Fascia iliaca compartment block (FICB) can be performed using anatomical landmarks or ultrasound guidance for analgesia after femoral fractures. This prospective, parallel-group, randomised controlled trial at Irrua Specialist Teaching Hospital, Nigeria, enrolled adults with femoral neck or shaft fractures and pain between 15 November 2021 and 14 January 2023. Participants were randomised 1:1 to landmark-guided or ultrasound-guided FICB, with 30 mL of plain 0.25% bupivacaine administered in each group. Co-primary outcomes were needle-tip precision and block effectiveness at 1 h; secondary outcomes included Numerical Rating Scale (NRS) pain scores, procedural time, time to block onset, time to first rescue analgesia, complications and satisfaction. Ninety participants were randomised and 89 were analysed. Needle-tip placement was confirmed in 44/44 participants (100.00%) with ultrasound and 29/45 (64.44%) with landmarks; the reported Fisher’s exact test statistic was 19.073 (P = 0.050). Effective block at 1 h occurred in 41/44 (93.18%) and 41/45 (91.11%), respectively. Median NRS scores were lower with ultrasound at 30 min (2 vs. 3; P = 0.009) and 1 h (1 vs. 2; P = 0.001). Landmark-guided FICB was faster to perform (901 vs. 2,414 s; P = 0.050), while time to first rescue analgesia did not differ (P = 0.608). No clinically apparent complications were observed. Ultrasound guidance improved needle-tip localisation and was associated with lower early pain scores, whereas landmark-guided FICB remained a feasible and efficient alternative. The aggregate data do not establish universal differences in overall analgesic effectiveness or safety.