The incidence of femoral neck fractures, one of the most common traumatic injuries in the elderly patients increases continuously among the ageing population on the planet1,2 The number of hip fracture worldwide is expected to increase from 1.7 million in 1990 to 6.3 million in 2050 assuming that the age related incidence will increase by only 1% per year, the number of hip fractures in the world will reach the figure 8.2 million in 20502 The incidence of hip fracture has been reported to be highest in older patients who are both, more likely to have unsteadiness of gait & reduced bone mineral density predisposing to fracture. Fracture neck femur is a significant cause of morbidity and mortality among the elderly3,4,5. Most patients with a femoral neck fracture have experienced a low energy trauma such as slipping of leg or falling from erect position to the ground. The usual symptoms include almost invariably pain in the affected hip, inability to move, inability to bear weight on the leg and pain on passive movement. Early adequate analgesia is the key management that has been highlighted in UK Guideline by Scottish Intercollegiate Guideline Network6 .and The Royal College of Physicians7. Almost all patients with femoral neck fracture are treated surgically, thereby requiring a suitable form of anaesthesia. Most preferred technique of anaesthesia for correction of fracture is subarachnoid block. However, positioning for subarachnoid block may be troublesome as even slight overriding of the fracture end is intensely painful3 Analgesia can be provided by conventional modes of pain relief like NSAIDS, opioid, and peripheral nerve blocks like femoral nerve block8 and fascia iliac block9 Clinician are frequently reluctant to administer adequate parenteral analgesia to these patients, for fear of worsening intercurrent disease or of precipitating unwanted side effects in patients who are often already frail. Systemic analgesia including both opioids and NSAIDS can have significant adverse effects especially in the elderly population due to age related changes in pharmacokinetics and pharmacodynamics. Further, more the long list of medications that accompany most patients also increases the risk of drug interactions. Since the use of systemic analgesic drugs may be limited due to unreliable neurological examination resulting from head injuries, adopting the methods with certain local effects is preferred to other analgesic agents such as opioids10 Performing preoperative and postoperative peripheral nerve block in patients reduces the risk, complications associated with intraneural, and intrathecal administration. Peripheral nerve block reduces operating room time and hospital length of stay and patients can be discharged sooner11. Local anaesthetic blockade of the femoral nerve at the level of the inguinal ligament in pre-hospital management or emergency department is a well described and efficient technique in achieving analgesia together with light sedation for femoral neck surgery12 A Cochrane collaboration review of nerve blocks for hip fractures undertaken shortly after admission to hospital concluded “Nerve blocks resulted in statistically significant reductions in reported pain levels and in the quantity of parenteral or oral analgesia administered to control pain from the fracture or during surgery” The most common approach is the femoral perivascular technique with a peripheral nerve stimulator. Several studies have demonstrated that this approach does not achieve a reliable block of all three nerves (femoral nerve, obturator nerve, lateral femoral cutaneous nerve). The femoral block fails mostly in areas supplied by the lateral femoral cutaneous nerve and the obturator nerve17 `But femoral nerve blocks, using the 3-in-1 technique originally described by Winnie15 have been shown to provide effective analgesia for these patients in the peri-operative period and to reduce other analgesic requirments. An alternative approach to the femoral nerve block and 3-in-1 compartment block is the fascia iliaca compartment block. Fascia iliaca was first decribed in children in 1989 It is widely use for postoperative analgesia after lower limb surgery in children and adult and provide effective postoperative analgesia after hip, femoral shaft or knee surgery Anaesthesia of the lateral femoral cutaneous nerve is achieved in 90% patients by using the fascia iliaca compartment block, as the puncture site lies much lateral to the femoral nerve. Local anesthetic drug not only reaches the lateral femoral cutaneous nerve, but also the femoral nerve because the needle tip and the femoral nerve are located in the same compartment. Therefore, the fascia iliaca compartment block could provide effective analgesia as an alternative to femoral nerve block.

Study design: It’s randomized controlled study. Thesis approved by the hospital Ethical Committee. Study population: One hundred ASA grade I-III patients with fracture neck femur, undergoing elective surgery under spinal anaesthesia and willing to participate was the study population. Inclusion criteria: 1. Age 18 and above 2. Patients with fracture neck femur, undergoing surgery under sub arachnoid block 3. ASA physical status I – III 4. Mini mental score >8/10 Exclusion criteria: – 1. Patient refusal 2. Known hypersensitivity to local anaesthetic agents of amide type 3. Anticoagulant therapy (warfarin / heparin infusion). 4. Clotting disorders [international normalised ratio (INR) or activated partial thromboplastin time ratio (APTR)] > 1.5, Platelets < 80,000 5. Previous femoral vascular surgery 6. Hepatic Impairment 7. Debilitated or acutely ill patients 8. Glasgow Coma Scale (GCS) less than 12/15 Sampling Technique and Size: The sample size and sampling technique was decided in consultation with the statistician, as per study in Anaesthesia 2013. The sample size of 100 patients was decided for calculating the paired t test for comparison of the two blocks at 2, 5, 10, 15, 20 minutes and after giving sitting position. Data Collection Technique: The subjects were informed about the study on the morning of the scheduled surgery, risks and benefits were explained, and informed consent was obtained from those who volunteered. These patients were divided in two groups on the basis by using computerized randomization with MS excel programme. GROUP F: Patients receiving femoral block. GROUP I: Patients receiving facia iliac block. • Detailed pre-anaesthetic evaluation and to rule out any associated disease. • A prospective Randomised Control Study was undertaken. • All the patients were explained about procedure, risk involved, advantages and disadvantages of procedure, effect of drug given by us. • A well explained written informed consent was obtained from each patient selected for the study. • Patients aged above 18 years, of either sex, scheduled to undergo fracture femur neck repair were included in the study. • Pre operative monitors ECG, NIBP, Pulse Oximeter was attached to the patient. • All aseptic precaution were taken like, cleaning 3 times with 2% chlorhexidine, sterile cloth around site of block. Patients selected for studies were in two group: 1. Femoral block: Here material used is stimuplex 5cm needle, nerve locator, 0.25% bupivacaine 20ml, 7.5 size gloves, 10cc syringe. 2. Facia iliac block: 20G needle hypodermic length 1.5 inch needle, 0.25% bupivacaine 20ml, 7.5 size gloves, 10cc syringe, 10 cm extension.

Blocks were performed in procedure room of operation theater. VAS scores were collected after every 2, 5, 10, 15, 20 min and at sitting after the block. We compared both groups in context of: • VAS scores during 2, 5, 10, 15, 20mins after block. • VAS score at sitting • Time required for procedure • To access adequacy of patient positioning for administering spinal anaesthesia. Table 1 - Comparison of mean VAS for occurrence of pain at 2min Group Number of patients VAS P value Mean SD Group FNB 50 7.16 0.83 0 Group FIB 48 5.2 0.82 Conclusion:- By using Mann-Whitney U test p-value < 0.05 therefore there is significant difference between VAS at 2min. Table 2 - Comparison of mean VAS for occurrence of pain at 5min Group Number of patients VAS P value Mean SD Group FNB 50 4.74 0.75 0 Group FIB 48 3.5 0.77 Conclusion:- By using Mann-Whitney U test p-value < 0.05 therefore there is significant difference between VAS at 5min Table 3 - Comparison of mean VAS for occurrence of pain at 10min Group Number of patients VAS P value Mean SD Group FNB 50 2.28 0.53 0.0989 Group FIB 48 2.04 0.61 Conclusion:- By using Mann-Whitney U test p-value > 0.05 therefore there is no significant difference between VAS at 10min. Table 4- Comparison of mean VAS for occurrence of pain at 15min Group Number of patients VAS P value Mean SD Group FNB 50 2.36 0.56 0.5418 Group FIB 48 1.95 0.68 Conclusion:- By using Mann-Whitney U test p-value > 0.05 therefore there is no significant difference between VAS at 15min Table 5- Comparison of mean VAS for occurrence of pain at 20min Group Number of patients VAS P value Mean SD Group FNB 50 o.1 0.3 0.7489 Group FIB 48 0.06 0.24 Conclusion:- By using Mann-Whitney U test p-value > 0.05 therefore there is no significant difference between VAS at 20min Table 6- Comparison of mean VAS for occurrence of pain at sitting Group Number of patients VAS P value Mean SD Group FNB 50 0.48 0.70 0.6383 Group FIB 48 0.5 0.79 Conclusion:- By using Mann-Whitney U test p-value > 0.05 therefore there is no significant difference between VAS at sitting. Table 7- Comparison of mean time(seconds) for performing block i.e. group FNB and group FIB. Group Number of patients Time(sec) P value Mean SD Group FNB 50 189.42 12.97 <0.0001 Group FIB 48 35.52 2.72 Conclusion:- By using 2 independent sample t-test p-value is < 0.05; therefore there is significant difference between mean time(seconds) for performing block i.e. group FNB and group FIB. Table 8: VAS of group FNB and group FIB at 2, 5, 10, 15, 20mins and at sitting VAS at Median VAS P value Group FNB Group FIB 2mins 7.16 5.2 0 5mins 4.74 3.5 0 10mins 2.78 2.04 0.0989 15mins 2.36 1.95 0.5418 20mins 0.1 0.06 0.7489 Sitting 0.48 0.5 0.6383 Conclusion:- By using Mann-Whitney U test p-value is < 0.05; therefore there is significant difference between median VAS score in group FNB and group FIB at 2mins and 5mins, but np difference at 10, 15, 20mins and at sitting as p-value is >0.05.

Since pain is a subjective sensation it’s assessment is very difficult. In this study we used a visual analogue scale for pain assessment which is a linear scale in millimeters marked from 0 ( no pain ) up to 10 ( worst possible pain). Pain was assessed 2, 5, 10, 15, 20mins after the block and at sitting position. It was found that onset of analgesia was faster in FIB group i.e VAS 5.2+/- 0.83, and this pain relief was 7.16 +/-0.82 VAS in FNB group at 2mins, and at 5mins VAS for FIB was 3.5 +/- 0.77 which is again good pain relief as compare to FNB; VAS 4.74+/- 0.77. The p-value using Mann-Whitney U test for VAS at 2min is 0 i.e. <0.05, so there is significant difference between VAS at 2mins. Similarly the p-value using Mann-Whitney U test for VAS at 5min is 0 i.e. <0.05. So this difference in VAS is also significant. So upto 5mins FIB provides better pain relief as compare to FNB. But as time prolongs quality of analgesic effect compared between two groups had insignificant difference after the block. The mean VAS for FNB group and FIB group at 10mins is 2.28 and 2.04 respectively. The p-value using Mann-Whitney U test for there values is 0.0989 which is >0.05 so insignificant. The mean VAS for FNB group and FIB group at 15mins is 2.36 and 1.95 respectively. The p-value using Mann-Whitney U test for there values is 0.5418 which is >0.05 so insignificant. The mean VAS for FNB group and FIB group at 20mins is 0.1 and 0.06 respectively. The p-value using Mann-Whitney U test for there values is 0.7489 which is >0.05 so insignificant The mean VAS for FNB group and FIB group at sitting postion is 0.48 and 0.5 respectively. The p-value using Mann-Whitney U test for there values is 0.6383 which is >0.05 so insignificant. In 2004 Salvatore Sia13 found that visual analog scale values during positioning (median and range) were lower in group A(FNB): 0.5 (0 –1) versus group B(i.v. fentanyl) 3 (2– 6) (p<0.001). And in 2005 Mosaffa14 found that visual analog scale values during positioning (median and range) were lower in group FIB: 0.5 (0-1) versus group i.v. fentanyl4 (2-6) (p<0.001). Simillar result were found by M.J. Yun15 in 2009 that VAS scores during positioning (mean and range) were lower in the FIC group than in the IVA group [2.0 (1-4) vs. 3.5 (2-6), P=0.001]. Even in 2014 ElsDochez16 repoeted that dynamic NRS-pain scores when transferring the patient from the accident scene to the ambulances stretcher, during transportation to the hospital and when transferring the patient to a hospital bed after giving FIB were, 4, 3 and 3.5 respectively which had high patient satisfaction. All studies favour use of regional analgesia over systemic for better pain relief and patient acceptance. In our study we compared two types of regional block and found that mean VAS score for FNB and FIB at 2 and 5mins were 7.16, 4.74 and 5.2, 3.5 respectively while 10, 15, 20mins after the block and sitting position were 2.28, 2.36, 0.1, 0.48 and 2.04, 1.95, 0.06, 0.5 respectively, hence at 2 and 5mins FIB had better analgesia than FNB and later both had equal pain relief and patient satisfaction while positing. Time required to perform fascia iliaca block was 35.52 sec +/-2.72 which was much less as compare to time required for FNB which was 189.42sec +/-12.97. By using 2 independent sample t-test we compare the time required to perform both the block and found that p-value was <0.0001 which had significant difference. This dimension of regional anaesthesia technique has not been studied in any of the references available. FIB proves to be better on this aspect as faster regional technique , gives earlier pain relief and will have better acceptance by the patient.

Fascia iliaca block has faster onset of action. It requires less time, simpler to perform and more cost effective when compare to FNB . Move rover it is independent in terms of any gadget requirement. Hence it could be preferred block of choice over FNB.

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