Lower Limb Peripheral Nerve Blocks In The Emergency Department: A Narrative Review Of The Literature

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Authors: Tsapara V^1a*, Koraki E^2a, Bareka M^2b, Arnaoutoglou E^2b

¹MD, MSc, Anesthesiology
²MD, MSc, PhD, Anesthesiology

^aAnesthesiology Department, General Hospital “Papageorgiou” Thessaloniki, Greece
^b Anesthesiology Department, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece

**Correspondence: Olympiados 115, 54634, Thessaloniki, Greece, tel.: +306987002445, e-mail: ,

ABSTRACT

Timely and effective analgesia in the Emergency Department (ED) constitutes an important element of patients’ therapeutic approach. Peripheral Nerve Blocks (PNB) are mainly used by anaesthesiologists in surgery, as part of their analgesic plan. However, the potential of implementing them in plenty of injuries and pathological situations and the fact that they spare the adverse effects of systemic analgesia (opioids, paracetamol, NSAIDs) makes them very useful at the ED setting. This study aimed to review the literature regarding the PNBs of the lower limb in ED.

Research of the literature was carried out in two databases, Pubmed and Cochrane, using the following free- text terms: (peripheral nerve blocks, OR nerve blocks, OR regional nerve blocks) and (emergency department).1343 studies were identified initially and 59 papers were included in this literature review. The most common causes of implementing a PNB of the lower limb in ED were analgesia in hip and femur fractures. It was observed that the analgesic effect of PNBs is comparable to those of systemic analgesia. In addition to that, PNBs are characterized by advantages such as haemodynamic stability, avoidance of sedation, early ambulation, prevention of chronic pain and reduction in length of stay and healthcare cost. The use of PNBs of the lower limb in ED is advantageous both for the patient and the healthcare system. However, the existing literature proves to be restricted. Conducting further studies in order to substantiate the efficiency of PNBs in the ED, is of great importance.

INTRODUCTION

Pain frequently constitutes the primary reason for patients’ presentation to the Emergency Department (ED). In most cases, however, pain is undertreated, as it is not adequately recognized, and even when identified, it is often not properly assessed—neither in terms of intensity nor quality—through the use of appropriate tools.

Inadequately managed acute pain, in the ED, results not only in psychological distress but also in multifactorial stress, affecting all major systems, including cardiovascular, renal, immune, and gastrointestinal. Acute pain leads to catecholamines and stress hormones release, which exert systemic effects and ultimately impair recovery. It increases myocardial oxygen demand and predisposes to ischemia, may restrict ventilation, reduces intestinal motility, and causes nausea and vomiting. Additionally, pain stimulates the secretion of antidiuretic hormone, leading to oliguria and urinary retention. Furthermore, it enhances the postoperative prothrombotic state by increasing platelet aggregation and the risk of deep vein thrombosis. Furthermore, acute traumatic pain in the ED may evolve into chronic pain syndromes, with long-term psychological consequences¹.

Acute pain in the ED can be managed by several available pharmacological agents, including paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids— usually administered parenterally. Nevertheless, these medications are associated with adverse effects that, particularly in the ED setting may expose patients to additional risks.

Peripheral nerve blocks (PNBs) are extensively employed in the operating room by anesthesiologists, serving as an important component of an effective postoperative analgesia plan. Currently, their use has expanded into the ED, where they represent an alternative or adjunctive analgesic technique. PNBs can be applied to a wide range of traumatic injuries, painful pathological conditions, and invasive medical procedures in the ED².

Considering that “oligoanalgesia” is a frequent phenomenon among both adult and pediatric patients presenting to the ED, PNBs—which are safe techniques with a relatively simple learning curve and short execution time—can provide excellent analgesia without compromising the patient’s hemodynamic or respiratory profile. Moreover, given the increasing utilization of ultrasonography in emergency medicine, and the adoption of this technology by non-anesthesiology personnel, the application of PNBs in the ED is likely to expand. An additional advantage is the reduced requirement for opioid administration and the avoidance of adverse effects such as sedation, thereby ensuring more accurate assessment of consciousness and acute surgical conditions².

Long-term benefits of PNBs include the potential reduction in the incidence and severity of chronic post-traumatic pain, improved surgical outcomes, and greater tolerance to physiotherapy. Sympathetic blockade and decreased catecholamine release in patients receiving PNBs enhance blood flow and may mitigate vasoconstriction. Nevertheless, all benefits and indications of PNBs must be validated through larger studies to support their broader adoption by emergency physicians².

The use of PNBs in patients with orthopedic injuries contributes to reduced ED length of stay and overall hospitalization time. Prolonged ED stays compromise patient safety, decreases satisfaction, and simultaneously increase healthcare costs. Regional anesthesia reduces costs by requiring less monitoring and nursing staff compared to intravenous sedation. Furthermore, the use of PNBs in orthopedic patients-particularly the elderly-has been shown to decrease the risk of postoperative delirium, as adequate analgesia is achieved, mobility is improved, and opioid use is avoided³.

MATERIAL AND METHODS

The objective of the present literature review is to investigate the application of lower limb peripheral nerve blocks, in the Emergency Department (ED). The study exclusively concerns ED patients, both adults and children, who underwent a peripheral nerve block of the lower limb for the purpose of pain relief and/or the facilitation of a medical procedure.

A comprehensive literature review was conducted regarding the use of peripheral nerve blocks in the ED. The search was performed in August 2025. The following electronic databases were utilized: PubMed and the Cochrane Library. For the PubMed database, the search terms employed were (peripheral nerve blocks, OR nerve blocks, OR regional nerve blocks) and (emergency department). This search strategy was appropriately adapted to conform to the requirements of the Cochrane Library. Exclusion criteria included: (a) studies involving non-human subjects, and (b) publications in languages other than English. No restrictions were applied regarding the year of publication. With respect to study design, in addition to previous systematic reviews and meta-analyses relevant to the research question, all other types of studies were included: randomized controlled trials, cohort studies, observational or comparative studies, case series, and case reports.

In total, 1.343 records were identified across the two databases. Of these, 345 were excluded prior to screening as duplicates or previous systematic reviews and meta-analyses. Consequently, 998 records entered the screening process. During screening, 897 records were excluded because either the title or the abstract content was not consistent with the objectives of the present study. Thus, 101 articles were included to full-text retrieval, of which 15 could not be retrieved. Ultimately, 86 articles were assessed for eligibility, and 27 were deemed unsuitable to address the research question. Therefore, 59 articles were included in the present literature review. The detailed search strategy is illustrated in Figure 1, presented in the format of a PRISMA Flow Diagram.

Figure 1. PRISMA Flow Diagram

RESULTS

Of the 59 articles concerning lower limb peripheral nerve blocks, 7 concerned pediatric population. Twenty-three (23) were randomized controlled trials, while among the remaining studies, 4 were cohort studies (1 retrospective and 3 prospective), 5 were observational studies

(2 retrospective and 3 prospective), and 5 were comparative studies (3 retrospective and 2 prospective). In addition, 3 case series and 12 case reports were included.

The most frequent injuries requiring the performance of PNBs were hip fractures and femoral fractures. Fascia iliaca compartment block (FICB) and the femoral nerve block (FNB) constituted the principal PNB techniques, most commonly performed under ultrasound guidance.Pain intensity, opioid consumption, the need for rescue analgesia, duration of analgesia, length of hospital stay, and the incidence of postoperative delirium, were the main study parameters. Detailed results are presented in Table 1, which reports the number of patients in each study, the indication for PNB administration, the type of intervention, and the main outcomes.

Author (Year)	Study Design	N	Indication	Intervention	End Points
Chu et al.⁴ (2003)	RDS	117 children	Femoral Fracture	FNB	The average time taken for a femoral nerve block to be performed for non-ED medical staff was significantly longer than for ED medical staff.
Wathen et al.⁵ (2007)	RCT	55 children	Femoral Fracture	FICB vs iv morphine	FICB group: lower CHEOPS scores at 30min and 6h and longer median duration of analgesia
Stewart et al.⁶ (2007)	RCT	40 children	Femoral Fracture	Continuous vs single shot FNB	Differences between the groups are not statistically significant for the primary outcome
Neubrand et al.⁷ (2014)	RCS	259 children	Femoral Fracture	FICB vs systemic iv analgesics	1.5 points lower median post intervention pain scores in the FICNB group. There was no difference in the total adverse events between the FICNB and control group
Turner et al.⁸ (2014)	RCohS	81 children	Femoral Fracture	FNB vs no intervention	FNB group: longer duration of analgesia, fewer doses of analgesic medications, and fewer nursing interventions
Curtis et al.⁹ (2021)	ROS	144 children	Femoral Fracture	FICB	Increase of the percentage of children with pain scores < 4/10 from 25% to 85%. Only 15% needed adjuvant analgesia
Frenkel et al.¹⁰ (2012)	CR		Femoral Fracture	USG FNB	The harness was placed 15 minutes after injection without any observed discomfort. Only 1 dose of pain medication was required during the next 18 hours.
Ruano et al.¹¹ (2023)	CR		Pain from Scorpio bite	USG popliteal sciatic block	VAS score = 0 in 45 min
Monzon et al.¹² (2007)	POS	63	Hip fracture	FICB	Decrease of VAS score from 8.5/10 pre-intervention, to 2.9/10, 2.3/10 and 4.4/10 at 15 min, 2h and 8h respectively, post- intervention
Foss et al.¹³ (2007)	RCT	48	Hip fracture	FICB vs im morphine (0.1 mg/kg)	Maximum pain relief was superior in the FICB group both at rest (P < 0.01) and on movement (P = 0.02). The median total morphine consumption was 0 mg in the FICB group and 6 in the morphine group (P < 0.01)
Henderson et al.¹⁴ (2008)	PrelS	14	Hip fracture	FNB guided by nerve stimulator vs standard iv analgesia	1 h post intervention mean NRS score was 2.7/10 for FNB group and 6.1/ 10 for standard analgesia group (p<0.04)
Graham et al.¹⁵ (2008)	Pilot RCT	40	Hip fracture	FNB vs iv morphine	At 30 min post intervention, the mean pain score was significantly lower in the FNB group (p=0.046)
Haines et al.¹⁶ (2012)	POS	20	Hip fracture	FICB	Decreased pain after the nerve block, with a 76% reduction in mean pain score at 120 min. 80% of the patients did not request additional analgesia
Beaudoin et al.¹⁷ (2013)	RCT	36	Hip fracture	FNB vs parenteral opioids	NRS scores at 4 hours were significantly lower in the FNB group (p < 0.001). Patients in the opioids group received significantly more IV morphine than those in the FNB group
Mangram et al.¹⁸ (2015)	RCS	108	Hip fracture	USG continuous FICB + standard analgesia care (group 1) vs standard analgesia care (group 2)	Patients who received SAC + CFIB had significantly lower pain score ratings than patients treated with SAC alone. There were no differences in inpatient morbidity and mortality rates. Patients treated with SAC + CFIB were discharged home more often (p < 0.05)
Groot et al.¹⁹ (2015)	Pilot POS	43	Hip fracture	FICB	Patients overall experienced less pain after the FICB (p=0.04). A clinically meaningful decrease in pain was achieved in 64% of patients without the use of opioids after 240 min. This percentage was 72% after 480 min
Todd et al.²⁰ (2015)	RCT	164	Hip fracture	FNB (group 1) vs standard opioid analgesia (group 2)	Significantly lower pain scores in group 1, at 2h and 3h post-intervention (p=0.001 and p=0.0006)
Chaudet et al.²¹ (2016)	RCT	55	Hip fracture	FNB with an initial bolus dose of LA+ continuous infusion of LA vs FNB with an initial bolus dose of LA+ continuous infusion of N/S	Significant reduction in morphine adverse effects (31% versus 69% for groups 1 and 2, respectively; P < 0.01), mainly nausea (31% versus 59%, P = 0.03)
Morrison et al.²² (2016)	RCT	161	Hip fracture	FICB + continuous infusion catheter vs standard analgesia	Significantly less pain,33% fewer parenteral morphine sulfate equivalents, significantly lower severe opioid-related side effect, better walking and stair climbing ability at 6 weeks in the study group
Aprato et al.²³ (2018)	RCT	120	Intra-capsular hip fractures	FICB vs intra-articular hip injection (IAHI)	Pain was significantly lower in the IAHI group during movement of the fractured limb at 20 min (p < 0.05), 12 h (p < 0.05), 24 h (p < 0.05) and 48 h (p < 0.05). In the FICB cohort 72.9% of patients needed to take oxycodone, in contrast to 28.6% of the IAHI cohort (p < 0.05)
Pasquier et al.²⁴ (2019)	RCT	30	Hip fracture	FICB vs placebo PNB using N/S	At baseline (before the injection) the mean pain score at rest was lower in the FIB group. The difference between groups remained unchanged 45 min after the injection. Over the 24-h follow-up period, cumulative intravenous morphine consumption was similar between groups.
Wennberg et al.²⁵ (2019)	RCT	127	Hip fracture	FICB vs placebo PNB using N/S	Decrease in mean VAS score for pain on movement by 1.0 in the intervention group from admission until 2 h, comparedwith an increase of 0.5 in the control group, (p = 0.002) The changein the BRS from admission to 2 h (improvement, no change or deterioration) differed significantly between the two groups in favour of the intervention (p = 0.01)
Hao et al.²⁶ (2019)	RCT	90	Hip fracture	FICB vs placebo PNB using N/S	Patients in the experimental group experienced less preoperative pain (p<0.05). The incidence of PD was lower in the experimental group,p=0.018
Ridderikhof et al.²⁷ (2020)	CS	22	Hip fracture	FICB	At 60 min median NRS pain scores decreased from 6.0 to 3.0 (p <0.001)
Chen et al.²⁸ (2021)	RCT	38	Hip fracture	FICB suprainguinal approach vs infrainguinal approac	Significantly lower VAS score in suprainguinal group during movement at 6h and 12h postintervention. At 24h suprainguinal group had significantly longer sleep duration. No difference regarding paracetamol and oxycodone consumption.
Fahey et al.²⁹ (2022)	POS	52	Hip fracture	PENG block vs FNB	No difference regarding pain and opioid consumption
Güllüpınar et al.³⁰ (2022)	RCT	39	Hip fracture	PENG block vs systemic analgesia (paracetamol and tramadol)	Significantly lower NRS scores in the PENG block group (p=0.001)
Kolodychuk et al.³¹ (2022)	PCohS	72	Hip fracture	USG FICB vs standard analgesia	Statistically significant differences regarding morphine equivalents consumption and LOS, in favor of the FICB group
Sangeeta et al.³² (2024)	RCT	60	Hip fracture	PENG block vs iv nalbuphine (IVN)	In the PENG group, the static NRS score was improved by 5.73 ± 1.17, while In the IVN group, the static NRS score was just improved by 2.13 ± 0.97 at 30 min. In the same duration, the Dynamic NRS score in the PENG group was improved by 6.13 ± 1.38, while In the IVN group, it improved just by 2.43 ± 1.28. Rescue analgesia was required in 50.0% of patients in the IVN group but none in the PENG group.
Gerlier et al.³³ (2024)	RCT	35	Hip fracture	FIB vs standard analgesia	The median of preoperative opioid consumption was reduced by 60% in the USG SFNB group compared to standard group, with a consumption difference of 9 MME (P < 0.001)
Di Pietro et al.³⁴ (2025)	RCT	64	Hip fracture	PENG vs FICB	In the PENG group, 28/32 patients achieved 33% SPID (percentage of summed pain intensity difference calculated from visual analogue pain scores measured during the first hour post-block) compared with 19/32 in the FIB group (p = 0.022)
Finlayson et al.³⁵ (1988)		36	Neck of femur fracture	FNB	Successful blockade in 29/36. There were no complications of the procedure.
Van Leeuwen et al.³⁶. (2000)	PCS	61	Femoral fracture	lumbar plexus blockade	VAS noticeably declined after 5 minutes suggesting good pain relief and a painless installation of traction on the fracture could be performed
Mutty et al.³⁷ (2007)	RCT	54	Diaphyseal or distal femoral fracture	FNB	Significantly lower pain scores at all time-intervals (VAS)
Elkhodair et al.³⁸ (2011)	PCohS	137	Neck of femur fractures	FICB	A reduction in the pain score of 3 points or more was achieved in 77.4% of all cases. No adverse events were reported.
Fletcher et al.³⁹ (2013)	RCT	50	Femoral fracture	FNB “3 in 1” + iv morphine vs iv morphine only	Patients receiving 3-in-1 nerve blocks recorded a faster time to reach the lowest pain score: 2.88 h for patients with nerve block and 5.81 hours for control patients. Nerve block recipients required significantly less morphine per hour than control patients (mean of 0.49 mg/h versus 1.17 mg/h).
Reavley et al.⁴⁰ (2014)	RCT	162	Neck of femur fractures	FNB “3 in 1” vs FICB	FIB is equivalent to the 3-in-1 block for immediate pain relief in adult neck of femur fractures.
Uysal et al.⁴¹ (2020)	RCT	91	Femoral fracture	Paracetamol 15 mg/kg every 8h vs FNB with catheter placement and administration of LA every 8h	Significantly lower mean VAS score 4h postintervention and while placing the patient for spinal anesthesia in favor of the PNB group (p<0.01). Less often delirium in favor of the PNB group (not statistically significant find)
Morrone et al.⁴² (2023)	RCT	60	Proximal femur fracture	PENG vs FICB	NRS score ≤ 4, 30 postintervention was achieved in53.3% of the patients (PENG group) and 53.6% of the patients (FIB group).
Tripathi et al.⁴³ ( 2021)	PIS	84	Femoral fracture	FNB	Reduction of mea μέσου VAS from 7.29/10 pre- intervention to σε 1.86/10 at 30min post-intervention (p=0.004) and 1.38/10 at 4 h (p=0.015). Reduction of mean Hamilton Anxiety score from 27.05/56 pre-intervention, to 8.07/56 at 4h post-intervention (p=0.013).
White et al.⁴⁴ (2008)	RCT	42	reduction of ankle dislocation	ankle block vs conscious sedation	No difference in analgesia provided. Average t for ankle reduction in the conscious sedation group81,5 min vs in the block group 63,8 min
Phillips et al.⁴⁵ (2011)	ROS	16	Popliteal sciatic nerve block	pain management during procedures of the leg, ankle, foot	All procedures were successfully completed. Post-procedural analgesia was excellent in all cases and lasted 90-120 min.
Herring et al.⁴⁶ (2012)	CR		Buttock abscess	Superior cluneal nerve blockade	Pain free abscess drainage
Sheth et al. ⁴⁷ (2008)	CR	2	Total hip arthroplasty dislocation reduction	Lumbar plexus block	Case1: pain reduction from 8/10 to 2/10 – left hip was reduced successfully in 1 attempt. Case 2: the procedure was augmented by etomidate 4 mg IV for moderate posterior hip pain- hip was easily reduced in 1 attempt
Eksert et al.⁴⁸ (2017)	CR		patellar dislocation reduction	USG FNB	The VAS score in the right knee was reduced from 8/10 to 0/10, 5 min postinjection. Successful reduction of the patella, without further analgesics requirement
Cisewski et al.⁴⁹ (2019)	CR	2	superficial cutaneous lateral leg injuries (burn, cellulitis)	lateral sural cutaneous nerve (LSCN) block	Regional anesthesia along the LSCN sensory distribution was experienced at 7-9 min post blockade. Peak analgesic effect was experienced at 25-29 min. The duration of anesthesia was 120-150 min. No motor deficit, ambulatory difficulty, or adverse effects were experienced in either patient post blockade.
Sobel et al.⁵⁰(2020)	CR		isolated right lateral tibial plateau fracture	superior lateral (SLGN), superior medial (SMGN), and inferior medial (IMGN) genicular nerve block	Initial pain 8/10. Reported 0/10 pain at rest and 1/10 pain with movement
Goldsmith et al.⁵¹ (2020)	CS	3	refractory back pain	USG transgluteal sciatic nerve block	NRS reduction from 10/10 to 1-3/10. Duration of analgesia:16-24 h
Luftig et al.⁵² (2020)	CS	3	pelvic fractures	PENG block	All patients had severe pain prior to their PENG block. Within 30 min of receiving a PENG block, all patients had effective analgesia, restoring the ability to range the hip with minimal or no pain. There were no complications
Selame et al.⁵³ (2021)	CR		Buttock abscess	USG sciatic nerve block	Successful drainage
Moorthy et al.⁵⁴ (2023)	CR		traumatic superior and inferior pubic rami fractures	Continuous PENG block	Immediate relief of pain was achieved and 48 hours later, the patient still reported satisfactory pain control and started to independently mobilize
Cross et al.⁵⁵ (2023)	CR		Herpes Zoster pain with I1 dermotome distribution	Sciatic nerve block (transgluteal approach)	Pain reduction without adverse effects
Shalaby et al.⁵⁶ (2024)	CR		tibia-fibula fracture	USG saphenous and popliteal sciatic nerve block	Complete pain resolution at 10 min. Duration of analgesia: 14 h
Thomas et al.⁵⁷ (2024)	CR		prosthetic hip dislocation reduction	PENG block	Adequate analgesia for hip reduction using Allis maneuver
Polischuk et al.⁵⁸ (2019)	RCS	665	Hip fracture	FNB vs no intervention	There were no significant differences in preoperative characteristics. Although there was no statistically significant difference in 1-year mortality, patients who did not receive an FNB were more likely to be nonambulant at 1 year (P =0 .005). There were no other significant differences in mobility, residence, or mortality
Gawthorne et al.⁵⁹ (2021)	PCohS	322	Hip fracture	FICB performed by doctors vs trained nurses	no differences between the nurse-inserted and doctor-inserted groups for mean pain scores 1 h and 4h postintervention; delirium incidence; opioid use post-FIBinsertion; or time to FIB insertion
Williams et al.⁶⁰ (2018)	ROS	384	Hip fracture	FICB by doctors vs trained nurses	Improved proportion of patients receiving blocks
Rashid et al.⁶¹ (2013)	p-survey	147	Hip fracture	Performance of any PNB in the ED	Sixty five of 147 (44%) of the respondents reported using RA blocks for hip fracture. Commonest reasons for not using PNBs: lack of trained staff (36%) or appropriate equipment (22%)
Reid et al.⁶² (2009)	PCS	67		FNB USG vs using landmarks	Complete block at 15 min was achieved 29% of patients (in the US group) and 6% (in the landmarks group P = 0.029).

Table 1. Articles included in the present literature review.

DISCUSSION

Hip fracture is one of the most frequent lower limb injuries in adults, accounting for 8.9 per 1000 emergency department visits among individuals over 50 years of age. Pain in these, typically elderly patients, constitutes a major barrier to recovery. Hip fractures are highly painful injuries, and inadequate pain management may lead to a prolonged stress response, increased morbidity, and higher mortality. Observational studies have demonstrated that hip fracture–related pain is associated with a greater risk of postoperative complications, prolonged bed rest, delayed mobilization, cancellation of physiotherapy sessions, and reduced functional capacity up to six months postoperatively. Non-steroidal anti-inflammatory drugs (NSAIDs) are often not recommended in this population due to adverse effects, including increased risk of gastrointestinal bleeding, deterioration of renal function, and inhibition of platelet aggregation. Paracetamol as monotherapy is usually insufficient. Although opioids can effectively control this type of pain, they are problematic in elderly patients because of their side effects. Evidence suggests that opioid administration in older adults may in crease the risk of developing delirium. Thus, regional analgesia techniques represent an attractive alternative in this patient group^22,24,63.

Hao-yang Wan et al., in their systematic review, report that geriatric patients with hip fractures who receive inadequate analgesia are reluctant to mobilize, thereby increasing the risk of complications and delaying recovery⁶⁴. It is also well established that these patients are prone to cognitive impairment. A previous study demonstrated that patients with intact cognitive function but insufficient analgesia were nine times more likely to develop delirium compared to those whose pain was effectively controlled. Furthermore, these patients are at increased risk of complications such as pneumonia, pressure ulcers, urinary tract infections, and deep vein thrombosis. Timely surgical repair remains the cornerstone of treatment. Current analgesia strategies include oral or parenteral analgesics such as paracetamol, NSAIDs, opioids, epidural or spinal analgesia, and peripheral nerve blocks (PNBs). Despite their widespread use, opioids may cause adverse effects in older adults, including delirium, somnolence, constipation, nausea, hypo-tension, and even respiratory depression, all of which may negatively affect prognosis. NSAIDs, on the other hand, increase the risk of bleeding and may exacerbate underlying gastrointestinal disorders. Achieving a balance between effective analgesia and minimal adverse effects remains a challenge.

Easily applicable techniques are of particular importance in the emergency department setting. Specifically, the fascia iliaca compartment block does not require complex or costly equipment and can be performed by residents or even trained nurses. Regarding hip fractures, studies have demonstrated superiority of this block compared to opioids or NSAIDs. However, controversy exists regarding its comparison with other peripheral nerve blocks. Fascia iliaca compartment block is a feasible and safe technique that provides satisfactory preoperative analgesia, avoids opioid-related side effects, reduces hospital stay, and promotes functional recovery.

Nagel et al. reported that PNBs are a safe and reliable alternative to systemic analgesia and sedation⁶⁵. The advantages of PNBs in patients with femoral fractures, include lower pain scores, reduced opioid requirements, facilitation of fracture reduction, easier patient transfer and positioning, and improved tolerance of imaging procedures. They also contribute to reduced risk of respiratory infections, earlier mobilization, and lower costs associated with systemic analgesics.

Generally, PNBs are indicated as adjunctive or alternative analgesia in patients at increased risk of respiratory depression, those with potentially difficult airways, patients preferring to remain fully alert, outpatients, individuals with severe acute pain, and those whose pain cannot be adequately controlled with systemic analgesia. Specific indications for femoral nerve block and fascia iliaca compartment block include femoral neck fractures, femoral shaft fractures, patellar injuries, and drainage of thigh abscesses.

Absolute contraindications to PNBs are few and include patient refusal, non-cooperative patients and allergy to local anesthetics. Relative contraindications include infection at the injection site, coagulopathy, and pre-existing neurological deficits in the distribution of the targeted nerve. Contraindications specific to femoral nerve and fascia iliaca blocks include severe traumatic injury at the anatomical site of injection and history of femoral bypass surgery.

In pediatric patients presenting with femoral fractures, the use of PNBs in the emergency department avoids administration of opioids and other sedatives, thereby allowing more accurate assessment of all systems for potential additional injuries. Case reports have also documented effective use of lower limb PNBs in the emergency setting for conditions such as gluteal abscess drainage, acute pain from chronic low back pain, pubic ramus fractures, patellar dislocation reduction, and ankle fracture or dislocation reduction.

Nevertheless, PNBs are not devoid of complications. Potential adverse events include infection, bleeding, vascular injury, and nerve damage. Nerve injuries are a major concern, with an incidence of approximately 0.5–1%, most resolving within three months. Although ultrasound guidance allows direct visualization of nerves and reduces minor complications, there is insufficient evidence that its use prevents long-term neurological damage⁶⁶. Administration of low-concentration local anesthetics without vasoconstrictors and the use of atraumatic regional anesthesia needles may reduce the risk of neurological complications. A thorough neurological assessment should always be performed and documented prior to regional anesthesia⁶⁷.

Local anesthetic toxicity may occur if attention is not paid to dosage modifications and confirmation of extravascular injection. Dosage must always be individualized, as patients with comorbidities may not tolerate otherwise acceptable doses.

The complications of lower limb PNBs vary, depending on the specific block performed. Complications of femoral nerve block include accidental intravascular injection and falls due to prolonged motor blockade. Similarly, accidental intravascular injection is a potential complication of sciatic nerve block. Lumbar plexus block complications are unique due to injection into the retroperitoneal space and include epidural spread, intrathecal diffusion, and retroperitoneal hematoma³.

Regarding compartment syndrome, systematic reviews report no conclusive evidence whether regional anesthesia techniques delay diagnosis. On the contrary, they may even facilitate its recognition, as the onset of new acute pain in a patient receiving continuous peripheral nerve block may serve as a warning sign. Thus, in clinical practice, effective analgesia can be achieved in patients with fracture-related injuries using continuous peripheral nerve blocks with low-concentration of local anesthetics (e.g., ropivacaine 0.2%).

Continuous PNBs involve percutaneous catheter placement near a peripheral nerve, allowing continuous infusion of local anesthetic to the targeted nerve. In trauma patients presenting to the emergency department, continuous PNBs contribute to acute pain management, surgical anesthesia, postoperative analgesia, patient transfer, and prevention of chronic pain development. Minor complications include accidental catheter removal, obstruction, or pump malfunction. More serious but rare complications include local anesthetic toxicity, catheter tear, and infection, particularly when catheters are placed under suboptimal aseptic conditions.

Finally, regarding safety, there is insufficient evidence to support reduced complication rates with ultrasound compared to nerve stimulation during PNB performance. Nevertheless, it is reasonable to assume that ultrasound imaging may provide greater safety during block execution.

Conclusion

In conclusion, lower limb peripheral nerve blocks (PNBs) have a clear role in pain management within the emergency department, as well as in the performance of minor procedures and joint reductions. They represent simple and safe techniques applicable to a wide range of traumatic and other painful pathological conditions, providing analgesic efficacy comparable to conventional systemic analgesia. Their advantages include hemodynamic stability, avoidance of sedation, early mobilization, prevention of chronic pain, and reduction in hospital length of stay. Nevertheless, further studies are required to substantiate their effectiveness in the emergency department setting.

Additional materials: No

Abbreviations: BRS – behavioral rating scale, im- intramuscular, iv- intravenous, FNB -femoral nerve block, FICB – fascia iliaca compartment block, LA-Local Anesthetic, LOS – Length of stay, MME – morphine milligram intravenous equivalent, NRS – numeric rating scale, N/S – normal saline, PD – postoperative delirium, PENG – pericapsular nerve group, USG – ultrasound guided, VAS – visual analogue scale, N – number of patients, RDS – Retrospective Descriptive Study, RCT- Randomized Controlled Trial, RCS – Retrospective Comparative Study, RCohS – Retrospective Cohort Study, ROS – Retrospective Observational Study, CR – Case report, CS -Case Series, POS – Prospective Observational Study, PrelS – Preliminary Study, PCohS – Prospective Cohort Study, PIS – Prospective Interventional Study, PCS – Prospective Comparative Study, P-survey – Postal Survey

Acknowledgements: Not applicable

Authors’ contributions: TV: data collection, planning, literature review, manuscript preparation, final draft, is the lead author, KE: literature review, manuscript preparation, critical review, BM: literature review, manuscript preparation, critical review, AE: supervision, critical review. All authors approved the manuscript.

Funding: Not applicable

Availability of supporting data: Not applicable

Competing interests: The authors declared no competing interests.

Received: November 2025, Accepted: December 2025, Published: March 2026.

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Citation: Tsapara V, Koraki E, Bareka M, Arnaoutoglou: Lower Limb Peripheral Nerve Blocks In The Emergency Department: A Narrative Review Of The Literature. Greek e j Perioper Med. 2026;25 (a):10-34.

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