Written by Chris Thom
Spoon Feed
In this randomized control trial of elderly hip fracture patients, the analgesic effect of the ultrasound-guided PENG block was greater than intravenous opioid therapy.
Delivering pain relief without the opioid side effects
This was an RCT comparing IV opioids with the US-guided PENG block in hip fracture patients at a single ED. Eligible patients were those with an acute hip fracture who had moderate-to-severe pain upon ED arrival. Patients were randomized to receive either an US-guided PENG block or a 0.1 mg/kg dose of intravenous morphine. A single ED physician performed the PENG blocks. The primary outcome was pain reduction after 30 minutes.
There were 17 patients enrolled in each arm. There was a significantly higher pain reduction in the PENG block arm at 30 minutes, with a median reduction in the 11-point pain score of -6 (IQR -6 to -5) compared to -3 (IQR -5 to -2) for those in the IV morphine arm (p=0.001). Three patients (17.6%) in the IV morphine group experienced an oxygen desaturation event compared to 0 in the PENG group. One patient (5.9%) in the IV morphine group required rescue IV opioid therapy for ongoing pain compared to 0 in the PENG group.
How will this change my practice?
While limited by a small sample size at a single center with a single operator, this RCT adds to the existing evidence. These are some of our most vulnerable patients with respect to IV opioid side effects, and US-guided regional anesthesia techniques continue to show benefits for these patients. I think the evidence is clear enough that we should be learning these blocks and offering them to this patient population.
POCUS Pro-Tips and Clips
The PENG block references bony anatomy for successful block delivery. This is advantageous, as the bony anatomy is fairly consistent from patient to patient and thus perhaps easier to learn for the novice operator. I start by finding the femoral head in the short axis with the probe indicator towards patient right. I then scan slightly cephalad until the femoral head “drops off” and is replaced by the anterior inferior iliac spine (AIIS). Here you can see the psoas tendon and the iliopubic eminence (IPE). You’ll deliver the anesthetic just lateral to the psoas tendon. With the pelvic bone directly underneath this tendon, you can advance until you feel the bone and then deliver the anesthetic just superficial to this.
Source
Ultrasound-guided pericapsular nerve group block versus intravenous morphine for pain management in older adults with hip fractures: a randomised controlled trial in the emergency department. Emerg Med J. 2026 Mar 19:emermed-2025-215388. doi: 10.1136/emermed-2025-215388. Epub ahead of print. PMID: 41856550.
