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Pain and its control in patients with fractures of the femoral neck while awaiting surgery
237
Pain and its control in patients with fractures of the femoral neck while awaiting surgery H. C. Roberts and H. Eastwood Elderly Care Unit, Southampton
General
Hospital,
Southampton,
A survey, by two methods, of the pain felt preoperatively by 100 elderly patients wifh an acute fracture of the femoral neck showed that most felt a great deal of pain and that a painless fracture was exceptional. No relationship was found between pain appreciation and the patient’s fracture type or their age. One of the methods suggested that elderly patients wifh preserved mental function felt more pain, and the other that less pain was felt by those taking regular prefracture analgesia. The amount of analgesic drugs given to the patients in this survey seemed inadequate for their levels of perceived pain; accordingly regular measurement by nurses of the degree of pain felt preoperatively by patients with this condition is recommended, together with agreater medical review of the medication being prescribed.
Injury, 1994, Vol. 25,237-239,
May
Introduction The recommended management of a fracture of the femoral neck is surgical treatment within 24 h of admission, providing that the patient is fit for an anaesthetic. In order to relieve pain while awaiting surgery, analgesia is prescribed and the affected leg is usually immobilized by traction, although the benefits of this have recently been questioned (Finsen et al., 1992). Most fractures of the femoral neck are sustained by elderly people, among whom sensitivity to cutaneous and visceral pain has been found to be diminished by comparison with younger age groups (Sherman and Robillard, 1960; Tucker et al., 1989). It is recognized that some normally painful conditions such as perforated peptic ulcer (Clinch et al., 1984) and myocardial infarction (Pathy, 1967) may be painless in the elderly. It is also reported that fractures of the femoral neck may occur without pain (Denham, 1989), but the frequency of this has not been studied, nor has the effect of age on pain appreciation in this condition. This study set out to determine the amount of pain felt by patients awaiting surgery for a fractured femoral neck, and the relationship, if any, between this and the type of fracture, the patient’s mental state, and their age and the taking of prefracture analgesia.
Patients and methods One hundred consecutive patients (80 females, 20 males) with an acute fracture of the femoral neck were studied 0 1994 Butterworth-Heinemann OOZO-1383/94/040237-03
Ltd
UK
prospectively. They were all interviewed by H. C. R. within 24 h of admission and prior to surgery. Details of regular analgesia and of the radiographic category of the fracture (whether intra- or extracapsular) were recorded. Each patient’s level of pain was subjectively assessed by two standard methods. First the patient was asked to verbally rate the pain which they had suffered since the fracture on a scale of O-IO, where 0 represented no pain, and 10 represented the worst pain that they had ever experienced. Secondly each patient was shown the Grimace Chart (Frank et al., 1982) (Figure I) and asked which face appeared to have suffered the same amount of pain as they had since the fracture. A painless fracture was classified as O/IO and either face I or 2 on the Grimace Chart. The analgesia given preoperatively was recorded and used as an index of the patient’s pain as perceived by the medical and nursing staff. The majority of patients had their fracture operated on the day following admission and all within 48 h. Each patient’s mental state was assessed using the IO-point modified Royal College of Physicians mental test score (Hodkinson, 1972); seven or more correct answers out of 10 was accepted as a normal score. Criteria for exclusion from the study included a fracture occurring more than 48 h prior to admission; confusion preventing adequate questioning; concurrent acute medical illness; chronic neurological disease; a fracture previously assessed in the study; and surgery before the patient could be interviewed. In statistical evaluation of the results, Mann-Whitney U-tests were performed to determine the relationship between the pain reported and the patients’ fracture type and their prefracture analgesia. Correlation coefficients were calculated to examine the relationships between the pain experienced and the patients’ mental test score, and their age.
Results The mean age of the 100 patients studied was 80.3 years (range 45-96), 42 of these sustaining an intracapsular fracture and 58 an extracapsular one. All patients could assess their pain by one of the two methods, although two were unable to use the D-10 scale and eight were unable to see the Grimace Chart. Only two patients felt no pain; of the 98 who did, 89 verbally reported pain levels of seven or more out of ten and 67 chose one of the four faces in most pain on the
Injury: International Journal of the Care of the Injured (1994) Vol. 25/No.
238
a
7
6
9
4
10
Figure 1. Grimace chart.
Grimace Chart. The actual levels reported are shown in Figure2. In just more than half of those able to use both scores, the levels differed by more than one value out of the ten available on both scoring systems. These differences seem to have been due to elderly patients finding the Grimace Chart rather confusing and they consistently felt face 8 to be in more pain than face 10. One-third of the 98 patients reporting pain received no analgesia in the Accident and Emergency department despite the fact that movement consequent on the process of admission to hospital is a major cause of pain. Eight patients received none in the period prior to surgery and 24 only received a single dose of one analgesic agent. 6050-
BY GRIMACE CHART
40302010-
NUMBER
O
0
1
2
3
4
5
I
6
7
6
9
10
OF PATIENTS 607 50-
7
BY VERBAL SCORE
4030-
Total number of doses of analgesia given preoperatively in 100 patients Analgesic type
InA&
Paracetamol/codeine NSAID Pethidine Morphine/opium alkaloid Mean no. of doses/person
1 36 7 15 0.62 (range O-l
Eclept
)
On ward 40 50 9 46 1.76 (range O-4)
Details of the type of analgesia and the hospital area where they were given are shown in Table 1. With neither scoring method was an association found between the reported pain and the type of fracture, both intra- and extracapsular fractures being equally painful. Patients taking prefracture analgesia for another complaint experienced less pain compared with those not taking drugs when assessed by the verbal pain reporting method (PC 0.02). This difference was not found with the Grimace Chart method. A correlation was found between the pain experienced as measured by the Grimace Chart and the mental test score, more pain being felt with those with scores in the higher ranges (correlation coefficient 0.374, P-C 0.001). This did not occur with the verbal rating method. No association was found between age and the pain levels, by either method.
Discussion
20101O
TableI.
0
1
2345676
9
10
Figure 2. Pain levels reported by patients after a fractured femoral neck.
The survey shows that on questioning elderly patients with fractured necks of femur, most report their pain as being severe, and a painless fracture is rare. Ageing does not appear to diminish the pain experienced in this condition, but there is a suggestion that falling mental test scores as commonly found in the elderly may blunt this
Roberts and Eastwood: Pain in femoral neck fracture patients awaiting surgery
sensation. Black (1987) has reported a similar finding in elderly patients with low mental scores who are less likely to complain of pain on admission from myocardial infarctions to hospital than those with preserved memories. The pre-operative analgesia given to these patients appears to have been inadequate, and this is likely to be due to several factors. First patients admitted to feeling little pain when lying still on traction, and so may deny pain when nurses do the drugs round. However, they experience much pain when manoeuvred on and off ambulance and casualty trolleys, bed-pans, etc. Secondly there was no formal system to assess these patients’ pain. A pre-printed score (such as a IO cm line from o representing no pain, to 10 representing worst pain) on the medical and nursing notes might help. Alternatively a requirement might be introduced for nurses to assess pain regularly on a pain scale of 0-4 where 0 = no pain and 4 = excruciating pain in patients awaiting operation, as is done with post-operative patients (Denning, 1993). These methods seem to be preferable to the Grimace Chart because of the finding that some elderly patients have difficulty with this method of pain assessment for the reasons mentioned. Finally, the analgesia was almost always prescribed whenever necessary, thus transferring the decision to treat to the nursing staff. Studies have shown that nurses tend to underestimate patients’ pain by comparison with patients’ own estimates (Halfens et al., 1990). We recommend greater medical involvement in the management of pain in this condition and the targeting of analgesia to times of likely patient movement such as before nursing procedures or going to the toilet. It is possible that the under-treatment of pain is a local phenomenon, though the total doses of analgesia given preoperatively do not differ from those given to patients in the survey
of the benefits
of traction
(Finsen
the optimum condition.
239
regimen
for pain
relief in this common
References Black D. A. (1987) Mental state and presentation of myocardial infarction in the elderly. Age Ageing 16, 125. Clinch D., Banejee A. K. and Ostick G. (1984) Absence of abdominal pain in elderly patients with peptic ulcer. Age Ageing 13,120. Denham M. J. (1989) Special features of illness in old age. Care of the Elderly 1,2. Denning F. (1993) Patient controlled analgesia. Br. 1. Nun. 2, 274. Finsen V., Borset M., Buvik G. E. et al. (1992) Preoperative traction in patients with hip fractures. Injury 23, 242. Frank A. J. M., Moll J. M. H. and Hort J. F. (1982) A comparison of three ways of measuring pain. Rheum. Rehab. 21,211. Halfens R., Evers G. and Abu-Saad H. (1990) Determinants of pain assessment by nurses. Inf. J Nurs. Sfud. 27,~. Hodkinson H. M. (1972) Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing I, 233. Pathy M. S. (1967) Clinical presentation of myocardial infarction in the elderly. Br. Heart J 29, 190. Sherman E. D. and Robillard E. (1960) Sensitivity to pain in the aged. Can. Med. 1. 83, 944. Tucker M. A., Andrews M. F., Ogle S. J. et al. (1989) Age associated change in pain threshold measured by transcutaneous neuronal electrical stimulation. Age Ageing 18,241. Paper
accepted
17 January
1994.
et al., 1992).
The mechanism of bone pain is not clear, but it is apparent that most elderly patients with fractured femoral necks suffer considerably. With the benefit of traction now being queried, there would still seem to be questions as to
Requests for repriinfsshould be addressed fo: H. Roberts, Elderly Services, South Block, Queen Alexandra Hospital, Cosham, Portsmouth PO6 3LY.
Pain and its control in patients with fractures of the femoral neck while awaiting surgery H. C. Roberts and H. Eastwood Elderly Care Unit, Southampton
General
Hospital,
Southampton,
A survey, by two methods, of the pain felt preoperatively by 100 elderly patients wifh an acute fracture of the femoral neck showed that most felt a great deal of pain and that a painless fracture was exceptional. No relationship was found between pain appreciation and the patient’s fracture type or their age. One of the methods suggested that elderly patients wifh preserved mental function felt more pain, and the other that less pain was felt by those taking regular prefracture analgesia. The amount of analgesic drugs given to the patients in this survey seemed inadequate for their levels of perceived pain; accordingly regular measurement by nurses of the degree of pain felt preoperatively by patients with this condition is recommended, together with agreater medical review of the medication being prescribed.
Injury, 1994, Vol. 25,237-239,
May
Introduction The recommended management of a fracture of the femoral neck is surgical treatment within 24 h of admission, providing that the patient is fit for an anaesthetic. In order to relieve pain while awaiting surgery, analgesia is prescribed and the affected leg is usually immobilized by traction, although the benefits of this have recently been questioned (Finsen et al., 1992). Most fractures of the femoral neck are sustained by elderly people, among whom sensitivity to cutaneous and visceral pain has been found to be diminished by comparison with younger age groups (Sherman and Robillard, 1960; Tucker et al., 1989). It is recognized that some normally painful conditions such as perforated peptic ulcer (Clinch et al., 1984) and myocardial infarction (Pathy, 1967) may be painless in the elderly. It is also reported that fractures of the femoral neck may occur without pain (Denham, 1989), but the frequency of this has not been studied, nor has the effect of age on pain appreciation in this condition. This study set out to determine the amount of pain felt by patients awaiting surgery for a fractured femoral neck, and the relationship, if any, between this and the type of fracture, the patient’s mental state, and their age and the taking of prefracture analgesia.
Patients and methods One hundred consecutive patients (80 females, 20 males) with an acute fracture of the femoral neck were studied 0 1994 Butterworth-Heinemann OOZO-1383/94/040237-03
Ltd
UK
prospectively. They were all interviewed by H. C. R. within 24 h of admission and prior to surgery. Details of regular analgesia and of the radiographic category of the fracture (whether intra- or extracapsular) were recorded. Each patient’s level of pain was subjectively assessed by two standard methods. First the patient was asked to verbally rate the pain which they had suffered since the fracture on a scale of O-IO, where 0 represented no pain, and 10 represented the worst pain that they had ever experienced. Secondly each patient was shown the Grimace Chart (Frank et al., 1982) (Figure I) and asked which face appeared to have suffered the same amount of pain as they had since the fracture. A painless fracture was classified as O/IO and either face I or 2 on the Grimace Chart. The analgesia given preoperatively was recorded and used as an index of the patient’s pain as perceived by the medical and nursing staff. The majority of patients had their fracture operated on the day following admission and all within 48 h. Each patient’s mental state was assessed using the IO-point modified Royal College of Physicians mental test score (Hodkinson, 1972); seven or more correct answers out of 10 was accepted as a normal score. Criteria for exclusion from the study included a fracture occurring more than 48 h prior to admission; confusion preventing adequate questioning; concurrent acute medical illness; chronic neurological disease; a fracture previously assessed in the study; and surgery before the patient could be interviewed. In statistical evaluation of the results, Mann-Whitney U-tests were performed to determine the relationship between the pain reported and the patients’ fracture type and their prefracture analgesia. Correlation coefficients were calculated to examine the relationships between the pain experienced and the patients’ mental test score, and their age.
Results The mean age of the 100 patients studied was 80.3 years (range 45-96), 42 of these sustaining an intracapsular fracture and 58 an extracapsular one. All patients could assess their pain by one of the two methods, although two were unable to use the D-10 scale and eight were unable to see the Grimace Chart. Only two patients felt no pain; of the 98 who did, 89 verbally reported pain levels of seven or more out of ten and 67 chose one of the four faces in most pain on the
Injury: International Journal of the Care of the Injured (1994) Vol. 25/No.
238
a
7
6
9
4
10
Figure 1. Grimace chart.
Grimace Chart. The actual levels reported are shown in Figure2. In just more than half of those able to use both scores, the levels differed by more than one value out of the ten available on both scoring systems. These differences seem to have been due to elderly patients finding the Grimace Chart rather confusing and they consistently felt face 8 to be in more pain than face 10. One-third of the 98 patients reporting pain received no analgesia in the Accident and Emergency department despite the fact that movement consequent on the process of admission to hospital is a major cause of pain. Eight patients received none in the period prior to surgery and 24 only received a single dose of one analgesic agent. 6050-
BY GRIMACE CHART
40302010-
NUMBER
O
0
1
2
3
4
5
I
6
7
6
9
10
OF PATIENTS 607 50-
7
BY VERBAL SCORE
4030-
Total number of doses of analgesia given preoperatively in 100 patients Analgesic type
InA&
Paracetamol/codeine NSAID Pethidine Morphine/opium alkaloid Mean no. of doses/person
1 36 7 15 0.62 (range O-l
Eclept
)
On ward 40 50 9 46 1.76 (range O-4)
Details of the type of analgesia and the hospital area where they were given are shown in Table 1. With neither scoring method was an association found between the reported pain and the type of fracture, both intra- and extracapsular fractures being equally painful. Patients taking prefracture analgesia for another complaint experienced less pain compared with those not taking drugs when assessed by the verbal pain reporting method (PC 0.02). This difference was not found with the Grimace Chart method. A correlation was found between the pain experienced as measured by the Grimace Chart and the mental test score, more pain being felt with those with scores in the higher ranges (correlation coefficient 0.374, P-C 0.001). This did not occur with the verbal rating method. No association was found between age and the pain levels, by either method.
Discussion
20101O
TableI.
0
1
2345676
9
10
Figure 2. Pain levels reported by patients after a fractured femoral neck.
The survey shows that on questioning elderly patients with fractured necks of femur, most report their pain as being severe, and a painless fracture is rare. Ageing does not appear to diminish the pain experienced in this condition, but there is a suggestion that falling mental test scores as commonly found in the elderly may blunt this
Roberts and Eastwood: Pain in femoral neck fracture patients awaiting surgery
sensation. Black (1987) has reported a similar finding in elderly patients with low mental scores who are less likely to complain of pain on admission from myocardial infarctions to hospital than those with preserved memories. The pre-operative analgesia given to these patients appears to have been inadequate, and this is likely to be due to several factors. First patients admitted to feeling little pain when lying still on traction, and so may deny pain when nurses do the drugs round. However, they experience much pain when manoeuvred on and off ambulance and casualty trolleys, bed-pans, etc. Secondly there was no formal system to assess these patients’ pain. A pre-printed score (such as a IO cm line from o representing no pain, to 10 representing worst pain) on the medical and nursing notes might help. Alternatively a requirement might be introduced for nurses to assess pain regularly on a pain scale of 0-4 where 0 = no pain and 4 = excruciating pain in patients awaiting operation, as is done with post-operative patients (Denning, 1993). These methods seem to be preferable to the Grimace Chart because of the finding that some elderly patients have difficulty with this method of pain assessment for the reasons mentioned. Finally, the analgesia was almost always prescribed whenever necessary, thus transferring the decision to treat to the nursing staff. Studies have shown that nurses tend to underestimate patients’ pain by comparison with patients’ own estimates (Halfens et al., 1990). We recommend greater medical involvement in the management of pain in this condition and the targeting of analgesia to times of likely patient movement such as before nursing procedures or going to the toilet. It is possible that the under-treatment of pain is a local phenomenon, though the total doses of analgesia given preoperatively do not differ from those given to patients in the survey
of the benefits
of traction
(Finsen
the optimum condition.
239
regimen
for pain
relief in this common
References Black D. A. (1987) Mental state and presentation of myocardial infarction in the elderly. Age Ageing 16, 125. Clinch D., Banejee A. K. and Ostick G. (1984) Absence of abdominal pain in elderly patients with peptic ulcer. Age Ageing 13,120. Denham M. J. (1989) Special features of illness in old age. Care of the Elderly 1,2. Denning F. (1993) Patient controlled analgesia. Br. 1. Nun. 2, 274. Finsen V., Borset M., Buvik G. E. et al. (1992) Preoperative traction in patients with hip fractures. Injury 23, 242. Frank A. J. M., Moll J. M. H. and Hort J. F. (1982) A comparison of three ways of measuring pain. Rheum. Rehab. 21,211. Halfens R., Evers G. and Abu-Saad H. (1990) Determinants of pain assessment by nurses. Inf. J Nurs. Sfud. 27,~. Hodkinson H. M. (1972) Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing I, 233. Pathy M. S. (1967) Clinical presentation of myocardial infarction in the elderly. Br. Heart J 29, 190. Sherman E. D. and Robillard E. (1960) Sensitivity to pain in the aged. Can. Med. 1. 83, 944. Tucker M. A., Andrews M. F., Ogle S. J. et al. (1989) Age associated change in pain threshold measured by transcutaneous neuronal electrical stimulation. Age Ageing 18,241. Paper
accepted
17 January
1994.
et al., 1992).
The mechanism of bone pain is not clear, but it is apparent that most elderly patients with fractured femoral necks suffer considerably. With the benefit of traction now being queried, there would still seem to be questions as to
Requests for repriinfsshould be addressed fo: H. Roberts, Elderly Services, South Block, Queen Alexandra Hospital, Cosham, Portsmouth PO6 3LY.