Chapter 80D: Infraclavicular Brachial Plexus Block

INTRODUCTION

The infraclavicular block provides a block of the arm below the shoulder. Unlike the axillary approach, it can be performed without abduction of the arm, making it useful for patients with limited shoulder mobility. It is amenable to continuous catheter placement by being more accessible and more comfortable for a catheter than the axilla.

Georg Hirschel, in 1911, is considered to have carried out the first percutaneous axillary block because he approached the plexus from the axilla.¹ His goal was to place the local anesthetic on top of the first rib via the axilla. He discovered after his own dissections of the plexus the reason for incompleteness of the axillary block, and was the first to describe that the axillary and musculocutaneous nerves separated from the plexus much higher than in the axilla. However, the needles in the early 1900s were not long enough to reach this area to block those nerves.² To remedy this problem in 1911, Diedrich Kulenkampff’s supraclavicular description was soon to follow.² He felt his technique was safer and more accurate than Hirschel’s, but after initial success, the reports of complications of pneumothorax ensued.

In 1914, Bazy³ described injecting below the clavicle just medial to the coracoid process along a line connecting with the Chassaignac tubercle. The needle trajectory was pointed away from the axilla, close to the clavicle, and was felt to present little chance of pleural damage. Several modifications occurred in the ensuing 8 years. Babitszky said that “to discuss the anatomical relationship and the technique more fully would be superfluous, as it is customary to familiarize oneself with the anatomy of the field in question on the cadaver any time one tends to use an unfamiliar technique.”² Gaston Labat, in 1922, essentially redescribed Bazy’s technique in his textbook, Regional Anesthesia,⁵ as did Achille Dogliotti⁶ in 1939. However, the technique seemed to fade into obscurity. For instance, infraclavicular block was not included in Daniel Moore’s Regional Block⁷ in 1981 or Michael Cousins and Phillip Bridenbaugh’s Neural Blockade in Clinical Anesthesia and Pain Management.⁸

Prithvi Raj⁹ is credited with reintroducing the approach in 1973 with modification from the earlier descriptions. He described the initial entry point at the midpoint of the clavicle and directed the needle laterally toward the axilla using a nerve stimulator. His data suggested a virtual absence of risk of pneumothorax with the technique. and a more complete block of musculocutaneous and the ulnar nerves.⁹ However, these results were not reproducible in other practitioner’s clinical practice.

Kurt Whiffler, in 1981, described what is commonly referred to today as the coracoid block. The injection site was very close to that detailed by Sims,¹⁰ but Whiffler felt that the shoulder should be depressed with the head turned to the opposite side and the arm abducted 45 degrees from the chest ...