Matthew Rg Menon

Comparative effectiveness of pain management interventions for hip fracture: a systematic review.

BACKGROUND Pain management is integral to the management of hip fracture. PURPOSE To review the benefits and harms of pharmacologic and nonpharmacologic interventions for managing pain after hip fracture. DATA SOURCES 25 electronic databases (January 1990 to December 2010), gray literature, trial registries, and reference lists, with no language restrictions. STUDY SELECTION Multiple reviewers independently and in duplicate screened 9357 citations to identify randomized, controlled trials (RCTs); nonrandomized, controlled trials (non-RCTs); and cohort studies of pain management techniques in older adults after acute hip fracture. DATA EXTRACTION Independent, duplicate data extraction and quality assessment were conducted, with discrepancies resolved by consensus or a third reviewer. Data extracted included study characteristics, inclusion and exclusion criteria, participant characteristics, interventions, and outcomes. DATA SYNTHESIS 83 unique studies (64 RCTs, 5 non-RCTs, and 14 cohort studies) were included that addressed nerve blockade (n = 32), spinal anesthesia (n = 30), systemic analgesia (n = 3), traction (n = 11), multimodal pain management (n = 2), neurostimulation (n = 2), rehabilitation (n = 1), and complementary and alternative medicine (n = 2). Overall, moderate evidence suggests that nerve blockades are effective for relieving acute pain and reducing delirium. Low-level evidence suggests that preoperative traction does not reduce acute pain. Evidence was insufficient on the benefits and harms of most interventions, including spinal anesthesia, systemic analgesia, multimodal pain management, acupressure, relaxation therapy, transcutaneous electrical neurostimulation, and physical therapy regimens, in managing acute pain. LIMITATIONS No studies evaluated outcomes of chronic pain or exclusively examined participants from nursing homes or with cognitive impairment. Systemic analgesics (narcotics, nonsteroidal anti-inflammatory drugs) were understudied during the search period. CONCLUSION Nerve blockade seems to be effective in reducing acute pain after hip fracture. Sparse data preclude firm conclusions about the relative benefits or harms of many other pain management interventions for patients with hip fracture. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

Diagnostic techniques in acute compartment syndrome of the leg.

Objectives: To review the efficacy of the current diagnostic methods of acute compartment syndrome (ACS) after leg fractures. Data Sources: A Medline (PubMed) search of the English literature extending from 1950 to May 2007 was performed using “compartment syndromes” as the main key word. Also a manual search of orthopaedic texts was performed. Study Selection and Extraction: The results were limited to articles involving human subjects. Of 2605 primary titles, 489 abstracts limited to compartment syndromes in the leg and 577 articles related to the diagnosis of compartment syndromes were identified and their abstracts reviewed. Further articles were identified by reviewing the references. Sixty-six articles were found to be relevant to diagnostic techniques for compartment syndrome in the leg and formed the basis of this review. Conclusions: Early diagnosis of an ACS is important. Despite its drawbacks, clinical assessment is still the diagnostic cornerstone of ACS. Intracompartmental pressure measurement can confirm the diagnosis in suspected patients and may have a role in the diagnosis of this condition in unconscious patients or those unable to cooperate. Whitesides suggests that the perfusion of the compartment depends on the difference between the diastolic blood pressure and the intracompartmental pressure. They recommend fasciotomy when this pressure difference, known as the Δp, is less than 30 mm Hg. Access to a precise, reliable, and noninvasive method for early diagnosis of ACS would be a landmark achievement in orthopaedic and emergency medicine.

Comparing Strategies Targeting Osteoporosis to Prevent Fractures After an Upper Extremity Fracture (C-STOP Trial): A Randomized Controlled Trial: C-STOP: A RANDOMIZED CONTROLLED TRIAL

We compared osteoporosis care after upper extremity fragility fracture using a low‐intensity Fracture Liaison Service (FLS) versus a high‐intensity FLS in a pragmatic patient‐level parallel‐arm comparative effectiveness trial undertaken at a Canadian academic hospital. A low‐intensity FLS (active‐control) that identified patients and notified primary care providers was compared to a high‐intensity FLS (case manager) where a specially‐trained nurse identified patients, investigated bone health, and initiated appropriate treatment. A total of 361 community‐dwelling participants 50 years or older with upper extremity fractures who were not on bisphosphonate treatment were included; 350 (97%) participants completed 6‐month follow‐up undertaken by assessors blinded to group allocation. The primary outcome was difference in bisphosphonate treatment between groups 6 months postfracture; secondary outcomes included differences in bone mineral density (BMD) testing and a predefined composite measure termed “appropriate care” (taking or making an informed decision to decline medication for those with low BMD; not taking bisphosphonate treatment for those with normal BMD). Absolute differences (%), relative risks (RR with 95% confidence intervals [CIs]), number‐needed‐to‐treat (NNT), and direct costs were compared. A total of 181 participants were randomized to active‐control and 180 to case‐manager using computer‐generated randomization; the groups were similar on study entry. At 6 months, 51 (28%) active‐control versus 86 (48%) case‐manager participants started bisphosphonate treatment (20% absolute difference; RR 1.70; 95% CI, 1.28 to 2.24; p < 0.0001; NNT = 5). Of active‐controls, 108 (62%) underwent BMD testing compared to 128 (73%) case‐managed patients (11% absolute difference; RR 1.17; 95% CI, 1.01 to 1.36; p = 0.03). Appropriate care was received by 76 (44%) active‐controls and 133 (76%) case‐managed participants (32% absolute difference; RR 1.73; 95% CI, 1.43 to 2.09; p < 0.0001). The direct cost per participant was

Current thinking about acute compartment syndrome of the lower extremity.

18 Canadian (CDN) for the active‐control intervention compared to

Pain Management Interventions for Hip Fracture

66 CDN for the case‐manager intervention. In summary, case‐management led to substantially greater improvements in bisphosphonate treatment and appropriate care within 6 months of fracture than the active control.