Background:Hip fractures in elderly is a common occurrence around the world and is associated with increased morbidity and mortality. Adding to this burden is the inadvertent pain management occurring frequently in the Emergency Department due to the fear of adverse effects of the administered pharmacotherapy. Hence, newly developed, safer Ultrasound guided nerve block modality is the cornerstone in the management of pain in these special populations attending the Emergency Department. Objectives: To determine the efficacy of Ultrasound (US)-guided three-in-one femoral nerve block as compared to intravenous opioids alone for analgesia in the elderly patients presenting to the Emergency Department (ED) with hip fractures. Methods: This was a single centre, pragmatic randomised controlled open-label trial. Older adults (age>55 yrs) with radiologically confirmed hip fractures were randomized into either of the two treatment arms: US-guided three-in-one Femoral Nerve Block plus Intravenous Morphine (FNB group) vs Intravenous Morphine alone Standard Care (SC group). Pain relief was measured with a 11-point numerical rating scale (NRS). Secondary outcome measures included the amount of rescue analgesia received and occurrence of adverse events (respiratory depression, hypotension, nausea/vomiting). Results: Thirty patients in each arm completed the study. There was no significant difference between the two groups with respect to baseline characteristics. There was a significant decrease in pain intensity over time in FNB group (p<0.001). The primary outcome measure, SPID over 1 hour was significantly greater in the FNB group [292.0(225-330) vs 106.5(45-195), p<0.001]. With regard to second outcome measure, parenteral opioid use, FNB group received significantly less parenteral opioid than those in the SC group [0.8 mg vs 9.5 mg, p<0.001]. Conclusion: US-guided femoral nerve block as an adjunct to intravenous opioids resulted in: 1) Significantly reduced pain intensity; 2) Decreased amount of rescue analgesia received; 3) Significantly reduced adverse events due to opioids. Hence, our study supports the routine use of US-guided three-in-one femoral nerve block for pain management in hip fractures in the ED.