![]() ![]() Directly following an injury, abducting and externally rotating the shoulder is often not possible, limiting the generalizability of these infraclavicular approaches to the brachial plexus. Second, in order to bring the brachial plexus out from under the clavicle, these blocks are commonly performed with significant upper extremity manipulation. Unfortunately, these blocks historically have been difficult to perform for two reasons.įirst, when performing a traditional ICB with the patient in the position of comfort (shoulder adducted, elbow flexed, and the fractured wrist resting at their side or on their chest/abdomen), the clavicle forces the operator to enter the skin at a very steep angle, significantly decreasing ultrasound visualization of the needle tip during the procedure and increasing the risk of iatrogenic pneumothorax. The most common mechanism of injury for radius and ulna fractures is sudden axial loading onto the radius/ulna, often from a fall onto an outstretched hand with wrist extension. The classic blocks in this region include the infraclavicular block (ICB) in the chest wall above the axilla and the axillary block (AXB) on the medial aspect of the upper arm at the axilla. ![]() Performing a block in the distal region of the brachial plexus, specifically below the clavicle, maximizes distal upper extremity anesthesia while minimizing phrenic nerve blockade. Also, when placing anesthetic in locations adjacent to the phrenic nerve, there is concern for ipsilateral diaphragmatic paralysis. They provide excellent analgesia to the shoulder and upper arm, but they commonly fail to provide analgesia adequate for closed reduction of distal radius fractures. 3 However, both of these blocks target the proximal portion of the plexus. The upper extremity regional blocks that most emergency physicians may be familiar with include the interscalene and supraclavicular blocks. Unfortunately, when performing brachial plexus blocks above the clavicle, we have noticed inconsistent analgesia for distal radius fractures. In our 10-year ED-clinical experience, blocks of the proximal portion of the brachial plexus (superior to the clavicle) offer better analgesia for injuries to proximal structures (ie, shoulder and upper arm), whereas blocks of the distal portion of the brachial plexus (inferior to the clavicle) offer better analgesia for distal structures (ie, elbow, forearm, wrist, and hand). There are many locations to block the brachial plexus as it emerges from the cervical column and then travels down the neck, underneath the clavicle, and into the arm. Ultrasound-Guided Posterior Tibial Nerve BlockĮxplore This Issue ACEP Now: Vol 37 – No 10 – October 2018 Clinical Conundrum. ![]() How to Perform Ultrasound-Guided Distal Sciatic Nerve Block in the Popliteal Fossa.Pain Control Using Ultrasound-Guided Superficial Cervical Plexus Block. ![]()
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