Written by Chris Thom
Spoon Feed
This review of analgesia for acute hip fractures provides an excellent synopsis of the evidence and techniques for ultrasound-guided regional anesthesia.
Ultrasound guided regional anesthesia is the way
In this review, the authors detail the supporting evidence and key techniques for ultrasound-guided regional anesthesia for hip fractures. There is mounting evidence that this vulnerable patient population benefits from regional anesthesia for acute hip fractures. Opioid consumption, pain, delirium, and pneumonia frequency decrease, while time to mobilization post surgery improves. The recent American Academy of Orthopedic Surgeons guidelines recommend incorporation of regional anesthesia for hip fractures (1).
The techniques discussed are the fascia iliaca block and the newer pericapsular nerve group (PENG) block. The fascia iliaca block is preferred over the femoral nerve block, as efficacy is higher, and the block may be safer, given that one does not need to place the needle directly adjacent to the nerve. There are two efficacious subtypes of fascia iliaca block: infrainguinal and suprainguinal. The PENG block provides similar levels of analgesia, but does not result in motor blockade, which can be a feature of fascia iliaca blocks. Choice of block likely depends on operator experience and the sonoanatomy visualized. Be mindful that the PENG block will not anesthetize fractures outside of the joint capsule, so it should not be used for subtrochanteric fractures.
How does this change my practice?
US-guided regional anesthesia is a gamechanger. We can substantially reduce pain and improve patient-centered outcomes. Given the current evidence and specialty society guidelines, you may have seen interest among your Orthopedic colleagues in an ED regional anesthesia pathway. There are many steps to make this successful. An internal training and credentialing pathway can help get attending physicians on board, particularly if there is an incentive offered by departmental leadership. Having a well-defined operational process is also critical, which involves a shared understanding between ED, Anesthesia, and Orthopedics on what the expectations and process will be. And a stocked and ready “block kit” is a popular and effective way to reduce the time burden in getting these done.
POCUS pro-tips and clips:
I grew up with the femoral nerve block, but have transitioned largely to the infrainguinal fascia iliaca block. In my opinion, this is very friendly sonoanatomy, with easy landmarks including the femoral vessels, sartorius muscle, and the iliacus muscle. Start by finding the femoral vessels and then slide slightly laterally and cephalad towards the groin crease. Do not worry about visualizing the actual femoral nerve. It’s fun when you see it, but not necessary for the fascia iliaca block. The suprainguinal fascia iliaca block is perhaps a bit more challenging, but may have slightly higher efficacy. And the PENG can be terrific. Use the femoral head as a starting point and then slide just cephalad to the acetabulum. The anatomy is not always easy to see, but one can often find the landmarks of the iliopsoas tendon and anterior inferior iliac spine needed for the block.
Source
Managing Analgesia for Hip Fractures. Ann Emerg Med. 2025 May 8:S0196-0644(25)00193-3. doi: 10.1016/j.annemergmed.2025.04.007. Epub ahead of print. PMID: 40338791
Work Cited
O’Connor MI, Switzer JA. AAOS Clinical Practice Guideline Summary: Management of Hip Fractures in Older Adults. J Am Acad Orthop Surg. 2022 Oct 15;30(20):e1291-e1296.
