What is the recommended pain management regimen for a patient with a femur fracture?

Pain Management for Femur Fracture

For femur fractures, implement femoral nerve block (or fascia iliaca compartment block) as the primary analgesic strategy, combined with scheduled paracetamol and NSAIDs (if not contraindicated), reserving strong opioids only for breakthrough pain that is inadequately controlled by regional anesthesia. 1

Regional Anesthesia: First-Line Approach

Peripheral Nerve Blockade

• Femoral nerve blocks are the recommended primary analgesic modality for femur fractures based on superior efficacy and reduced side-effect profile compared to systemic opioids 1
• Continuous catheter techniques are superior to single-shot blocks, providing extended analgesia duration and greater proximal spread of effect 1
• Fascia iliaca compartment block (FICB) is equally effective, safe, reliable, and reproducible for perioperative pain management in femur fractures 1
  • Single-shot technique: 30-40 mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine 1
  • Continuous technique: 10-20 mL bolus of 0.2% bupivacaine followed by continuous infusion at 6 mL/hour 1
• Posterior lumbar plexus blocks (psoas compartment blocks) have greater efficacy than femoral nerve blocks but carry higher complication risk; use when risk-benefit analysis favors more complete blockade 1

Clinical Benefits of Regional Anesthesia

• Reduces acute confusional state and postoperative delirium 1
• Decreases chest infection rates 1
• Promotes earlier mobilization 1
• Significantly reduces morphine consumption (0.4 mg vs 19.4 mg in one study, P=0.05) 1
• Does not negatively impact cognitive status even in patients with moderate cognitive impairment 1

Multimodal Non-Opioid Analgesia

Baseline Medications (All Patients)

• Paracetamol (acetaminophen) is mandatory baseline treatment for all pain intensities as it decreases supplementary analgesic requirements 1
• Paracetamol should always be combined with other analgesics, never used alone 1
• COX-2 selective inhibitors or conventional NSAIDs should be added unless contraindicated (renal dysfunction, bleeding risk) 1
• Avoid NSAIDs in patients with renal impairment 2, 3

Opioid Use: Rescue Therapy Only

Strong Opioids (High-Intensity Pain)

• Reserve intravenous strong opioids for breakthrough pain when regional anesthesia plus non-opioid analgesics are insufficient 1
• IV patient-controlled analgesia (PCA) is preferred over fixed-interval or on-demand administration 1
• Intramuscular administration is NOT recommended due to injection-associated pain 1
• Intraoperative strong opioids should be administered to ensure analgesia upon awakening 1

Dosing Considerations

• Starting dose for IV morphine: 0.1-0.2 mg/kg every 4 hours as needed, administered slowly 4
• Rapid IV administration may cause chest wall rigidity 4
• Reduce doses in elderly patients and those with hepatic/renal impairment, titrating slowly while monitoring for side effects 4

Weak Opioids (Moderate-to-Low Intensity Pain)

• Weak opioids (codeine, tramadol) are NOT recommended for high-intensity pain in the early postoperative period (<6 hours) 1
• After 6 hours, weak opioids may be used in combination with paracetamol when NSAIDs are contraindicated or insufficient 1
• Evidence suggests codeine and tramadol can provide adequate pain control for most femur fractures when combined with regional anesthesia and non-opioid analgesics 5

Neuraxial Anesthesia Options

Spinal Anesthesia

• Spinal anesthesia with local anesthetic plus low-dose opioid (fentanyl preferred over morphine 0.1-0.2 mg) provides excellent perioperative analgesia 1
• Use lower doses of intrathecal bupivacaine (<10 mg) to reduce hypotension risk 1
• Fentanyl is preferred over morphine or diamorphine due to lower risk of respiratory and cognitive depression 1
• Do NOT combine spinal anesthesia with general anesthesia due to risk of precipitous hypotension 1

Epidural Analgesia

• Continuous epidural with local anesthetic and opioids is recommended for patients with cardiopulmonary risk factors due to decreased cardiopulmonary morbidity 1
• Epidural analgesia may limit early mobilization and requires higher monitoring intensity compared to peripheral blocks 1
• Do NOT use epidural clonidine due to hypotension, sedation, and bradycardia risks 1

Critical Pitfalls to Avoid

• Never use opioids as the sole analgesic adjunct in femur fracture patients due to increased risk of respiratory depression and postoperative confusion 1
• Avoid intramuscular opioid administration 1
• Do not use weak opioids for severe pain in the first 6 hours postoperatively 1
• Avoid NSAIDs in patients with renal dysfunction 2, 3
• Do not combine general and neuraxial anesthesia 1
• Avoid epidural clonidine and spinal clonidine 1

Evidence Quality Note

The most recent high-quality guidelines (2024 WSES) 1 strongly support peripheral nerve blocks as first-line therapy, with systematic reviews demonstrating reduced opioid consumption, fewer complications, and improved patient satisfaction. While older guidelines 1 from 2005-2012 provide detailed technical recommendations that remain valid, the 2024 evidence reinforces the opioid-sparing, regional anesthesia-first approach as optimal for morbidity and quality of life outcomes.