This week, we are highlighting a Cochrane summary on nerve blocks for initial pain management of thigh bone fractures in children.
Fractures (breaks) of the thigh bone can be very painful, particularly when a child arrives in a stressful emergency environment and is undergoing assessment. Moving the child to get X-rays or transferring the child to a special bed to support the leg in traction (keeping the leg straight) can cause additional pain, as can placing traction (a pulling force) on the broken thigh. This means that prompt provision of pain relief is an essential part of initial emergency management. This review investigated whether a nerve block, involving the injection of a freezing/numbing medication at the top of the thigh, would provide more effective pain relief than pain medicine given by mouth or into a vein (intravenously, e.g. morphine).
We searched several medical databases and trial registries up to January 2013 and contacted researchers. We found one study that looked at the comparison we were interested in. This study was potentially biased, mainly because the care providers, parents and children were aware of the type of pain relief the children received. The study was small, involving 55 children aged 16 months to 15 years, and showed that the children who received one of the two main types of nerve block tended to have less pain after 30 minutes than those who received intravenous morphine for initial pain control. The nerve blocks led to some pain and redness at the injection site in a few cases, while intravenous morphine caused more serious problems such as depressed breathing (lack of oxygen), excessive sleepiness and vomiting in a small number of children.
Moreover, children who had nerve blocks continued to have lower pain scores over a six-hour period with less need for additional pain relief. There was insufficient evidence to determine whether children or parents were more satisfied with one method of pain relief than the other. Use of resources (e.g. nursing time, cost of medications) was not measured.
The quality of the study included in this review was low and so these conclusions are not certain. Further well designed studies investigating whether nerve blocks are more effective and safer than other means of pain relief are needed.
Low quality evidence from one small trial suggests that FICB provides better and longer lasting pain relief with fewer adverse events than intravenous opioids for femur fractures in children. Well conducted and reported randomised trials that compare nerve blocks (both FNB and FICB) with systemic analgesia and that use validated pain scores are needed.
Check out the full Cochrane systematic review below:
Black, K. J., Bevan, C. A., Murphy, N. G., & Howard, J. J. (2013). Nerve blocks for initial pain management of femoral fractures in children. Cochrane Database Syst Rev, 12, Cd009587. doi: 10.1002/14651858.CD009587.pub2
Related TREKK Resources:
This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.
Published by arrangement with John Wiley & Sons.