complicated 3-in-1 block did notppear in the Emergency Medicine literature until

988, 15 years after it was first described; it only found (

ts way into the U.S. Emergency Medicine literature in003 (22,24).

Anatomically, the FICB is an anterior regional anes-hetic block of the lumbar plexus, specifically the femo-al, lateral femoral cutaneous (LFC), and obturatorerves. Although the block is done below the level of aip fracture, anatomical studies on adult cadavers andiving patients demonstrate that anesthetic solution in-ected into the fascia iliaca compartment spreads to theerves innervating the hip, and may reach the femoralnd lateral cutaneous nerve of the thigh and then spreadedially over the psoas muscle. The deep fascial fold

etween the psoas and iliacus muscles may act as aarrier to the anesthetic reaching the obturator nerve inome patients (25). The anesthetic rarely reaches theumbar plexus (26).

The action of the FICB is similar to the commonlysed 3-in-1 block, although the FICB has been shown toe much simpler to perform, have a more rapid onset,nd be more effective, at least in adults, for simulta-eously blocking the lateral femoral cutaneous nerve ofhe thigh, and femoral nerves (26). The 3-in-1 blockften fails because the catheter is not placed under theascia iliaca, and the success rate does not improve withither the use of a neurostimulator or increased doses ofocal anesthetic (26,27). After these failures or failures toerform standard lumbar plexus blocks, the FICB haseen easily used. It has also been used as a route forontinuous infusion of local anesthetic after knee surgeryalthough the authors called it a type of 3-in-1 block)28,29).

Only 35% of patients get complete sensory blockadeo the three lumbar nerves supplying the thigh fromither the FICB or the 3-in-1 blocks. Complete blockrimarily depends upon whether the obturator nerve islocked—which may be difficult to obtain and unpre-ictable (30). The difficulty is that, although injectednesthetic entering the IFC blocks the femoral and LFCerves, sufficient anesthetic does not always migrateroximally to block the obturator nerve, which, with theenitofemoral nerve, lies on the internal edge of thesoas muscle in a separate plane from the femoral andFC nerves (31). With the FICB, an early predictor ofptimal pain relief for femur fractures is a sensory blockf the inner thigh (19).

We report two minor complications (local hemato-as) of the procedure. There has been only one prior

eport of a complication after an FICB. Because thenjection site is distant from the femoral nerve and ves-els, it is much safer than the 3-in-1 block. Reporting onease of a persistent sensory deficit after a post-operativetotal hip replacement) FICB when the patient was not in

condition to report paresthesias during the procedure

which should not, in any event, be necessary), the au-

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Fascia Iliaca Block 261

hors suggested that the sensory deficit may have beenue to her surgery, incorrect placement of the needle, ornormal anatomic variant. The problem resolved after 8ays (32).

FICB has rarely been used in Emergency Medicine,lthough the technique is remarkably simple to learn andse. One study demonstrated its effectiveness in pre-ospital care, although an anesthesiologist who typicallytaffed ambulances in that system administered the FICB.

In our study, the single-injection FICB produced sig-ificant benefit by controlling pain far better than stan-ard parenteral medications without any evidence ofncreased delirium. We also found that it allowed us tobtain a better history from and physical examination ofhe patient, including more normal vital signs. Analgesicequirements after FICB injection were minimal, far lesshan normally used, and limited to non-parenteral anti-nflammatory agents. The apparent prolonged analgesicffect (8 h) was unexpected, but possibly due to the largeascial space with substantial surrounding muscle massnto which it was injected.

The limitation of this study were that, althougharked pain diminishment was demonstrated preopera-

ively, after epidural anesthesia (with sedation) used forany of these patients’ surgeries, they lacked pain

ensation for a prolonged period. After awakeningrom general anesthesia, they experienced some discom-ort. These situations, however, are standard practice,nd patient outcomes should be similar wherever theyre used.

CONCLUSIONS

he FICB is a rapid, effective, safe and easily performedethod of achieving excellent pain control in ED pa-

ients with hip fractures. Emergency physicians can per-orm the FICB with standard ED equipment and therocedure is easy to learn.

Based on extensive literature that demonstrates itstility, future studies will explore the efficacy of usinghe FICB for knee and femoral shaft fractures in adultsnd children. A particular group that might benefit fromICB use is multiple trauma patients with hip, femoralhaft, and knee injuries who would need less systemicnd potentially destabilizing analgesics using the FICB.

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