Challenging the Paradigm: Fascia Iliaca Blocks May Not be Necessary for All Neck of Femur Fractures

Fascia iliaca blocks (FIB) are recommended by national guidelines for analgesia in neck of femur (NOF) fractures to reduce opioid burden. However, evidence supporting universal administration is largely derived from patients with moderate-to-severe pain. It remains unclear whether ``blanket'' FIB protocols benefit the heterogeneous population presenting to emergency departments.

To evaluate real-world analgesic efficacy of FIBs across baseline pain severities and to assess whether a targeted approach is justified.

Single-centre, retrospective case-control study of adults presenting to a UK Major Trauma Centre with radiologically confirmed NOF fractures. Changes in pain scores and opioid consumption (Morphine Milligram Equivalents [MME]) were analyzed pre- and post-intervention. Outcomes were compared between FIB and standard analgesia, and between ultrasound-guided and landmark techniques.

Of 112 included patients (80.2 ± 9.4 years; 74.1% female), 87 (77.7%) received a FIB. While FIB resulted in a statistically significant reduction in pain scores (4.7 ± 3.8 to 2.0 ± 2.8; p = 0.003), it did not significantly alter opioid consumption (median 0.00 vs 0.47 MME/h; p = 0.961). Subgroup analysis revealed that analgesic benefit was strongly correlated with baseline pain (r = 0.771, p < 0.001); patients with rest pain <4 derived minimal benefit. No significant difference in efficacy was observed between ultrasound-guided and landmark techniques.

Universal FIBs for NOF fractures may represent an inefficient use of resources for patients with low baseline pain. A stratified protocol prioritising patients with moderate-to-severe pain (Visual Analogue Scale [VAS]/Numerical Rating Scale [NSR] ≥ 4) is recommended.