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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Pain relief management following proximal femoral fractures:

Options, issues and controversies
Theodoros H. Tosounidis a,c,*, Hassaan Sheikh a, Martin H. Stone b,c, Peter V. Giannoudis a,c
a
Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Leeds General Infirmary, Floor A, Great George Street,
LS1 3EX Leeds, UK
b
Hip Reconstruction Unit, Chapel Allerton Hospital, Leeds, West Yorkshire, LS7 4SA, UK
c
NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK

A R T I C L E I N F O A B S T R A C T

Keywords: The majority of proximal femoral fractures occur in the elderly population. Safe and adequate pain relief
Elderly is an integral part of the overall management of hip fractures. Inherent difficulties in the assessment of
Pain pain in elderly need to be taken into account and unique considerations should be made regarding the
Hip fractures effective analgesia due to different elderly physiology, and their response to trauma and subsequent
Proximal femoral fractures
surgery. The pain management should start as soon as possible and special emphasis should be paid to
Analgesia
contemporary methods of regional anaesthesia whilst a multimodal approach should be adopted in the
perioperative period. The present review summarises the contemporary treatment options and
controversies pertaining to the management of pain in elderly patients with proximal femoral fractures.
ß 2015 Elsevier Ltd. All rights reserved.

Introduction proximal femur and the special considerations pertaining to the

Fractures of the proximal femur are the second commonest
fragility fractures and their worldwide incidence is increasing
[1]. It is estimated that in the United States of America the total
number of hip fractures will be 289,000 by 2030 [2]. Their number
in the United Kingdom has been estimated to be 77,000 per year
with a projected annual incidence of 100.000 by 2033 [3]. In
Germany more than 125,000 people suffer a hip fracture every year
[4]. Proximal femoral fractures are most common in women older
than 65 years old [5].The mean age of a patient with a fracture of
the proximal femur is above 80 years, the presence of dementia in
these patients is high [6] and the pain experienced severe [7,8]. It is
well documented that cognitively impaired patients with a
fractured proximal femur receive less analgesia than their
cognitively intact counterparts [9]. It has also been demonstrated
that monitoring of pain and appropriate analgesia in this
population improves post-operative functional outcome [10].
This review aims to summarise the current evidence and
techniques available for analgesia following a fracture of the
* Corresponding author at: Academic Department of Trauma & Orthopaedic
Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds
General, Infirmary, LS1 3EX Leeds, UK. Tel.: +44 113 3922750.
E-mail address: ttosounidis@yahoo.com (T.H. Tosounidis).
geriatric population. The contemporary options and controversies
are presented.
Physiological considerations in the elderly
Different cut off ages have been used to define the ‘‘elderly’’
population but the geriatric hip fracture literature is best reviewed
using the age of 60 as cut off point [11]. The elderly population in
general has a lower physiological reserve than their younger
counterparts. Elderly trauma patients are more vulnerable and
their treatment may be associated with greater complications as
they are likely to have other co-morbidities and the index trauma
decreases the already compromised physiological reserve of the
patient [12–18]. Physiological changes of increased age are various
including but not limited to reduced cardiac output, reduced lean
body mass, increased fat storage, a varying plasma volume and
impaired renal and hepatic functions, affected drug metabolism
and elimination [19]. The decreased compensation and mainte-
nance of homeostasis in elderly suffering trauma has been
described with the term ‘‘Homeostenosis’’ and is well known to
occur after hip fracture surgery in elderly [20,21]. The term ‘‘pain
homeostenosis’’ has also been used in elderly to describe the effect
of persistent pain in the ability to accommodate physiologic
stressors [22].

http://dx.doi.org/10.1016/j.injury.2015.08.014
0020–1383/ß 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Tosounidis TH, et al. Pain relief management following proximal femoral fractures: Options, issues
and controversies. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.08.014
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Adequate pain management is of paramount importance pre-
and post-operatively as it has been shown that it facilitates nursing
care [23]. Additionally there is evidence suggesting that not well-
controlled pain during the post-operative period is related to
significant complications including infection and thromboembo-
lism [24]. Pain relief in elderly has been demonstrated to be more
difficult compared to young people due to concomitant diseases
and medication, different pharmacokinetics and pharmacodynam-
ics, decreased physiologic reserve, different pain response and
difficulties in pain assessment [23].
The assessment of pain
Adequate assessment of pain is crucial to the administration of
adequate analgesia. Pain in the trauma patient is a dynamic
phenomenon and pain assessment must be a continuous process,
as a single point-assessment of pain is likely to be inaccurate
whilst repeat assessments are likely to better correlate with
analgesia requirements. Motion related pain at a fracture site and
expanding hematoma inevitably contribute to the dynamic and
changing characteristics of pain generated thus necessitating
continuous monitoring and assessment. Additionally the possi-
bility of the development of a compartment syndrome mandates
constant vigilance and continuous monitoring of pain levels.
Oligoanalgesia is a well-described phenomenon in elderly
patients [25] and the term is used to describe undertreatment
of pain. In a recent retrospective study Quattromani et al. [26]
reviewed the analgesia provided in 460 blunt trauma patients in a
Level-1 Trauma Centre Emergency Department. The authors
concluded that patients older than 65 years were less likely to
receive sufficient analgesia in timely manner compared to
younger patients.
The vast majority of proximal femoral fractures are managed
operatively with the aim of surgery being the early and secure
mobilisation of the patient whilst at the same time providing the
best chances for adequate functional recovery to pre-injury levels.
Postoperative mobilisation and rehabilitation constitute an inte-
gral part of the overall management. Dynamic pain relief at the
immediate postoperative period that allows comfortable mobili-
sation and adequate respiratory efforts is paramount to effective
rehabilitation and the prevention of complications associated with
immobility and recumbency.
Multiple scoring systems are utilised for the assessment of pain.
Self reported one-dimensional scales include the Visual Analogue
Scale (VAS-rated on a 10 cm line labelled 0–10), Verbal Rating Scale
(VRS-rated verbally as no pain, mild, moderate or severe pain) and
Numeric Rating Scale (NRS-rated as a pain score given as a range 0–
3 or 0–10) [27]. These scales require that the patient is not
confused and is able to communicate. In this subset of patients, the
VRS and NRS are reliable scales validated for reproducibility as well
as being preferred by patients and clinicians [28]. In the mildly
confused patient, or when the verbal assessment of pain is
challenging, there is a role for the use of a VRS as long as the patient
is able to communicate [28]. VAS for pain assessment is validated
for impaired cognition but a vertically orientated line is preferable
if it is used [29].
In patients with severe delirium or dementia the assessment of
pain presents a unique challenge. These patients are less likely to
outwardly complain of pain or request analgesia and therefore are
at risk of being undertreated for pain [9,30]. Options to assess pain
are to use non-verbal cues, formal behaviour scales and surrogates
such as family or carers [31]. Non-verbal pain indicators may
include vocalisation on movement of the affected limb, facial
expressions and changes to usual demeanour or posture [31].The
patient’s family or carers may be able to assist with the
identification of expressions specific to the patient’s individual
Please cite this article in press as: Tosounidis TH, et al. Pain relief management following proximal femoral fractures: Options, issues
and controversies. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.08.014
response to pain. Formal pain behaviour reporting tools such as
Doloplus and the Discomfort Scale for Dementia of the Alzheimer’s
Type, have been validated, however these are time consuming and
require specific skills to administer and therefore not necessarily
viable in clinical practice [31,32]. Interestingly, in a recent
prospective study of 344 patients with hip fractures, Radinovic
et al. [33] identified dementia and low levels of education as
independent predictors of severe postoperative pain after hip
fracture surgery.
The type of injury and the surgical intervention in relation to
pain levels have been examined in various studies. In a
retrospective report of 231 patients above the age of 65 with a
surgically fixed hip fracture, Strike et al. [34] found no difference in
postoperative pain or opioid analgesics based on the type of
fracture (femoral neck, intertrochanteric) and the surgical
procedure (hemiarthroplasty, cannulated screws, intramedullary
nail, total hip arthroplasty, dynamic hip screw). On the other hand,
Foss et al. [35] in a descriptive prospective study of 117 patient
with hip fractures receiving epidural analgesia and following a
standarised perioperative rehabilitation protocol, concluded that
cumulated pain levels were significant lower in patient with
hemiarthroplasty compared to patients that underwent fixation
(dynamic hip screw, intramedullary nail).
Analgesia at admission to the emergency department
Adequate pain relief is considered part of good clinical practice
and a key feature of improving patients’ experience. Regional
anaesthesia is gaining popularity across Emergency Departments
in UK but its use has not been universally adopted. In a national UK
Emergency Department survey, Rashid et al. [36] found that only
44% of the departments who participated were using regional
analgesia for adults with proximal femoral fracture. Likewise in a
Canadian study, Haslam et al. [37] demonstrated that nerve block
analgesia is grossly underutilised in Emergency Departments.
Fascia Iliaca blockade
Fascia Iliaca blockade is a simple and effective procedure that
provides superior analgesia to parenteral morphine in patients
with a fracture of the proximal femur [38]. This is a relatively safe
technique with few reported complications [39]. It is performed by
locating the junction between the lateral and middle thirds of
the inguinal ligament and piercing disinfected skin 1 cm below
this point with a semi-blunt needle. The needle is advanced
perpendicular to the skin and the practitioner feels for two loss-of-
resistance ‘pops’ (the fascia lata and then the fascia iliaca). At this
point 30–40 mls of local anaesthetic is injected after aspiration to
ensure that the needle is not in a vessel [38,40].
The technique is easy to teach to junior physicians and can be
used before or after radiographic diagnosis of proximal femoral
fracture [38,41]. Theoretically, the spread of local anaesthetic
along the fascia iliaca should block the femoral nerve, the obturator
nerve and the lateral femoral cutaneous nerve [42,43]. In practice,
however, a femoral nerve block is superior in providing analgesia
than fascia iliaca block (see below). Its use in the ED setting is
therefore often limited, perhaps due to its limited efficacy. A recent
study, however, promoted its use as it is quick to teach, easy to
administer, does not require ultrasound or nerve stimulator
guidance as well as being cheaper [40].
Femoral nerve blockade
Injection of local anaesthetic around the femoral nerve with
ultrasound guidance or a nerve stimulator is an effective and
relatively safe method of pain relief following fracture of the
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proximal femur that can be administered in the ED [44]. It has been
shown to provide superior analgesia to parenteral morphine and
reduces additional opioid requirements thereby reducing their
adverse effects [45,46]. This technique may be used with a
continuous infusion of local anaesthetic with a perineural catheter
and gives excellent analgesia up to 72 h post-operatively. It has
also been shown to provide superior analgesia to fascia iliaca
blockade [40,47].
Its use, however, may be limited by a higher cost as well as the
requirements of expertise and time that may be limited in an
expensive ED [40]. From an anatomic perspective, this technique
will often not provide complete analgesia as the innervation of the
hip capsule is complex and the posterior hip capsule receive
innervation from nerves other than the femoral nerve [48]. Com-
plications are rare and include damage to the neurovascular
bundle (although neuropraxias will resolve with time), bacterial
colonisation and abscess formation [49]. A parallel, two-group
randomised equivalence trial comparing the fascia iliaca compart-
ment block to ‘‘3 in 1’’ block concluded equal efficacy of the two
techniques [50].
Perioperative analgesia
The choice of perioperative analgesia deserves special consid-
eration as there are multiple different modalities of delivery of pain
relief and they have potential implications on post-operative
rehabilitation. However, the choice and combination of analgesia
in the elderly must be carefully adjusted to the patient’s co-
morbidities and concurrent medication. A multimodal approach to
analgesia to the treatment of postoperative pain has been
recommended to reduce the doses of systemic analgesics and
therefore their side effects [49].
Local infiltration anaesthesia (LIA) and opiate sparing anaesthesia
(OSA)
Local infiltration analgesia (LIA) was developed by Kerr and
Kohan [51] in Australia and has become a standard part of most
enhanced recovery programmes following elective surgery. They
described a systematic wound infiltration of ropivacaine, ketor-
olac, and adrenaline injected around all deep structures of the
wound at the time of surgery. Their results were published as a
case series of 325 patients in addition to detailed descriptions of
the LIA technique. Their case series demonstrated that in addition
to good pain control scores postoperatively, two third of patients
required no morphine, and most patients were able to mobilise
within 5–6 h of surgery with some assistance, and independently
within the first 48 h postoperatively. The LIA technique has been
developed further in hip and knee replacement surgery and Salhab
et al. [52] reported on the addition of 48 h continuous infusion of
bupivacaine, delivered through a special intra-articular wound
catheter (PainKwell1 needle/catheter) delivering between 4 and
6 mls of bupivacaine 0.5%/hour [53] (Salhab 2014). Reduced opiate
use, reduced nausea and urinary retention in the first 48 h after
surgery, but also reduced VAS for pain, and importantly no
infections following its use was also recorded. While it has been
widely used successfully for hip and knee replacement surgery, the
above technique is now being used for fractured neck of femur
with equally promising results. Keehan et al. [54] reported
enhanced recovery with minimal opiate use and good tolerance
by elderly patients having fractured neck of femur surgery.
Titrating parenteral morphine
This method is commonly employed in the post-anaesthetic
recovery room to treat immediate postoperative pain and boluses
Please cite this article in press as: Tosounidis TH, et al. Pain relief management following proximal femoral fractures: Options, issues
and controversies. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.08.014
3
of intravenous morphine can be used to deliver rapid and effective
analgesia. Boluses of 3 mg of intravenous morphine every 5 min
(reduced to 2 mg in patients over 65 years of age) are generally
used with good effect and little risk of respiratory depression
[55]. With increasing age, renal clearance declines and therefore
the boluses should be reduced to 1 mg in the very elderly. Boluses
of morphine can be also delivered subcutaneously, however,
fragile skin and varying levels of subcutaneous fat and vascularity
means that dosages of morphine may be under or overestimated.
For these reasons, it is better to reduce or altogether avoid
subcutaneous morphine in the elderly [56].
Patient controlled intravenous analgesia (PCA)
Patient controlled intravenous analgesia (PCA) has been shown
to provide a better level of continuous analgesia than intermittent
morphine injections and is effective regardless of advancing age
[57,58]. It has the advantage that the patients feel in control of their
analgesia and can self-administer without having to wait for a
nurse whilst the physician remains in control of the maximum
dose given. It should be used with caution in patients with mild
cognitive impairment that can understand its use but on the other
hand it cannot be used in advanced dementia patients who are not
capable of understanding its operation [59]. Morphine is com-
monly used for analgesia via this route and a bolus of 1 mg every 5–
10 min with a maximum hourly dose is used along with oxygen
supplementation. This dose should be reduced or the lockout
period should be increased in the very elderly to reduce the risk of
respiratory depression. A continuous background infusion should
be avoided as it is a risk factor for respiratory depression. A
common adverse effect is nausea but can be overcome with the
addition of an anti-emetic in the PCA mixture [60].
Epidural analgesia
Post-operative epidural analgesia can also be used instead of
PCA. It has shown to be superior than PCA regardless of analgesic
agent and regimen [61]. A randomised controlled trial has also
demonstrated that the superior postoperative analgesia provided
by the epidural route can decrease the risk of cardiac events as
compared to conventional analgesia in patients with a proximal
femur fracture [62]. Compared to continuous epidural analgesia,
patient controlled epidural analgesia reduces consumption of
analgesic agents and adverse effects but the apparatus used may be
difficult to operate by elderly patients [63]. There is a risk of
hypotension, urinary retention and motor blockade following
epidural nerve blockade as well as a risk of respiratory depression
(with opioid agents) [64]. Due to these issues, post-operative
mobility may be limited and this is the main reason for not gaining
wide acceptance in the management of trauma patients.
Intrathecal morphine
Single shot intrathecal morphine has a limited use in practice as
an alternative to epidural analgesia owing to dose related adverse
effects including hypotension, urinary retention and respiratory
depression [63]. Nevertheless it provides good analgesia for several
hours postoperatively even in the elderly and reduces additional
opioid use [65]. In patients with advancing age undergoing hip
surgery, doses of morphine should be reduced to achieve the same
analgesic effect but reduced adverse effects [66].
Peripheral nerve blockade
This technique is extensively used in orthopaedic surgery to
provide pain relief as effective as epidural analgesia and at the
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same time allow easier ambulation following surgery for a
proximal femoral fracture. The analgesic effect may last longer
(depending on the agent used) and thus facilitating easier
rehabilitation [63,67]. The actual technique and its adverse effects
are as described in the Femoral Nerve Blockade section above. For
any of the above described techniques there is an additional risk of
missing a ‘silent’ thigh compartment syndrome (before or after
surgery) and consequently clinical vigilance is required to prevent
this from happening [68].
Systemic analgesia
Paracetamol
Paracetamol (acetaminophen) acts to block prostaglandins
centrally. It has few adverse effects aside from dose dependent
hepatocyte necrosis in overdose or established hepatic failure
[69]. Paracetamol is widely used and is the first step in the
analgesic ladder owing to its relatively safe side effect profile
despite advancing age. The usual oral dose is 1 g every 6 h and the
maximum intravenous dose is also 1 g every 6 h. With intravenous
paracetamol, caution must be paid in patients with a total body
weight under 50 kg, hepatocellular insufficiency, chronic alcohol-
ism or malnourishment and the total daily dose must be reduced
[70].
Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs produce their analgesic effects by the inhibiting the
action of cyclo-oxygenase isoenzymes (COX) 1 and 2. They can be
non-selective or COX2 selective (that reduce gastrointestinal
adverse events). Common non-selective NSAIDs (that inhibit
COX1 and COX2) include aspirin, ibuprofen, diclofenac, naproxen,
mefenamic acid and ketoprofen. A common COX2 inhibitor is
celecoxib. These are potent analgesics and produce excellent
analgesia following fracture of the proximal femur [41].
Aspirin has been linked with increased intraoperative bleeding
[41], but the evidence regarding other NSAIDs causing increased
intraoperative bleeding is conflicting [71,72]. Other side effects of
non-selective NSAIDs include an increased risk of cardiovascular
events [73], acute kidney injury and gastrointestinal bleeding
[63]. These risks increase with advancing age. COX2 inhibitors are
linked with a similar incidence of renal and cardiovascular side
effects as their non-selective counterparts [74,75].
NSAIDS interact with a host of other common drugs used in the
elderly including diuretics, angiotensin converting enzyme inhi-
bitors, warfarin and may reduce the cardio-protective effect of
aspirin [76]. An important consideration relating to orthopaedic
trauma is that the risk of fracture non-union seems to increase
with NSAID use [77]. The initial inflammatory process of the
fracture healing cascade may be delayed by COX2 inhibitors
[78]. Whilst this is of little concern in arthroplasty surgery, its
implications can be great when a stable weightbearing fixation is
required, such as with sliding hip screws or intramedullary nailing,
especially when there are other risk factors of non-union present
such as smoking or diabetes mellitus [79].
Opioids
Opioids drugs are central to the management of pain of patients
with proximal femoral fractures. They can be used orally or
parenterally, however, they should be used with caution in the
elderly due to the increased risk of impaired renal excretion and
possible increased central sensitivity and subsequent increased
risk of respiratory depression [80]. Other side effects include
nausea, sedation, delirium, constipation, urinary retention and
Please cite this article in press as: Tosounidis TH, et al. Pain relief management following proximal femoral fractures: Options, issues
and controversies. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.08.014
tolerance [81]. All non-opioid analgesics reduce opioid require-
ments and NSAIDs are especially effective at reducing pain caused
by fractures. However, as previously stated the side effect profile of
NSAIDs in the elderly often precludes their use.
Tramadol
Tramadol is an atypical central opioid analgesic that binds to m
receptors and inhibits noradrenaline and serotonin reuptake. It has
a 1/3 of the potency of morphine and has a maximum dose of
400 mg daily in divided doses. Following hepatic metabolism, its
active metabolite (O-desmethyltramadol) is renally excreted and is
more potent than the parent drug. In hepatic or renal impairment,
therefore, the dose should be reduced accordingly. Unlike codeine,
tramadol may also be delivered parenterally on the ward. Its side
effect profile is better than morphine and is therefore generally
better tolerated by patients [63]. Tramadol is associated with a
higher risk of delirium and seizures [82,83]. It is relatively contra-
indicated with concomitant antidepressant use as it can increase
serotonin levels and cause a life threatening serotonin syndrome
[83].
Codeine
Codeine (3-methylmorphine, a natural methylated morphine)
is a weak opiate that is 10–20 times less potent than morphine. It is
converted to its active form, morphine, by the liver and binds with
weak affinity to m receptors to exert its central analgesic effect.
Codeine-6-glucuronide is an active metabolite that is renally
excreted and therefore the dose of codeine should be reduced in
patients with renal impairment [84].
Morphine
This is a strong opiate that binds with strong affinity to central
m receptors. With advancing age, patients become more sensitive
to morphine and therefore smaller doses can exert the same
analgesic effect. Its active metabolite, morphine-6-glucuronide is
renally excreted and may accumulate in the elderly with impaired
renal function [85]. This metabolite is commonly implicated in the
development of respiratory failure following morphine adminis-
tration. The use of supplemental oxygen and monitoring the
patient for sedation, especially with parenteral morphine use is
therefore highly recommended. The dose of morphine (regardless
of delivery route) should be reduced with advancing age and
declining renal function [86].
Discussion
The severe pain following a hip fracture should be managed as
soon as possible. The pain pathway management of the patients
with a suspected or documented proximal femur fracture is a
process that should be conceptualised as a continuum extending
from the pre-hospital period to the rehabilitation phase of recovery
after surgery.
There is a current trend towards early and effective pain
management even before the patient arrives to the hospital by
paramedics in the prehospital setting. Recently, a non-blinded
randomised controlled trial by McRae et al. [87] comparing the
paramedic-performed fascia iliaca compartment block with
lidocaine and epinephrine to the standard of care (intravenous
morphine) suggested that the former modality offers a safe and
effective pain relief in patients with suspected hip fractures.
Likewise, Oberkircher et al. [88] in a prospective study evaluate the
prehospital pain levels of 153 patients older than 60 years who
suffered a hip fracture, demonstrated that only a small number of
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these patients actually received adequate analgesia. Moreover, the
authors documented substantial pain relief in the patients who
actually received prehospital analgesia. The above recent studies
emphasise the contemporary direction of clinical research which
points to the administration of early, safe and adequate analgesia
from appropriately trained personnel to the patients with proximal
femoral fracture. Whilst acknowledging the difficulties and the
specific technicalities that might prohibit its use, we would
recommend its use to a wider scale and the same time encourage
the conduction of additional studies to provide more robust
evidence on its safety and efficacy.
Emergency Department pain relief is challenging but current
evidence suggests that its use should be further promoted. Elderly
hip fracture patients constitute a well-recognised subgroup of
population that suffers from significant pain and thus analgesia
should be provided as soon as possible. Current evidence suggest
that fascia iliaca blockade is probably they way to go forward.
Hanna et al. [89] in a prospective case-control study and feasibility
assessment of a junior-doctor-delivered service demonstrated that
fascia iliaca blockade is safe and efficient procedure in the
emergency department even when administered by junior doctors.
The authors underpinned the additional benefits of the method
including the educational opportunities for young doctors.
Nevertheless the implementation of any changes and new
practices in the demanding emergency department should be
closely monitored. Patrick et al. [90] found that the implementa-
tion of a new analgesia policy in patients with known acute painful
conditions such as hip fractures, sickle cell anemia crisis and renal
colic actually decreased the proportion of these patients who
received analgesia within 30 minutes. Based on the above we
would suggest cautioned implementations of any changes along
with meticulous monitoring and auditing of their effects.
Systemic and regional analgesia are the mainstay of pain
management during the patients in-hospital stay. A recent Clinical
Practice Guideline Summary published from the American
Academy of Orthopaedic Surgeons [91] strongly supports the
use of preoperative regional analgesia in the management of hip
fractures in the elderly based on existing evidence showing
reduced incidence of delirium with this approach. Nevertheless the
systemic analgesia continues to constitute an essential element in
pain management in patients with proximal femoral fractures. As
mentioned previously, analgesic agents need careful selection in
the elderly population due to co-morbidities, increased risk of
Table 1
Options of analgesia to be considered in elderly patients with proximal femoral fractures.
Please cite this article in press as: Tosounidis TH, et al. Pain relief management following proximal femoral fractures: Options, issues
and controversies. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.08.014
5
adverse effects and interactions with concurrent medications.
Abou-Setta et al. [92] in a recent systematic review of 83 studies
looked into the comparative effectiveness of pharmacologic and
non-pharmacologic techniques for the management of hip pain in
elderly people after hip fractures. Studies included in this review
analysed the nerve blockade, spinal anesthesia, systemic analgesia,
traction, multimodal pain management, neurostimulationa, reha-
bilitation and complementary/alternative medicine. The results
indicated that despite the fact that there is only moderate evidence
for the use of nerve root blockades they seem to be effective for the
management of acute pain after hip fractures. Data collected in
relation to the other pain relief modalities were not adequate and
no useful conclusions could be drawn. Of note is the remark made
by the authors that systemic analgesics were understudied during
the search period. We consider systemic and regional analgesia as
complimentary/synergistic modalities and we would like to stress
that whilst the adherence to predetermined protocols is recom-
mended, every effort should be made to tailor the analgesia plan to
the individual needs of the patient.
In summary the population of patients with fractured proximal
femur constitute a diverse group of patients that poses specific
challenges in their safe and effective management. Special
consideration should be paid to the age and cognitive abilities
of each individual patient without delaying the delivery of
analgesia from the moment the patient is encountered in the
prehospital setting. Fascia iliaca blockade is a quick and effective
analgesic technique and its use along with other regional
preoperative analgesia techniques should be promoted in the
ED. In the perioperative phase a multi-modal approach to analgesia
should be favoured to achieve effective and dynamic pain relief, so
that easy and safe rehabilitation can be established. Table 1
summarises the current treatment options of pain management in
elderly with proximal femoral fractures as described in the present
article. Evidence of the safety and effectiveness of regional versus
systemic analgesia in the setting of hip fractures in elderly is sparse
and high quality studies are needed to shed light on this issue.
Additionally, future research directions to the topic should aim to
explore the best methods of management of pain according to the
specific diagnosis (type of fracture), comorbidities that are
currently not well appreciated/studied such as dementia and other
conditions that constitute the elderly patient even more difficult to
assess and manage, and the effects of the changing practice of
emergency departments in relation to pain management.
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Conflict of interest
All the authors declare no conflict of interest with regard to the
content of his study.
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