Reference: Binder ZW et al. “Ultrasound-Guided Nerve Block for Pediatric Femur Fractures in the Emergency Department: A Prospective Multi-Center Study.” Academic Emergency Medicine, 2025. Date: November 24, 2025 Dr. Lauren Westafer Guest Skeptic: Dr. Lauren Westafer is an Associate Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School, Baystate. She is the co-founder of FOAMcast and a researcher in pulmonary embolism and implementation science. Dr. Westafer serves as the research methodology editor for Annals of Emergency Medicine. Case: A 9-year-old boy presents to the emergency department after a trampoline injury. He was at a party with his friends and they were all bouncing together and competing to see who could bounce the highest. The boy fell down on his right leg and a friend accidentally landed on it. On your exam, the boy is in significant pain and has a deformity of his right leg. You do not note any additional injuries. X-rays confirm a mid-shaft femur fracture. You administer some IV morphine, but the boy is still whimpering in pain. One of the other attending physicians on shift who happens to be an ultrasound enthusiast, suggests using an ultrasound-guided nerve block as a way to manage the boy's pain. The boy’s parents ask “What is that?” Background: Femur fractures are one of the most painful injuries in pediatric patients and frequently require hospital admission for definitive treatment, often with long ED stays prior to operative management. Traditional pain management for these injuries relies heavily on IV opioids, which have well-documented side effects including nausea, respiratory depression, and sedation. Increasing public awareness of the opioid crisis has also led to growing parental concern over opioid exposure in children. There is growing interest in opioid-sparing pain control methods. The fascia iliaca compartment nerve block (FICNB) is a regional anesthesia technique that targets the femoral nerve and adjacent sensory nerves to provide localized pain relief. While landmark-based FICNB techniques have been used successfully in adult patients, recent studies suggest that ultrasound guidance improves the accuracy and safety of these procedures. However, evidence on the effectiveness and safety of ultrasound-guided FICNB in pediatric patients, particularly when performed by emergency physicians in real-world ED settings, remains limited. Clinical Question: In children with femur fractures, is ultrasound-guided FICNB more effective at reducing pain compared to systemic analgesia? Reference: Binder ZW et al. “Ultrasound-Guided Nerve Block for Pediatric Femur Fractures in the Emergency Department: A Prospective Multi-Center Study.” Academic Emergency Medicine, 2025. Population: Children aged 4–17 years presenting to the ED with isolated, acute femur fractures. Excluded: Patient with neurovascular compromise, multi-trauma, GCS ≤13, bilateral fractures, allergy to anesthetics, prisoners, pregnancy. Intervention: Ultrasound-guided fascia iliaca compartment nerve block (FICNB) performed with ropivacaine or bupivacaine Comparison: Systemic analgesia administered at discretion of ED treating team Outcome: Primary Outcome: Reduction in pain intensity at 60 minutes using the Faces Pain Scale–Revised (FPS-R). Secondary Outcomes: Reduction in pain at 240 minutes, opioid consumption (oral morphine equivalents per hour), occurrence of adverse events, and emergency department (ED) length of stay. Trial: Prospective multi-center observational study conducted at 12 pediatric emergency departments in the US and Australia. Some sites performed FICNB. Other sites did not. Dr. Zachary Binder Guest Author: Dr. Zachary Binder is a pediatric emergency medicine attending physician at UMass Memorial Health and Associate Professor at UMass Chan Medical School. He is the Director of Point-of-Care Ultrasound for the Department of Pediatrics and the medical school. Authors’ Conclusions: Children who received FICNB had greater reductions in pain intensity and required less opioid medication than those who did not. This is the largest prospective study evaluating the ultrasound-guided FICNB performed on children in the ED, and its findings support the procedure’s use for pediatric femur fracture pain management. Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes. Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes. How precise are the results? Fairly precise Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes. Funding
