Background Femoral fracture is the most painful bone injury and performing spinal anesthesia is extremely challenging due to very poor positioning unless we have a very good mode of analgesia. Intravenous strong opioids are commonly used but to date nerve blocks are also being utilized. The reliability and effectiveness of the aforementioned methods are not conclusive to practice worldwide. The objective of the study was to compare the analgesic effect of intravenous fentanyl, femoral nerve block (FNB) and fascia iliaca block (FICB) during positioning patients with femoral fracture for spinal anesthesia. Methods A randomized controlled trial study was conducted on 72 elective adult patients with femoral fracture aged 18–65 years and ASA I and II those were allocated randomly into three groups. The intravenous fentanyl (IVFE) group received 1µg/kg IV fentanyl, FNB group received nerve stimulator guided FNB with 30 mL of 1% lidocaine with adrenaline and FICB group received FICB with 30 mL of 1% lidocaine with adrenaline. Pain intensity in numeric rating score (NRS), time to perform spinal anesthesia, quality of positioning and patient acceptance were assessed. SPSS version 26 and Kruskal–Wallis test were used to analyze data and p value <0.05 was considered significant. Results NRS Pain score during positioning was significantly lower in FNB and FICB groups than IVFE group [median (IQR)]; 2 (1–2.5), 2 (2–3)) vs. 3 (3–4) respectively; P<0.001 and P=0.001. However, FNB and FICB groups were not significantly different with (P=1.000). Time to perform spinal anesthesia was significantly longer in IVFE group 9.5 (9–10) minutes than both FNB and FICB groups 7 (6–8), 8 (6–8) respectively, P<0.001. The quality of positioning was significantly lower in the IVFE group than both FNB and FICB groups (P<0.001). Conclusion Preoperative FNB and FICB reduce pain score during positioning, shorten time to perform spinal anesthesia, better patient positioning and higher patient acceptance in a patient undergoing elective femoral bone fracture surgery. Trial Registration Pan African Clinical Trial Registry, PACTR202006669166858, registered on June 19, 2020. https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12127 .