[Fascia iliac blocks for pre operative analgesia for hip fractures]

by

ACKNOWLEDGEMENT

I would take this opportunity to thank my research supervisor, family and friends for their support and guidance without which this research would not have been possible.

DECLARATION

I, [type your full first names and surname here], declare that the contents of this dissertation/thesis represent my own unaided work, and that the dissertation/thesis has not previously been submitted for academic examination towards any qualification. Furthermore, it represents my own opinions and not necessarily those of the University.

Signed __________________ Date _________________

ABSTRACT

Adequate pre-operative analgesia for elderly patients with femoral neck fractures is difficult to assess and is often an overseen aspect of their care. We aimed to assess the efficacy of fascia iliaca blocks inserted via plexus blockade catheters in the pre-operative period. Our simple technique allowed the block to be administered safely without the need for a nerve stimulator. We assessed the effectiveness of the block with a novel objective sitting score and by assessing the degree of passive hip flexion that could be achieved comfortably. Visual analogue scores were also used. We studied 30 consecutive patients, regardless of their mental state. One hour following the block, there was a significant improvement in the sitting scores as well as the passive hip flexion (mean increase 44°). Visual analogue scores also score improved significantly from 7.2 to 4.6 (S.D. 2.4) in the 18 patients without cognitive impairment. We conclude that fascia iliaca blocks can provide significant benefit in the pre-operative period and allow patients to sit up more comfortably while they await surgery.

Table of Contents

ACKNOWLEDGEMENTII

DECLARATIONIII

ABSTRACTIV

CHAPTER 1: INTRODUCTION1

Aim of the research7

CHAPTER 2: LITERATURE REVIEW8

Hip Fracture8

Hip Disorders and Injuries9

Injuries and Disorders in Children10

Osteoarthritis of the hip13

Rheumatoid Arthritis of the Hip14

Bursitis15

Fracture15

Dislocation16

Treatment Of Articular Versus Non-Articular Injuries And Disorders17

Surgical intervention18

Anaesthetic technique for arthroplasty19

Multi-modal analgesia19

Epidural anaesthesia and analgesia20

Spinal anaesthesia and intrathecal opioids20

Peripheral nerve blocks23

Innervation of the hip and knee23

Total hip arthroplasty: peripheral nerve blocks26

Femoral nerve block27

Fascia iliaca block27

Sciatic nerve block28

Total knee arthroplasty: peripheral nerve blocks28

Femoral nerve block29

Sciatic nerve block30

Lumbar plexus block30

Obturator nerve block31

Step-down analgesia32

Osteoporosis33

Fractures36

Myofibroblasts37

Fascial expansions of entheses39

The functions of fascia41

The circulatory-support function of deep fascia - the muscle pump phenomenon48

The protective role of fascia50

CHAPTER 3: METHODOLOGY52

Patients and method52

CHAPTER 4: DISCUSSION AND ANALYSIS57

CHAPTER 5: CONCLUSION70

REFERENCES73

CHAPTER 1: INTRODUCTION

Fractures of the femoral neck in the elderly represent a major part of the workload in UK trauma departments and Surgery is very often delayed for more than 24 h for a variety of reasons. Providing satisfactory analgesia is a major challenge while patients wait for surgery. Many studies suggest that peripheral nerve blocks may have a role to play in the perioperative management of pain, but little is known about their specific value in the pre-operative period. The needs for a nerve stimulator or a cooperative patient have made some published techniques unattractive in this setting.

Furthermore, the difficulties of assessing analgesia in this elderly population have also been highlighted. We have observed difficulties with nursing patients waiting for surgery because they are unable to sit up comfortably largely limited by pain in the injured ...