Current practice in the use of femoral nerve blocks when splinting femoral fractures

Abstract

Introduction: Missed compartment syndrome can have potentially devastating long-term impacts on individuals. In the reported literature ipsilateral femoral fracture has been present in 52-58% of acute thigh compartment syndromes. Time to diagnosis of acute thigh compartment syndrome has been cited as a key determinant of subsequent functional outcome. The role of femoral nerve blocks in splinting of femoral fractures is somewhat controversial as it can be argued it may mask early compartment syndrome. We present the attitudes of emergency department (ED) and orthopaedic staff at acute NHS trusts in England with regard to this issue.Methods and materials: Survey of all 171 acute hospitals in the United Kingdom accepting trauma admissions. On-call middle grade doctors in both the emergency and orthopaedic departments were contacted to complete a telephone survey into departmental protocol and their own experience of femoral nerve blocks for lower limb fractures.Results: Middle grades from all 171 acute trusts completed the survey (100% response rate). 54 emergency departments (30.8%) reported having a protocol for the use of femoral nerve blocks. Middle grades in the ED reported using a nerve block routinely in 95 hospitals (54%) with 63 opting for a long-acting agent and 32 for short-acting. Of those that did not 70% (n = 53) felt they were unnecessary, 21% (n = 16) were not confident in using the technique and 9% (n = 7) had worries over compartment syndrome. 116 out of 171 (68%) said they would be worried about compartment syndrome in high-energy injuries. Orthopaedic departmental protocols for nerve block use were reported in 16 trusts (9%). 45 orthopaedic middle grades (26%) indicated that they would use them routinely with 17 using long-acting and 28 using short-acting agents. 59.5% (n = 75) of orthopaedic middle grades that did not use nerve blocks felt they were unnecessary, while 22% (n = 28) had worries about compartment syndrome and 18% (n = 23) were not confident with the technique. 131 out of 171 (77%) orthopaedic middle grades would be more worried about compartment syndrome in high energy injuries.Conclusion: Most units appear to have no protocol guiding the use of femoral nerve blocks. ED middle-grade staff were more likely to use a block than orthopaedic staff, and the most common reason for not doing so was feeling that a block was unnecessary. Our results suggest that there is future scope for developing a universal protocol for analgesia when splinting femoral fractures.