Management of Acute Pain After Hip Fracture

Emma Hitt, PhD

May 25, 2011

May 25, 2011 — In patients 50 years or older with hip fracture, nerve blockade appeared to reduce acute pain and delirium, but few data were available regarding the efficacy of other pain management techniques, according to findings of a new systematic review.

Ahmed M. Abou-Setta, MD, and colleagues, with the University of Alberta, in Edmonton, Canada, report their findings in the May 16 issue of the Annals of Internal Medicine.

According to the researchers, little evidence regarding pain management after hip fracture was available in the literature, even though hip fracture is associated with significant pain. The studies identified precluded "firm conclusions for any single approach or for optimal overall pain management."

"More stringent evidence regarding hip fracture pain management that carefully examine current practices is needed, including large-scale, multicenter randomized trials conducted in North America," Dr Abou-Setta told Medscape Medical News.

No Evidence-Based Guidelines to Date

"To our knowledge, no evidence-based guidelines are available for pain management associated with hip fractures," the researchers note in their report. "The objective of this comparative effectiveness review was to analyze the best evidence on the effectiveness and safety of pharmacologic and nonpharmacologic techniques for managing pain in older adults after acute hip fracture compared with usual care or other interventions," they add.

The current report involved a search of 25 electronic databases and clinical trial registries published between January 1990 and December 2010, as well as a search of scientific meeting proceedings and reference lists.

The inclusion criteria for studies included publication in 1990 or later, inclusion of subjects 50 years or older who were hospitalized for acute hip fracture caused by low-energy trauma, and examination of any pain management intervention.

They found 83 unique studies, including 64 randomized controlled trials (RCTs), 5 non-RCTs, and 14 cohort studies, evaluating various interventions, including nerve blockade (n = 32), spinal anesthesia (n = 30), systemic analgesia (n = 3), traction (n = 11), multimodal pain management (n = 2), neurostimulation (n = 2), rehabilitation (n = 1), and complementary and alternative medicine (n = 2).

Results significantly favored nerve blockade over no blockade for reducing acute pain with low heterogeneity, expect for 3-in-1 and fascia iliaca blockade. In addition, nerve blockade significantly reduced the incidence of delirium compared with no blockade, but it showed no advantage over other approaches with respect to other complications, such as cardiac complications and infection.

The study authors noted a lack of data supporting the benefits or drawbacks of other commonly used pain management interventions. According to their findings, systemic analgesics, such as nonsteroidal anti-inflammatory drugs and narcotics, are understudied.

"The lack of available data on commonly used analgesic methods was maybe the biggest sign of a gap in the literature," Dr. Abou-Setta noted. "For instance, individual variation in narcotic tolerance is a clinical issue that was not adequately addressed."

Further, little evidence in the literature supported the continued use of traction as a pain management intervention. Published studies reported no benefit for skin traction compared with no traction for yielded acute pain, length of stay for acute care hospitalization, or the use of additional analgesics, he said.

According to the researchers, because of the paucity of evidence in the literature, efforts are needed to clarify pain management interventions for hip fracture. "There is currently little evidence to support the most commonly used pain management strategies," noted Dr. Abou-Setta. "While this doesn't mean that current practices are wrong, it does mean that we should be focusing our research efforts to identify best practices for pain management after a hip fracture."

The common belief that pain following hip fracture surgery is inevitable, or is self-limited and not worth treating, is false. We can make a material difference to the outcome of these patients if we follow simple, known strategies...

Moreover, the study authors indicate a need to clarify misconceptions regarding pain management after hip fracture.

"The common belief that pain following hip fracture surgery is inevitable, or is self-limited and not worth treating, is false," Dr. Abou-Setta said. "We can make a material difference to the outcome of these patients if we follow simple, known strategies, but some changes might need to be made in the way we organize care for these patients in the hospital (from admission to discharge)."

Pain of Fracture and Surgery

"These findings highlight the usefulness of regional anesthetic interventions in the operative setting, although spinal anesthesia and systemic analgesia were also effective," said independent commentator Roger Chou, MD, associate professor with the Departments of Medicine and Medical Informatics & Clinical Epidemiology at the Oregon Health & Science University in Portland. 

"The major practical application [of these findings] is in making decisions regarding management of operative/postoperative pain," he told Medscape Medical News.

"The results suggest that regional anesthetic techniques are useful, though it is not as clear whether they are superior to spinal anesthesia or systemic analgesia," he said. "In many cases a multimodal approach may be the most helpful."

According to Dr. Chou, it is important for clinicians to understand that many of these studies were conducted in operative settings so the interventions studied were not just to reduce the pain of the hip fracture itself but also pain related to the surgery.

The study was not commercially sponsored. The study authors and commentator have disclosed no relevant financial relationships.

Ann Intern Med. Published online May 16, 2011.


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