...And We All Fall Down... Eventually : Nonpharmacologic pain management for hip fractures in the elderly?

Your patient is an elderly male with history of dementia and multiple medical comorbidities who is sent to the emergency department after a fall from standing. He complains of left hip pain and his X-rays demonstrate a comminuted intertrochanteric left hip fracture. Since the elderly and demented constitute an at-risk population for inadequate analgesia as well as increased risk of fall, respiratory depression and delirium from polypharmacy, you wonder what nonpharmacologic pain control interventions may supplement your pain control management for this patient?

Clinical question: 

Are nonpharmacologic pain control interventions effective in treating pain associated with hip fracture? Do nonpharmacologic pain control interventions reduce the need for opiates in patients with hip fracture?

The Literature: 

Several studies have examined the efficacy of skin traction (foam boot connected to weight via pulley) versus position of comfort (pillow support) for pain relief in patients with various hip fractures. In two randomized studies, skin traction showed no benefit over pillow support:
The first study, published in 2001, was a randomized study enrolling 100 participants. They compared skin traction with a 5lb weight versus pillow support. The authors found that patients who were treated with pillow support required less pain medication and reported statistically significantly lower pain scores prior to surgery (after overnight stay awaiting operative intervention) than their traction treated counterparts (p 0.04). They had an average reduction of pain score of 2.82 points versus a reduction of 1.76 points. The average age of patients in the study was 78 and nearly half had intertrochanteric hip fractures (other half were femoral neck fractures). The study was limited in that they excluded demented patients in their study as they were felt unable to demonstrate adequate understanding of the pain scale and reliably report pain scores.
The second study, released in 2010, included 108 patients randomized to either weighted traction, unweighted traction apparatus or pillow support. Similarly, they observed no difference in pain control between pillow and weighted traction. However, unweighted traction had a statistically significant improvement in pain control compared to the other two. They attributed this to a placebo effect as it provided no actual support of the fracture fragments and did not restrict movement.
Neither study reported negative outcomes associated with pillow treatment, however both observed minor negative outcomes with skin traction either weighted or unweighted. These included blistering, pressure sores and neurapraxia.

Take home: 

- At least two studies demonstrate no improvement in pain control by employing skin traction over pillow support. 
- Moreover, while the pillow group had no reported negative outcomes related to treatment, the skin traction groups in both studies reported wounds, blistering, nerve compression, and pain with application of the treatment. 
- In this population with advanced age, comorbid illness, and potentially limited ability to sense or communicate discomfort with a boot, these minor problems could develop important long term sequelae.
- My treatment plan for the next elderly hip fracture: Pillow support + adequate pharmacologic analgesia + consideration for local nerve blocks. 

References:
1) Rosen, JE et al, “Efficacy of preoperative skin traction in hip fracture patients: a prospective, randomized study,” 2001. Journal of Orthopedic Trauma. Vol. 15(2) 81-85.
2) Sayqi, B et al, “Skin traction and placebo effect in the preoperative pain control in patients with collum and intertrochanteric femur fractures.” 2010 Bulletin of the NYU Hospital for Joint Diseases. Vol. 68(1) 15 - 17.


Contributed by Sara Manning, PGY-3