Emergency Medicine Training

Year 2 Pre-Sale is LIVE! Master 4 new high-stakes procedures. Secure Your Spot
Menu
Menu

Hip Tricks: Battle of the Blocks

Hip Tricks: Battle of the Blocks

Contributors: Jason Hine MD

Welcome back to SimKit, and our podcast today on hip fracture blocks. Today’s post focuses on a significant study comparing peri capsular nerve group (PENG) block and fascia iliac block for managing acute pain in hip fracture patients. Conducted by D Pietro et al., this research, published in Anesthesia in December 2025, offers insights into pain relief techniques within a single-center academic site in Italy. The primary focus was on immediate pain relief achieved within 60 minutes of the block procedure, with secondary outcomes analyzing pain intensity and opioid consumption.

Transcript
 
Hello everybody and welcome back to the SimKit podcast, and I am your host, Dr. Jason Hine in my Grizzly Adams form here in our, you know, Maine winter. Uh, we are going to be talking about a pretty cool, kind of little, but I think an important study on a super important topic. And this is a, a paper related to hip fractures.
So the paper itself, this is comparing the peri capsular nerve group block and fascia iliac block for acute pain management in patients with hip fracture, a randomized clinical trial. This is by D Pietro, et al. It’s in anesthesia and this is, this is fresh off the presses. This is December, 2025. So what they do, this is a single center academic site study in Italy.
It was conducted in Italy comparing the peri capsular nerve block or pang block, PENG block to the fascia iliac block for patients with hip fractures. Now, their primary outcome was pain relief over a 60 minute interval after the block was conf performed. Their secondary outcomes included some pretty good ones and important ones.
They looked at the number of patients who had a 33 or 50% decrease in the SPID. That is the summed pain intensity difference. So how many patients had their pain go down by 33% and 50% respectively? And of course, that’s on our visual analog scale, that VAS, which goes from zero to 10 or in here, they were actually doing zero to 100, but it’s the same scale, basically 10 x.
They also looked at the total amount of opioids administered in morphine, milli equivalents, or HMEs in that 60 minute timeframe after the block. I wish they’d put that out a little further, but we’ll get into that detail. And of course, they also looked at things like adverse events. So what were their inclusion criteria?
Who did they study? Patients were included if they were 18 years of age or older. In the emergency department with a radiologically confirmed proximal femur fracture. This could be subcapitate, transc, cervical intertrochanteric, or perter in nature, they had to have moderate to severe acute pain with a score of four or 40 at rest, or with movement that’s not that high of a bar.
And certainly when you add the with movement, that’s a pretty good number of patients who are gonna have that degree of pain. Now they had to have capacity on their own. They had to have the capacity to provide consent and be able to do the VAS on their own, which I appreciate. Right. If we think about the patient population they’re studying, patients were excluded.
If they had a known hypersensitivity to the anesthetic that was being used, if they had a subtrochanteric or dile or periprosthetic fracture, of course they were excluded there. They didn’t have the right fracture. Morphology. If they were hemodynamically unstable or if they had a history of severe cognitive impairment or evidence of dementia or delirium.
Again, they had to be able to engage on their own, give consent on their own, and do that VAS score themselves. Now, a couple other important exclusions that keep in mind. They were also patients were also excluded if they had a BMI greater than 35, or if they weighed less than 40 kilograms. All right.
Inclusions exclusions. They’re pretty reasonable that BMIA little soft, but anyway, that’s what they did. So study design, what did they do? How did they kind of go through their process? Patients were randomized in a one-to-one fashion between the two block groups, and then they were tested for pain at rest and with movement.
Which was hip flexion to like 15 degrees, which seems kind of terrible. It’s a little bit of a torturous thing to do for a patient with a hip fracture, but they kind of had to get a baseline pain score for these patients. After they did that set assessment, they were again, randomizing that one-to-one fashion and to either the Pang block or the fascia IA block.
Now, I thought this was pretty clever. Obviously you can’t really blind the proceduralists. To the procedure to what they’re doing, but the rest of the team was blinded. Now, to maintain some of that blinding, what they did was they used local disinfectant in both of the areas where the ping block would be done and where the fascia iliac a block would be done so that the chlorhexidine iodine, whatever it is.
Is covering both areas and trying to keep from the unblinding, uh, from happening, right? So the blocks themselves, they were done by a total of si, excuse me. They were done by a total of six clinicians. It’s actually initially four emergency medicine docs, but two left the institution and they had to be replaced by two others, so a total of six.
And they were senior emergency medicine physicians. Who are trained in both blocks, and as I said already, they could not be blinded to the block technique, but they completed the block and then they weren’t really involved in the patient care anymore. And the treating physicians and those who are assessing the pain outcome scores, they were blinded to the block technique.
Now, interestingly. All patients in both groups got 15 milligrams per kilogram of paracetamol or acetaminophen in the United States, and none were given any anxiolysis or opioids for the procedural block itself. Now, for doing the blocks, what did they do? What did they use? They use actually 0.375 Lev Bupivacaine.
0.375 lev vacate and four milligrams a dexamethasone. That was what they injected for these blocks. Now for the Pang block, interestingly, all patients got 20 mls of the lev vacate, plus the Dex. And for the fascia iliac block, they got 30 mls of the lab bupivacaine plus dexamethasone. So after the blocks were done, patient had the pain score assessment and they did it at five.
15, 30 and 60 minute intervals post block. Now they screened 92 patients, 28 were excluded for several reasons, and that left 64, 32 in each group. ’cause again, they were randomizing them one to one. Now interestingly, and pretty importantly, there were two dropouts from the Pang Block Group. One patient was dropped out because of body habitus, which precluded their ability to actually do the technique properly, and one that had a diaphysis fracture, so should have been excluded, and it was kind of a failure of randomization.
So, uh, with these patients out, they decided actually to have them in their intention to treat analysis, which is good, right? They should be kept there and they. Decided to score them with their SPID. That summed pain intensity difference of zero saying basically the block didn’t work. They were kept in the intention to treat for Pang and they just said we’re, we didn’t do it.
We’re gonna say the block didn’t work. So that actually shows a potential signal for increased effect if they were included. But we will, again, we’ll talk about that a little bit later. All right, so results. What did they find in their results? So the Pang Block Group, when they looked at the randomization in the patients, the Pang Block Group actually had a higher pre block VAS visual analog score with an average of nine or 90 versus the Fasc block group of eight or 80.
But the effects are pretty dramatic and are shown really, really well in figure two, and we are gonna reproduce that in our show notes for you. By five minutes at the five minute bark, both groups had equal general pain at around a seven VAS, or 70. From there, the pain block block group dropped significantly relative to the FAS IAC block Group in the pain scores as they did ’em at 15, 30 and 60 minutes.
The Ping Block Group also had significantly greater summed pain intensity difference that SPID. Compared to that of the fascia ACA block 63% versus 38%. Now, how about that 33% drop in 50% drop? Looking at how many patients had that 33% SPID change or greater. We saw that 28 of the 32 in the Panlock group did, and 19 of the 32 in the fascia iliac block, 28 versus 19.
Now getting down to a 50% sum pain intensity difference. 24 of the 32 in the Pang Block Group had that versus seven of the 32 in the fascia iliac block. And these differences were, as you might imagine, statistically significant. Okay. What about secondary outcomes? Rescue analgesia. Analgesia was given in five of the 30 in the Pang Block group versus 10 of the 30 in the Fascia iliac block group.
So it was definitely different, but not statistically. So now the average MME milliequivalents of morphine in the pen block group was three versus eight in the fascia ICA block. So different. Again, statistical power, not there. All right, so what are the strengths of this paper? This is a well executed academic study with generally good study protocols, blinding and follow through for these patients.
It was prospective data collection with independent observers, which helps minimize bias, doesn’t eliminate it, but certainly helps. Now while it’s an academic center, it is a pretty widely applicable process, right? Doing these types of blocks to emergency medicine practitioners everywhere. So I don’t hold too many qualms about that academic center.
How about limitations? The thing I wanted more of was the details about the physicians performing the block and their prior experience in this. I like that their EM docs, it’s not pulling in anesthesia, which is unrealistic for most of us, but I’d love to know a little bit more about their prior experience.
A little limited. The exclusions of the BMI of 35 or higher is certainly, you know, it’s somewhat limiting, particularly in the United States with our obesity epidemic. So that restriction, eh, not my favorite. And now they actually wanted to do this as a two site study, but they were unable to enroll a second site, which was gonna be in the uk.
So it is a single center site, so that is somewhat limiting. I would’ve loved to have included an additional site in the uk, obviously us. We’d love that stuff too. But again, back to the strengths. This procedure is performed by emergency physicians, whether it be academic or community. We all can do this.
So it’s generally pretty applicable and it can be performed by most or many of us practicing emergency medicine. Now they did have one patient excluded from the Pang Block Group. I said, because of anatomy and one enrollment violation, so that, you know, tempers our enthusiasm a little bit. But if you go back to those results and see the amount of drop in each group, remember we are looking at they, they kept them in there as an intention to treat.
So that denominator of 32, the changes are there, despite having two people that were gonna have no change no matter what. So. We can certainly just keep these numbers at face value and still be impressed by the differences in pain scores. But it’s also impressive that they were able to do that with the two enrollment violations or people that had to be kept in intention to treat, but actually didn’t even get a paying block.
And you know, the last limitation I would mention is they were underpowered for that milli uh, Millie equivalence of morphine. And so even though there’s a difference in there, we can’t say that it’s statistically significant. Alright, so what do we think about what kind of discussion elements of this?
Personally, I think these authors did a great job in their introduction, talking about the multimodal analgesic approach to patients with these types of fractures and generally our desire to avoid the use of opioids in frail elderly patients who tend to be the ones who break their hips. They actually cite the Royal College of Emergency Medicine Best Practice Guideline about the use of the Fascia ICA block in emergency departments as a best practice for patients with this fracture pattern.
And I think they present pretty convincing data, though relatively small numbers with 30 or 32 patients in each arm, but that it really showed the improved efficacy of the P block over the fascia ica. Now the authors also talk about the potential benefit, though less relevant for US emergency physicians.
Probably more ortho of the motor sparing effect of the quadriceps with the pang block, so that’s certainly interesting too. The authors do a really nice job of citing their own limitations, which are similar to the ones that we had mentioned, the idea of it being single centered and ideally we would’ve loved that UK site involved, et cetera, et cetera.
The other thing that they mentioned, which is important to note, the general, they had a generally short duration of observation for their anesthetic effect. They observed it up to one hour, 60 minutes. Now I recognize, and the authors explain that they did this because they wanted to prevent confounding of, you know, physical exams by consultants, patients moving onto hospital beds and other things that might.
Interfere with longer durations of time and things that might influence that pain over time, but one hour of analgesia, you know, that’s good. Seeing that effect of these blocks that we’re doing for a longer duration of time and the collective ES used by the patients in the coming, say 10, 12, 24 hours would be really insightful and nice to have.
All right, so what are the author’s conclusions? They say, and I quote, the P block provides superior analgesia for the first hour after intervention when compared with the infra inguinal fascia iliac block, and represents a promising modality for acute pain management in emergency departments. What are our conclusions?
Well, I tend to agree with them. I don’t think that this is the most robust study that we will have comparing the pain block and the Fascia Block, but is a well conducted study and shows a pretty dramatic effect related to pain scores and probably the ES of opioids. Given I personally don’t need a more robust study comparing these two approaches, and yes, I am in full agreement that regional anesthesia should be.
Standard practice for elderly patients with hip fractures. I myself have been a fascia I ACA block person for the entirety of my career, but I have recently moved to doing some of these pain blocks and with this study. This may be my preferred location for elderly patients with hip fractures. Of course, we need to keep in mind body habitus.
The fact that this is a above the inguinal eliminate ligament approach, and we have to consider that in patients that have anticoagulated state, et cetera. But when both the fascia iliac a block and pang block are an options for the patients I’m caring for, I’m gonna be reaching for peg. So I hope that was interesting and insightful for you.
We have a reference to the article itself. Again, take a look at that Figure two, which really shows that dramatic difference. And for those who subscribe to Sim Kitt, know that we have a robust regional anesthesia library for you available. It includes the Pang Block, fascia ACA Block, and many, many others.
So if you’re interested in learning these techniques, consider signing up or check out that resource library where we have all of these blocks to do. Thanks for listening.

Keeping your skills up in rare procedures is an uphill battle.  Let SimKit do all the heavy lifting with simulation training that delivers to your door once a month. Use coupon code SimKit10 for 10% off

Subscribe Today

The Paper

Comparing the pericapsular nerve group block and fascia iliaca block for acute pain management in patients with hip fracture: a randomised clinical trial.This was by Di Pietro et al in   Anaesthesia. 2025 Dec.[Pubmed]

 

Full citation: Di Pietro S, Maffeis R, Jannelli E, Mascia B, Resta F, De Silvestri A, Musella V, Centurioni CE, Regeni E, Grassi FA, Locatelli A, Perlini S; Regional Anaesthesia in Emergency Medicine (RAEM) Research Group. Comparing the pericapsular nerve group block and fascia iliaca block for acute pain management in patients with hip fracture: a randomised clinical trial. Anaesthesia. 2025 Dec;80(12):1484-1492. doi: 10.1111/anae.16695. Epub 2025 Jul 29. PMID: 40727959; PMCID: PMC12614414.

What They Did

This was a single Center academic site study in Italy comparing the pericapsular nerve block or Pang block to the fascia iliaca block for patients with hip fracture. 

-Primary outcome was pain relief over a 60 minute interval after the block was performed

-Secondary outcomes included:

— The number of patients who had 33% and 50% decreases inThe SPID or summed pain intensity difference, on the visual analog scale (0 to 10 or 0 to 100 mm)

–The total amount of opioids administered in morph humility equivalents or MMEin the 60 minutes after the block

–Adverse Events

Patients were included if they were 18 years of age or older in the emergency department who had a radiologically and confirmed proximal femur fracture this could be subcapitate transcervical intro-canteric or paratrocanteric. they had to have moderate to severe acute pain with a score of four or 40 at rest or with movement,  they had to have capacity to provide their own consent and be able to do the vas on their own.

 patients were excluded if they had a known hypersensitivity to then aesthetic sub truck enteric diaphysical or periposetic fracture or hemodynamically unstable had a history of severe cognitive impairment or evidence of Dementia or delirium. they were also excluded if they had a BMI greater than 35 or were less than 40 kg 

Study Design

Patients were randomized and then were tested for pain at rest and with movement which was hip flexion of 15° which seems like a terrible thing to do to a patient with a hip fracture but they had to get baseline scores. Patients were randomized in a one-to-one group to the PENG block or the fascia block. Smartly, when the procedure was performed the operating position who of course could not be blinded to what type of block was done they did used local disinfectant in both areas where the PENG block and the  fascia iliaca block would be done.

The blocks were done by a total of six- initially four but two left the institution were replaced by two others- but a total of six senior Emergency Medicine physicians who are trained in both blocks. They were of course not blinded to the block technique but they completed the block and then we’re not in other ways involved in patient care so the treating Physicians and those assessing outcomes in pain scores were blinded to the block technique

 interestingly all patients got 15 mg per kilogram of paracetamol or acetaminophen in the United States and none were to receive anxiolysis or opioids for the procedure block itself. 

For the blocks themselves they used 0.375% Levobupivicaine and 4 mg of dexamethasone.For the pain block interestingly they got 20 ml of the Levo bupivacaine plus the decks and for the fascial block they got 30 MLS of the levobupivicaine + dex.

After the blocks were done patients had a Pain Scale assessment at 5, 15, 30 and 60 Minutes post block

They screamed 92 patients with 28 being excluded leaving 64, 32 in each group. interestingly and importantly there were two dropouts from the Pang block group. one because of body habitus precluding the ability to do the technique properly and one had a diaphysical fracture, so should have been excluded from randomization. with these patients they decided to have them have a percent SPID of zero in the intention to treat analysis. which actually shows potential signal for increased effect if they were included we’ll talk about that later.

Results

The PENG block group actually had a higher pre-block vas at average pains score of 90 versus 80. But the effects are pretty dramatic and are shown very well in Figure 2, reproduced below. By 5 minutes both groups had equal general pain at around 70 on the VAS,  and from there the PENG block group dropped significantly relative to the facia iliaca block related to paint scores. 

The PENG block group had a significantly greater summed pain intensity difference compared to that of the fascia iliaca block- 63% versus 38%. 

33% SPID

Looking at how many patients had a 33% SPID change or greater we saw 28 of 32 in the PENG block group and 19 of 32 in the fascia iliaca block group

50% SPID 

 24 of the 32 in the PENG Block versus seven of the 32 in the fascia block. these differences were statistically significant.

 For secondary outcomes, rescue analgesia was given in 5of 30 in the PENG block versus 10 of 30 in the fascia iliaca block group– different but not statistically significant. The average MME in the PENG block group was 3 versus 8 in the fascia iliaca block group.

Strengths

-This is a well executed academic study with generally good study protocols, blinding and follow-through.

-It is prospective data collection with independent observers minimized bias.

-While in academic center it is widely applicable to Emergency Medicine practitioners everywhere.

Limitations

-Details about the physician’s performing the block and their prior experience are limited.

-Exclusions of a BMI of 35 or higher is somewhat limiting particularly in the United States with the Obesity epidemic.

-They actually wanted this to be a two-site study but they were unable to enroll the second site so it is somewhat limited by being a single Center, but as noted in the strengths the topic and procedures performed are generally applicable and can be performed by most or many Emergency clinicians.

-They had the one patient excluded from the pain block group because of anatomy and one enrollment violation.

-They were underpowered for MME difference.

Discussion

The authors do a great job in their introduction of talking about multimodal analgesia and generally a desire for avoidance of significant opioids in frail elderly patients who tend to be those who break their hips. they cite the Royal College of emergency medicine best practice guideline about the use of the fascia iliac Block in the emergency department as a best practice for patients with this fracture pattern.

They present pretty convincing data though relatively small numbers with 30 to 32 patients in each arm about the improved efficacy of the paying block over the fascia iliaca. the authors also talk about the potential benefit, though less relevant for us Emergency Physicians, of the motor sparing of the quadricep with the Peng block.

The authors do a nice job of citing their own limitations which are similar to our own the idea of it being single-centered and ideally we would have loved to have that UK site involved,  and the general short duration of observation of analgesic effect, stopping at 1 hour. I recognize why the authors did this to prevent confounding of physical exams by Consultants moving patients to hospital beds other things that are happening that might influence pain over time, but one hour of analgesia is good,  but seeing the effect over a longer duration of time and the collective mme used by patients in the coming say 10 to 12 hours would be very insightful. 

Authors' Conclusion

The PENG block provides superior analgesia for the first hour after intervention when compared with the infra-inguinal FIB and represents a promising modality for acute pain management in Emergency Departments.

Our Conclusions

I tend to agree. I don’t think that this is the most robust study we will have comparing Peng to fascia iliaca, but is a well conducted study and shows pretty dramatic effect related to pain scores and actually mme of opioids given. I personally don’t need a more robust study comparing these two approaches. cool I am in full agreement that a regional block should be standard practice for elderly patients with hip fractures. I myself have been a fascia iliaca block person for the entirety of my career,  but recently have done a few of the paying blocks and with this study will have that as my first preferred location for elderly patients with hip fractures, keeping in mind body habitus,  the fact that we are above the inguinal  ligament and considering that related to anticoagulated state etc.- but when both are an option for patient I will be reaching for PENG.

← Back to Podcasts

Need help? We're here to assist you!