MANAGEMENT OF FRACTURE NECK OF FEMUR IN MEDICALLY UNFIT ASA 4 PATIENTS USING DIRECT INFILTRATION LOCAL ANESTHESIA RATHER THAN REGIONAL BLOCKADE

Abstract

Introduction: Patients presenting with fracture of the femoral neck are usually elderly, and often have extensive co-morbidity. Patients who are considered too unwell for surgery are often keep being delayed until assumed optimised or treated non-operatively. These patients have a high morbidity and mortality and present significant nursing difficulties.

Materials and Methods: We describe a technique of fixation of fracture of the femoral neck under direct infiltration local anaesthesia; that can be performed on the sick elderly patient without the risks associated with general or regional anaesthesia. In a series of twenty eight patients all diagnosed with serious co-morbidity (ASA4) on pre-operative assessment. Twenty three patients suffered from extracapsular fracture neck of femur and five intracapsular fracture neck of femur. All patients were informed about the risks of anesthesia by the senior anesthetist prior to surgery. A mixture of 20 mls n.saline + 20mls of 1% lignocaine with 1:200,000 adrenaline + 20mls 0f.25% plain marcaine (total 60 mls used). This can be increased up to 140 mls in the same ratios.

Results: All patients were operated by various grade registrars. Twenty four (24) DHS and four Hemiarthro-plasty were performed. The patients were all able to complete the surgery using this technique; none required conversion to another form of anaesthesia.

The average duration of surgery was 44 min. All patients survived the procedure and until discharge form hospital.

Discussion: Finlayson and Underhill (1988) suggested that extracapsular fractures are supplied predominantly by the femoral nerve and are therefore more amenable to this type of treatment.

We recommend the consideration of this technique for management of patients with severe co-morbidity and fracture of the femoral neck in order to optimise their chance of survival and avoid the morbidity associated with bed rest.