Authors (year) Setting Groups N Sample Size Justification Blinded Assessment Main Outcome Main Findings Technical Remarks
Chudinov et al. [34] Ward Femoral neck fracture Intermittent LA boluses through a LP catheter (1-2 mg/kg of adrenalized bupivacaine 0.25% q 8 hours) vs. IM meperidine (1mg/kg q 5 hours) and diclofenac for breakthrough pain (1 mg/kg) 40 N N ? LP catheters: lower pain scores at 8 and 16 hours during the 48h-preoperative period. LOR used to identify the space between the quadratus lumborum and psoas muscles. Blocks performed by anesthesiologists.
Luger et al. [37] ER Hip fracture in patients > 80 years Continuous 3-in-1 block (6 ml/h of bupivacaine 0.125%) vs. IV piritramide (0.05 mg/kg) and additional piritramide (3 mg SC) or paracetamol (1 g IV) for breakthrough pain 20 Y Y Pain scores Lower dynamic pain scores and paracetamol consumption (0.1 ± 0.32 vs. 1.7 ± 1.4 mg/d; p < 0.05) with 3-in-1 block in the preoperative period. Similar piritramide consumption in the preoperative period. 3-in-1 block: US technique. Success of 3-in-block assessed by testing sensory blockade of femoral, LFC and obturator nerves. 86.7% success rate for 3-in-1 block at 1 hour. Blocks performed by anesthesiologists.
Graham et al. [36] ED/ ward Femoral neck fracture 3-in-1 block vs. IV morphine (0.1 mg/kg) 33 N N Pain scores 3-in-1 block: lower pain score at 30 minutes (p = 0.046). No intergroup differences in pain scores at other measurement intervals during 12-hour assessment period. No intergroup differences in 24-hour opioid consumption 3-in-1 block: PNS technique. Minimal stimulatory threshold not specified. Blocks performed by ED physicians or trainees.
Fletcher et al. [35] ED Femoral neck fracture 3-in-1 block vs. IV morphine (5-10 mg hourly) 50 Y Y Pain scores 3-in-1 block: quicker time to lowest pain score (2.88 vs 5.81 hours) and lower hourly morphine consumption (0.49 mg/h vs. 1.17 mg/h) during 24-hour study period. 3-in-1 block: EP technique. Blocks performed by ED physicians.
Monzon et al. [38] ED Hip fracture FIB vs. IV NSAIDs 154 Y Y Pain scores NSAIDs: lower pain scores at 15 minutes (6.24 ± 0.17 vs. 2.9 ± 0.16; p < 0.001). No differences in pain at 2 and 8 hours. FIB: fascial click technique performed with 21-gauge “intramuscular injection” needle. Performed by ED physicians.
Mouzopoulos et al. [39] Ward Hip fracture FIB: bupivacaine vs. NS 207 N N Incidence of perioperative delirium in moderate and high risk patients FIB: lower incidence of (10.78 vs. 23.8%) and shorter duration (5.22 ± 4.28 vs. 10.97 ± 7.16 days) of delirium. No differences in pain scores. Fascial click technique performed with a sharp 24-gauge needle. FIB repeated every 24 hours. Performed by orthopedic surgeons.
Foss et al. [40] ED Suspected hip fracture (prior to X ray exam) FIB vs. IM morphine (0.1 mg/kg) 48 Y Y Pain scores FIB: superior analgesia at rest at 60 and 180 minutes (both p £ 0.03). FIB: superior analgesia with 15 degree leg lift at 180 minutes (p = 0.04), decreased breakthrough IV morphine consumption (0 vs 6 mg: p < 0.01). No differences in nausea/vomiting, sedation (p = 0.05), oxygen saturation (p = 0.08) and hemodynamics. Fascial click technique for FIB with a blunt 24-gauge needle. FIB: 67% success at 30 minutes (absence of cold sensation on anterior and lateral thigh). Performed by Anesthesiology residents.
Wathen et al. [41] ED Children with femoral fracture (proximal, middle or distal) FIB vs. IV morphine 55 Y N Pain scores FIB: lower pain scores during the 6 hours of the study, longer analgesia and less breakthrough analgesic requirement, and higher satisfaction from the medical staff. FIB performed with the fascial click technique using an 1-inch short beveled needle. Blocks performed by ED physicians (with instruction by an anesthesiologist).
Barker et al. [45] Accident site Knee trauma Femoral block vs. IV metamizole (1 g) 52 Y N Pain scores Femoral block: decreased pain, anxiety and signs of vasoconstriction during ambulance transport to hospital. Femoral block: PNS-guided technique (minimal stimulatory thresold = 0.3-0.4 mA; 0.1 ms). Performed by ED physicians.
Mutty et al. [43] ED Diaphyseal and distal femoral fracture Femoral block vs. IV hydromorphone 54 Y N Pain scores Femoral block: lower pain scores at all measurement intervals (last assessment = 90 minutes after block). Femoral block: PNS technique but minimal stimulatory threshold not specified. Performed by orthopedic residents.
Schiferer et al. [44] Accident site hip dislocation/ fracture, femoral fracture, patellar tendon rupture Femoral block vs. IV metamizole (1 g) 62 Y N Pain scores Femoral block: decreased pain, anxiety and heart rate between the on-site and transport values (both p < 0.001). Femoral block: PNS-guided technique (minimal stimulatory thresold = 0.3-0.4 mA; 0.1 ms). Performed by ED physicians.
Haddad and Williams  [42] Ward Extracapsular femoral neck fracture Femoral block vs. PO co-dydramol/ IM pethidine/ IM diclofenac 50 N N ? Femoral block: decreased pain at 15 minutes and 2 as well as lower requirements of IM opioids. Femoral nerve located with double click technique and EP. Block performed by orthopedic residents.
ED = Emergency Department; EP = elicitation of paresthesia; FIB = fascia iliaca block; IM = intramuscular; IV = intravenous; LA = local anesthetic; LOR = loss of resistance; LP = lumbar plexus; N = no; NSAIDs = non-steroidal anti-inflammatory drugs; PNS = peripheral nerve stimulation; PO = per os; US = ultrasonography; Y = yes.
Table 2: Summary of randomized controlled trials pertaining to lower extremity trauma.