Peripheral nerve blocks of the upper extremity may be used for anesthesia, postoperative analgesia, and the diagnosis and treatment of chronic pain syndromes. Preoperative analgesia may be obtained, and catheter techniques enable post-operative pain management with continuous infusions of local anesthetic, with or without an opioid. Such infusions can improve perfusion to the operative extremity, reduce pain with movement, facilitate early joint mobilization, and improve the quality of life weeks after discontinuation of the infusion. The types of upper extremity nerve blocks are listed in Table 14-1.
TABLE 14-1Examples of Peripheral Nerve Blocks of the Upper Extremities ||Download (.pdf) TABLE 14-1 Examples of Peripheral Nerve Blocks of the Upper Extremities
|Peripheral Nerve Block ||Nerve Involved ||Surgical Indication |
|Brachial plexus ||Interscalene || |
Total shoulder arthroplasty
| ||Supraclavicular ||Mid-humerus |
| ||Infraclavicular ||Elbow |
| ||Axillary ||Elbow |
|Forearm block || |
|Digital nerves ||Branches of the median, ulnar, and radial || |
Successful regional anesthesia of the upper extremity requires knowledge of the brachial plexus (Figures 14-1 and 14-2). Brachial plexus nerve roots arise from the ventral rami from C5 to T1, and course anterolaterally and inferiorly to form three trunks between the anterior and middle scalene muscles. The trunks form three anterior and three posterior divisions at the lateral edge of the first rib at the midportion of the clavicle, which recombine to create lateral, middle, and posterior cords named for their relationship with the second part of the axillary artery. At the lateral border of the pectoralis minor muscle, the cords further divide into terminal branches that supply all motor and sensory innervation of the upper extremity except (1) the skin over the shoulders, which is supplied by the cervical plexus; and (2) the medial aspect of the arm, which is supplied by the intercostobrachial branch of the second intercostal nerve.
Brachial plexus. (Reproduced with permission from Morton DA, Foreman KB, Albertine KH, eds. The Big Picture: Gross Anatomy. 1st ed. New York, NY: McGraw-Hill Education, Inc.; 2011: Fig. 29-4.)
Cutaneous innervations of the upper extremity. (Reproduced with permission from Butterworth JF, Mackey DC, Wasnick JD, eds. Morgan & Mikhail’s Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill Education, Inc.; 2013: Fig. 46-7.)
Local anesthetic solution is injected into the interscalene groove adjacent to the transverse process of C6. This provides nerve blockade at the level of the superior and middle trunks. Brachial plexus nerve roots emerge between the anterior and ...