Is a PENG (Pericapsular Nerve Group) block effective for managing pain in an intertrochanteric hip fracture?

PENG Block for Intertrochanteric Hip Fracture Pain Management

Yes, a PENG (Pericapsular Nerve Group) block is effective for managing pain in intertrochanteric hip fractures and should be considered as part of multimodal analgesia for these patients.

Evidence Supporting PENG Block for Hip Fractures

The PENG block specifically targets the sensory branches of the femoral, obturator, and accessory obturator nerves that innervate the anterior hip capsule, making it particularly suitable for hip fracture pain management 1. Strong evidence confirms that peripheral nerve blocks (PNBs) in managing acute pain associated with traumatic fractures in elderly patients effectively decrease opioid use, pain levels, and length of hospital stay 1.

Advantages of PENG Block for Intertrochanteric Fractures

• Targeted Pain Relief: Specifically targets the sensory innervation of the hip joint capsule, which is the primary source of pain in intertrochanteric fractures
• Reduced Opioid Requirements: Multiple studies show significant reduction in opioid consumption when peripheral nerve blocks are used 1
• Minimal Motor Blockade: Unlike femoral nerve blocks, PENG blocks typically preserve quadriceps function, facilitating earlier mobilization
• Effective Pain Reduction: Studies show a decrease of at least 3 points on pain scales after PENG block administration 2

Clinical Evidence and Applications

Recent research demonstrates the effectiveness of PENG blocks specifically for hip fractures:

• A 2023 study showed that PENG blocks provided effective analgesia in all patients with hip fractures, with an average decrease of 7.5 points on the Visual Numerical Scale (VNS) 2
• PENG blocks allow for patient transfer and positioning without pain exacerbation or hemodynamic alterations 2
• Continuous PENG blocks via catheter placement can provide extended analgesia for both pre- and post-operative pain management 3, 4

Implementation in Clinical Practice

The 2022 AAOS Clinical Practice Guidelines strongly recommend multimodal analgesia incorporating preoperative nerve blocks to treat pain after hip fracture 1. While the guidelines don't specifically mention PENG blocks, they support peripheral nerve blocks as part of multimodal analgesia.

Technique Considerations

1. Ultrasound Guidance: Essential for proper placement between the iliopsoas muscle and iliopubic eminence
2. Continuous vs. Single Shot: Consider catheter placement for continuous infusion in patients awaiting surgery or for extended postoperative analgesia
3. Safety Precautions: Be aware of potential vascular structures in the area; repositioning may be necessary if blood aspiration occurs 4

Potential Limitations and Considerations

• Technical Expertise: Requires ultrasound guidance and anatomical knowledge
• Limited Long-term Data: While promising, current evidence consists primarily of case reports and series 5
• Vascular Complications: Careful technique is needed to avoid intravascular placement when using continuous catheters 4

Alternative Regional Techniques

If PENG block is not feasible, other regional techniques with proven efficacy include:

• Fascia iliaca compartment block (FICB)
• Femoral nerve block
• Epidural analgesia (though this may limit early mobilization) 1

Conclusion

The PENG block represents an effective regional anesthesia technique for intertrochanteric hip fractures, providing targeted pain relief while potentially preserving motor function. While more robust randomized controlled trials are needed, current evidence supports its use as part of a multimodal analgesic approach for these patients.