Comparison Between Pericapsular Nerve Group Block (PENG) and Morphine Infusion
Condition: Analgesia; Femur Fracture
MeSH terms: Femoral Fractures
Study type: Interventional

Summary: 
      The pericapsular nerve group block (PENG) is a regional anaesthetic technique that was
      developed in 2018, primarily for total hip arthroplasties (THA) as a postoperative analgesia
      modality with motor sparing benefits.

      The block is thought to provide more complete analgesia to the hip by depositing local
      anaesthetic within the myofascial plane of the psoas muscle and superior pubic ramus.

      In this study, the investigators will assess the effect of pericapsular nerve group (PENG)
      block on pain control in patients with proximal femur fracture in the emergency department.

      The Control group will receive morphine as regular patient control analgesia (PCA) The
      interventional group will receive PENG block before being attached to regular morphine PCA
    

Detailed description: 
      The pericapsular nerve group block (PENG) is a regional anaesthetic technique that was
      developed in 2018, primarily for total hip arthroplasties (THA) as a postoperative analgesia
      modality with motor sparing benefits.

      The block is thought to provide more complete analgesia to the hip by depositing local
      anaesthetic within the myofascial plane of the psoas muscle and superior pubic ramus.

      The indications for THA often include degenerative hip disease and traumatic hip fractures.
      These indications for surgery are relatively common in the elderly population and are
      associated with significant morbidity and mortality.

      Operative intervention, such as THA, has also been associated with significant pain.

      Historically, the most commonly performed peripheral nerve blocks include a lumbar plexus
      block, a femoral nerve block, or a fascia iliaca compartment block to manage post-operative
      analgesia.

      With the understanding that additional articular branches (i.e., from the sciatic nerve)
      these blocks will provide incomplete analgesia to the hip and may also predispose the patient
      to fall due to weakness of the quadriceps muscles.

      Therefore the ideal block technique should provide complete analgesia of the hip joint and
      without muscle weakness.

      The PENG has been described for postoperative pain control for surgery at the hip joint or
      the management of post-traumatic pain associated with fractures of the proximal femur/
      femoral head.

      There are currently no unique contraindications that are specific to the PENG block.
      Therefore, similar guidelines applicable to most peripheral nerve blocks would apply and
      include:

        -  Lack of patient consent

        -  Skin infection at the site of injection

        -  Systemic bacteremia or sepsis

        -  Anticoagulation and antithrombotic medications precautions as detailed by the American
           society of regional anaesthesia for peripheral nerve blocks The hip joint has a complex
           innervation, and the pain following hip fractures or total hip arthroplasties is
           particularly severe. An appropriate plan for perioperative analgesia is challenging, but
           a multimodal approach including acetaminophen, cox-2 selective NSAIDs, regional
           anaesthesia, and periarticular infiltration techniques improves patient outcomes.

      The ultrasound-guided PENG block allows for coverage of the hip joint, targeting the proximal
      articular branches that innervate the joint capsule. This proximal approach via ultrasound
      guidance can confer several advantages over a femoral nerve block by providing more complete
      analgesia to the hip joint. Additionally, the motor function of the involved extremity should
      be spared. The PENG block can be used alone as a primary analgesic or in conjunction with
      other forms of anaesthesia during surgery or in the perioperative period. For lateral
      surgical incisions, a supplemental lateral femoral cutaneous nerve block provides additional
      coverage.

      With the patient in the supine position, the ultrasound probe is placed on a transverse plane
      over the anterior superior iliac spine (ASIS). Once the ASIS is identified, the transducer is
      aligned with the pubic ramus and rotated at approximately 45 degrees, parallel to the
      inguinal crease. The transducer is then slid medially along this axis until the anterior
      inferior iliac spine (AIIS), iliopubic eminence (IPE), and the psoas tendon is identified,
      serving as anatomic landmarks.

      Sliding the probe distally or gently tilting the caudal will expose the head of the femur.
      Returning to the initial starting position, a standard 20-22 gauge 100mm needle is inserted
      in-plane, from lateral to medial, in the plane between the psoas tendon and the pubic ramus.
      15-20ml of a long-lasting local anaesthetic ((i.e., 0.5% ropivacaine) is then deposited in
      this plane, lifting the psoas tendon. Care should be taken to avoid puncturing the psoas
      tendon. In this study, the investigators will assess the effect of pericapsular nerve group
      (PENG) block on pain control in patients with proximal femur fracture in the emergency
      department.

      The Control group will receive morphine as regular patient control analgesia (PCA) The
      interventional group will receive PENG block before being attached to regular morphine PCA
    

Intervention name(s): Pericapsular nerve group block; Morphine Sulfate
Intervention type(s): Procedure; Drug
Intervention description(s): patients will receive pericapsular nerve group block; morphine will be given to both groups as patient-controlled analgesia PCA
Intervention MeSH terms: Morphine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Supportive Care