Journal Club Article Summary: Comparing the pericapsular nerve group block and fascia iliaca block for acute pain management in patients with hip fracture
- 4 days ago
- 2 min read
PENG: The New Kid on the block for Hip Fracture Analgesia?
By Jonny Russell
The fascia iliaca block has long been the go-to regional technique for hip fracture analgesia in the ED. But a newer technique — the pericapsular nerve group (PENG) block — is gaining attention. This randomised clinical trial, published in Anaesthesia, asked a simple question: does PENG provide better pain relief than the traditional fascia iliaca block in ED patients with hip fracture?
64 patients with moderate to severe pain were randomised to receive either a PENG block (20 ml levobupivacaine 0.375% with dexamethasone) or an infra-inguinal fascia iliaca block (30 ml levobupivacaine 0.25% with dexamethasone). Pain scores were measured over the first hour and reported using the percentage summed pain
intensity difference (%SPID).
Results
The PENG block produced significantly greater early analgesia, with a mean %SPID of 62.7% compared with 38.0% in the fascia iliaca group. More patients receiving PENG also reached clinically meaningful analgesic thresholds. There was no statistically significant difference in rescue opioid use or adverse events. However, in raw numbers roughly half as many patients in the PENG group required rescue opioid compared with the fascia iliaca group. As a small study, it was underpowered to detect meaningful differences in these secondary outcomes.
Discussion
At journal club, our discussion focused on several limitations. Follow-up was limited to one hour, meaning meaningful outcomes like longer-term analgesia, total opioid consumption, incidence of delirium and functional outcomes were not assessed. Patients with obesity and cognitive impairment were excluded—likely improving the reliability of pain scoring and reducing anatomic challenges to successful block placement, but limiting generalisability to all comers with hip fractures in the real world.
Another important issue was the comparator: the study used the infra-inguinal fascia iliaca block, whereas the supra-inguinal approach may provide better analgesia. Finally, discussion centred on the practical implications. Once upon a time emergency physicians needed only to master a single technique for hip fracture analgesia. Introducing PENG alongside infra- and supra-inguinal fascia iliaca blocks increases training complexity and potentially dilutes proficiency in each approach. While it may be helpful to have multiple tools available, there was debate about whether a modest improvement in short-term pain scores justifies the additional training burden.
Bottom line
This well-designed but small single-centre ED-based RCT suggests that the PENG block provides superior short-term analgesia for hip fracture. However, the short time horizon, lack of downstream outcomes and comparison with only the infra-inguinal fascia iliaca block limit conclusions about meaningful clinical benefit. The study moves the needle toward PENG—but it does not close the case.
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