Overview
Hip fracture is one of the most common and serious injuries in the elderly population, affecting approximately 1.6 million people worldwide annually. It is associated with moderate-to-severe postoperative pain that can delay mobilisation, prolong hospital stay, and increase morbidity and mortality. Despite this, pain after hip fracture is frequently undertreated — particularly in older patients where concerns about opioid adverse effects lead to under-dosing.
Effective perioperative analgesia is not merely about comfort. In the geriatric hip fracture patient, it directly impacts:
- Time to mobilisation and physiotherapy compliance
- Risk of postoperative delirium (opioid-related and pain-related)
- Pulmonary complications (hypoventilation, atelectasis)
- Length of hospital stay and discharge destination
- 30-day and 1-year mortality
PROSPECT 2021 summary ESRA PROSPECT systematic review (Pissens et al. 2024, PROSPECT search date 2021) recommends: paracetamol + NSAIDs/COX-2 inhibitors as first-line multimodal analgesia; single-shot femoral nerve block (FNB) or fascia iliaca compartment block (FICB) as regional technique; opioids for rescue only. Epidural, lumbar plexus block, and gabapentinoids are not recommended.
Geriatric Considerations
The hip fracture patient is typically elderly, frail, and polymedicated. Standard analgesic protocols must be adapted accordingly.
Analgesic Pathway — At a Glance
- Paracetamol 1g IV/PO (if not contraindicated)
- Single-shot FNB or FICB in ED — reduces opioid need preoperatively
- PENG block — increasingly used for positioning pain before spinal
- Avoid NSAIDs if dehydrated or AKI risk on admission
- Opioid (low-dose morphine/oxycodone PO) if NRS ≥ 5 and block not yet placed
- Spinal anaesthesia preferred over GA — lower mortality in meta-analyses
- Intrathecal morphine 0.1 mg — optional; provides 12–18h analgesia but with PONV/respiratory risk
- Paracetamol 1g IV if not given preop
- Dexamethasone 8 mg IV — antiemetic + analgesic adjuvant
- Local infiltration analgesia (LIA) — surgeon-injected around wound
- Ketamine infusion — insufficient evidence for this population
- Paracetamol 1g QDS (regular, not PRN)
- COX-2 inhibitor (e.g. celecoxib 200 mg BD) if tolerated — use ≤5 days
- Opioid PRN for rescue (e.g. oxycodone 5 mg PO) — lowest effective dose
- Early physiotherapy and mobilisation
- Regular opioid prescription — avoid if pain controlled
- Gabapentinoids — not recommended in elderly
✓ Recommended | ◎ Optional/conditional | ✗ Not recommended Pathway based on PROSPECT 2021, ESRA, and current literature.
Systemic Analgesia
Paracetamol (Acetaminophen)
Paracetamol is recommended as a cornerstone of basic multimodal analgesia, pre-, intra-, and postoperatively. It should be administered regularly (not PRN), contributes to pain relief particularly when combined with NSAIDs/COX-2 inhibitors, and has a favourable safety profile in elderly patients.
| Agent | Dose | Route | Frequency | Notes |
|---|---|---|---|---|
| Paracetamol | 1 g | IV or PO | QDS (6-hourly) | Reduce to 500 mg–750 mg if body weight <50 kg or hepatic impairment. Avoid if severe liver disease. |
NSAIDs / COX-2 Inhibitors
NSAIDs or COX-2-selective inhibitors are recommended as part of basic multimodal analgesia when not contraindicated. GI, cardiac, and renal complications must be carefully considered in older patients. A COX-2 inhibitor (e.g. celecoxib, etoricoxib) may be preferred over non-selective NSAIDs to reduce GI risk.
Caution in elderly patients: NSAIDs should be used at the lowest effective dose for the shortest duration (typically ≤5 days). Avoid if: eGFR <30, active peptic ulcer, decompensated heart failure, or severe cardiovascular disease. Consider gastroprotection (PPI) if using non-selective NSAIDs.
| Agent | Dose | Route | Frequency | Class |
|---|---|---|---|---|
| Celecoxib | 200 mg | PO | BD | COX-2 — preferred in elderly; less GI risk |
| Etoricoxib | 60–90 mg | PO | OD | COX-2 — once daily; avoid if CVD risk high |
| Ibuprofen | 400 mg | PO | TDS | Non-selective — add PPI; avoid if renal impairment |
| Diclofenac | 50 mg | PO | TDS | Non-selective — higher CV risk; avoid in elderly where possible |
Opioids
Opioids should be reserved as rescue analgesia when non-opioid multimodal analgesia is insufficient. Use at the lowest effective dose and shortest duration. Strong opioids (e.g. morphine, oxycodone) are preferred over tramadol in the elderly due to unpredictable tramadol metabolism and serotonin syndrome risk.
| Agent | Dose | Route | Notes |
|---|---|---|---|
| Oxycodone | 2.5–5 mg | PO PRN 4–6h | Preferred oral option in elderly; predictable pharmacokinetics |
| Morphine | 1–2.5 mg | IV PRN (titrated) | Use with caution in renal impairment — M6G accumulation; reduce dose |
| Fentanyl | 12.5–25 mcg | IV/SC PRN | Preferred in severe renal impairment; short duration |
| Tramadol | — | — | Avoid in elderly — seizure risk, serotonin syndrome, unpredictable metabolism |
Regional Analgesic Strategies
Regional anaesthesia plays a central role in hip fracture analgesia. Both single-shot techniques are effective from the emergency department onwards, reducing preoperative opioid requirements and facilitating positioning for spinal anaesthesia.
Femoral Nerve Block (FNB)
PROSPECT ✓Blocks the femoral nerve (L2–L4), providing analgesia to the anterior thigh and femoral neck region. Well-established evidence base.
Fascia Iliaca Block (FICB)
PROSPECT ✓Targets femoral nerve + lateral femoral cutaneous nerve (LFCN). Supra-inguinal approach preferred — broader spread, better hip coverage than infra-inguinal.
PENG Block
Emerging ◎Pericapsular Nerve Group block — targets articular branches of femoral, obturator, and accessory obturator nerves. Motor-sparing. Excellent for positioning pain. Not yet in PROSPECT 2021 but growing evidence base.
PENG Block — Pericapsular Nerve Group
Emerging technique: The PENG block was first described by Girón-Arango et al. in 2018. It is not yet included in PROSPECT 2021 recommendations due to the evidence timeline, but a 2024 meta-analysis of 6 RCTs (831 patients) demonstrates significant opioid-sparing and pain reduction at 24h. It is increasingly adopted as first-line for hip fracture positioning analgesia, particularly where motor preservation is important.
Mechanism & Target
The PENG block deposits local anaesthetic in the musculofascial plane between the iliopsoas muscle tendon and the superior pubic ramus, targeting the articular branches that supply the hip joint capsule:
- Articular branches of the femoral nerve (primary target)
- Accessory obturator nerve (when present, ~25% of patients)
- Obturator nerve articular branches (variable coverage)
Unlike FNB, the PENG block is motor-sparing — it does not block the main femoral nerve motor branch to the quadriceps, allowing earlier mobilisation and reducing falls risk.
Technique Summary
-
Position & probe placement
Patient supine. Place linear or curvilinear probe in the inguinal region, parallel to the inguinal ligament, to identify the AIIS (anterior inferior iliac spine) and the iliopubic eminence (IPE) of the superior pubic ramus.
-
Identify target plane
The target is the plane between the iliopsoas tendon (anteriorly) and the superior pubic ramus (posteriorly), medial to the AIIS. The femoral artery and nerve are visible medially — avoid.
-
In-plane needle approach
Insert needle from lateral to medial, in-plane, advancing to the target plane. Aspirate, then inject 1–2 mL to confirm correct plane (LA should spread between psoas tendon and ilium, not beneath periosteum).
-
Injection
Inject 20 mL of 0.25% bupivacaine (or 0.2–0.375% ropivacaine) in incremental aliquots with aspiration. Observe hydrodissection in the correct plane.
Dosing
| Agent | Concentration | Volume | Duration | Notes |
|---|---|---|---|---|
| Bupivacaine | 0.25% | 20 mL (50 mg) | 12–20 h | Standard choice; good analgesic duration |
| Ropivacaine | 0.2–0.375% | 20 mL | 10–18 h | Slightly less dense block; better safety profile |
| Levobupivacaine | 0.25% | 20 mL | 12–20 h | Equivalent to bupivacaine with better cardiac safety |
Fascia Iliaca Compartment Block (FICB)
Single-shot FICB is recommended. The supra-inguinal approach provides broader spread (femoral nerve + LFCN + sometimes obturator nerve) than the infra-inguinal approach. No catheter recommended. Choice between FNB and FICB should be based on clinician experience — evidence does not favour one over the other.
Supra-inguinal vs Infra-inguinal
| Supra-inguinal FICB | Infra-inguinal FICB | |
|---|---|---|
| PROSPECT preference | Preferred | Acceptable |
| Nerves covered | FN + LFCN ± obturator | FN + LFCN |
| Volume required | 30–40 mL | 30–40 mL |
| US difficulty | Moderate | Easy |
| Hip coverage | Better — proximal branches | Variable |
Dosing
| Agent | Concentration | Volume | Duration |
|---|---|---|---|
| Ropivacaine | 0.2% | 30–40 mL | 10–16 h |
| Levobupivacaine | 0.25% | 30–40 mL | 12–18 h |
| Bupivacaine | 0.25% | 30 mL max | 12–18 h |
⚠ High volumes are used — calculate maximum safe dose (mg/kg) carefully. Ropivacaine maximum 3 mg/kg; bupivacaine 2 mg/kg. Reduce dose in elderly and low body weight patients.
Femoral Nerve Block (FNB)
Single-shot FNB (including 3-in-1 block) is recommended. No catheter recommended — evidence does not support added benefit of continuous infusion over single-shot for hip fracture. Easy to perform; established safety profile. No evidence to favour FNB over FICB — use based on clinician experience.
Dosing
| Agent | Concentration | Volume | Duration | Notes |
|---|---|---|---|---|
| Ropivacaine | 0.2–0.5% | 15–20 mL | 8–14 h | First-line; 0.2% sufficient for analgesia, 0.5% for denser block |
| Bupivacaine | 0.25–0.5% | 15–20 mL | 12–18 h | Longer duration; careful with max dose in elderly |
| Levobupivacaine | 0.25–0.5% | 15–20 mL | 12–18 h | Preferred over bupivacaine in frail elderly — safer cardiac profile |
Techniques Not Recommended
The following are explicitly not recommended by PROSPECT for hip fracture repair, as adverse effects outweigh benefits in this population:
Adverse effects (hypotension, urinary retention, immobility, haematoma risk) outweigh benefits in the typical elderly hip fracture patient. Not recommended unless specific indication.
Greater risk of retroperitoneal haematoma, deeper technique, and no evidence of superiority over FNB or FICB in this population.
Sedation, dizziness, and delirium risk are especially concerning in elderly patients. No evidence of clinically meaningful pain benefit in hip fracture surgery that outweighs these risks.
No evidence of added analgesic benefit over single-shot techniques sufficient to justify increased complexity, cost, and infection risk.
Intrathecal morphine 0.1 mg — may be used as part of spinal anaesthesia and provides 12–18h postoperative analgesia. However, PROSPECT emphasises the risks (PONV, respiratory depression, urinary retention, pruritus) and states that adequate analgesia may be achieved without it. Consider risk/benefit individually — not recommended as routine in frail elderly.
Practical Analgesic Protocol
Suggested protocol for a typical elderly patient (70 kg, eGFR >45, no NSAID contraindication) undergoing dynamic hip screw or hemiarthroplasty under spinal anaesthesia:
Always individualise: This protocol requires adaptation for patient-specific factors — renal function, anticoagulation, cognitive status, contraindications. Consult local formulary and SmPC before prescribing.
References
- Pissens S, Cavens L, et al. Pain management after hip fracture repair surgery: a systematic review and PROSPECT recommendations. Acta Anaesthesiol Belg. 2024;75(1):15–31. PDF ↗
- ESRA PROSPECT. Hip Fracture Repair Surgery — Summary Recommendations 2024. esraeurope.org ↗
- Anger M, Valovska T, Beloeil H, et al. PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2021;76:1082–1097. PubMed ↗
- Girón-Arango L, Peng PWH, Chin KJ, et al. Pericapsular Nerve Group (PENG) Block for Hip Fracture. Reg Anesth Pain Med. 2018;43(8):859–863.
- Peng PWH, Bhatt S. PENG Block reduces opioid use after hip surgery: systematic review and meta-analysis of RCTs. PMC. 2024. PMC11548832 ↗
- Guay J, Parker MJ, Griffiths R, et al. Peripheral nerve blocks for hip fractures in adults. Cochrane Database Syst Rev. 2017;5:CD001159.
- Steenberg J, Møller AM. Systematic review of the effects of fascia iliaca compartment block on hip fracture patients before operation. Br J Anaesth. 2018;120(6):1368–1380.
- Wongrakpanich S, et al. A Comprehensive Review of Non-Steroidal Anti-Inflammatory Drug Use in the Elderly. Aging Dis. 2018;9(1):143–150. Link ↗
- Çelebioğlu B et al. Emergency department hip fracture analgesia: choosing the right comparator for the PENG block. Anaesthesia. 2025. DOI ↗