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Upper extremity nerve blocks: Techniques

Upper extremity nerve blocks: Techniques
Literature review current through: May 2024.
This topic last updated: Mar 18, 2024.

INTRODUCTION — Peripheral nerve blocks of the upper extremity are used for operative anesthesia and/or postoperative analgesia for a variety of upper extremity surgeries.

This topic will discuss the innervation of the upper extremity, techniques and drugs used for upper extremity nerve blocks, and complications specific to these blocks. Indications, contraindications, comparison of techniques relevant to all peripheral nerve blocks, equipment, and complications common to all nerve blocks are discussed separately. (See "Overview of peripheral nerve blocks".)

INNERVATION: UPPER EXTREMITY — The brachial plexus is formed by the ventral rami of the lower cervical and upper thoracic nerve roots (figure 1 and figure 2). It supplies cutaneous and muscular innervation to the upper extremity, with the exception of the trapezius muscle, the cape of the shoulder, and a small area of skin near the axilla (figure 3). The superficial cervical plexus supplies cutaneous innervation over the clavicle, the cape of the shoulder, and the first two anterior intercostal spaces (supraclavicular nerves, C3 and C4).

The nerve roots emerge in the neck adjacent to the transverse processes of the cervical vertebrae and posterior to the vertebral artery. The nerve roots continue as the trunks of the brachial plexus (superior [C5,C6], middle [C7], inferior [C8,T1]) and pass between the anterior and middle scalene muscles. At this point, the phrenic nerve is located anterior to the anterior scalene muscle. Each trunk divides into an anterior and posterior division, which in turn correspond to the ventral and dorsal upper extremities, respectively (figure 2).

All three trunks pass over the first rib and continue deep to the clavicle. The cords of the brachial plexus form from the trunks just distal to the first rib and are named according to their position relative to the axillary artery (lateral, posterior, and medial). The cords give rise to the five major nerves of the upper extremity:

Musculocutaneous nerve (from lateral cord) – The musculocutaneous nerve passes between the biceps brachii and brachialis muscles to the lateral side of the upper arm, continuing to the forearm. It innervates the flexor muscles of the upper arm (biceps brachii, coracobrachialis, and brachialis) and provides sensation to the lateral forearm (lateral antebrachial cutaneous nerve).

Axillary nerve (from posterior cord) – The axillary nerve (AN) is a terminal branch of the posterior cord of the brachial plexus. It forms at the lateral border of the subscapularis, and runs toward the posterior aspect of the surgical neck of the humerus. It is located beneath the shoulder joint 2 to 3 mm below the inferior capsule. The AN runs with the posterior humeral circumflex artery, passing through the quadrilateral space – the teres minor above, teres major below, long head of biceps medially, and proximal humerus laterally. It provides sensory innervation to the inferior, lateral, and anterior shoulder joint capsule, the humeral head, upper humeral neck, and cutaneously, the skin over the deltoid. It also provides motor innervation to the deltoid and teres minor muscles.

Radial nerve (from posterior cord) – The radial nerve continues posterior to the axillary artery then winds around the humerus, providing branches to the extensor muscles of the upper arm. After passing anterior to the lateral epicondyle of the elbow, it continues into the forearm to supply the extensor muscles of the forearm and hand. Sensory branches supply the dorsum of the forearm and hand, as well as portions of the upper arm.

Median nerve (from lateral and medial cords) – The median nerve continues along the posterior and lateral surface of the axillary artery and then courses medial to the brachial artery. It travels between and innervates the forearm flexor muscles, then passes through the carpal tunnel, providing motor and sensory function to the hand.

Ulnar nerve (from medial cord) – The ulnar nerve runs along the medial upper arm initially adjacent to the brachial artery, diverging in the distal upper arm to pass posterior to the medial epicondyle of the elbow into the forearm along the ulna, where it branches to supply some of the forearm flexors. It joins the ulnar artery, traversing the wrist deep to the flexor carpi ulnaris and into the hand, providing motor and sensory function to the hand.

The suprascapular nerve is a branch of the superior trunk of the brachial plexus. It travels along the omohyoid muscle to the scapula, passes along the lateral margin of the scapular spine to terminate in the infraspinatus muscle. The suprascapular nerve provides sensory innervation to most of the posterior, medial, and superior shoulder joint capsule and innervates the glenoid, acromion, and posterior surface of the scapula. It also innervates the supraspinatus and infraspinatus muscles (figure 4).

The intercostobrachial nerve (T2) is a lateral cutaneous branch of the second intercostal nerve and is not part of the brachial plexus. It leaves the second intercostal space in the midaxillary line, pierces the serratus anterior muscle, and enters the subcutaneous tissue of the axilla. This nerve, along with the medial cutaneous nerve of the arm (a branch of the ulnar nerve), provides sensory innervation of the axilla and the medial aspect of the upper arm (figure 3).

BRACHIAL PLEXUS BLOCKS — The brachial plexus can be blocked at several levels: in the neck using an interscalene block, above the clavicle with a supraclavicular block, below the clavicle with an infraclavicular block, or in the axilla with an axillary block (figure 5).

Interscalene block — The interscalene block is used for surgery of the shoulder and proximal upper extremity. It anesthetizes the C5 through C7 nerve roots as well as the superficial cervical plexus (C3 and C4, including the supraclavicular nerve) (figure 5 and figure 6). Depending on the volume of local anesthetic (LA) injected, the roots of C8 and T1, which form the lower trunk, are often not blocked, so the interscalene block may not provide analgesia for medial (ulnar distribution) hand surgery. The technique for interscalene block is discussed in detail separately. (See "Interscalene block procedure guide".)

Suprascapular nerve block — The suprascapular nerve (SSN) block provides partial analgesia to the glenohumeral joint, and may be particularly useful for shoulder surgery if interscalene block is contraindicated because of the associated phrenic nerve block (eg, patients with chronic obstructive pulmonary disease). This block may be used in combination with axillary nerve block to provide phrenic nerve-sparing analgesia after shoulder surgery (figure 4) [1]. This combination provides less complete analgesia for shoulder surgery than interscalene block, and general anesthesia will usually be required in addition to the block for surgical anesthesia [2,3]. Selective SSN block can also be combined with infraclavicular block along with LA infiltration of the skin (to block the cutaneous innervation from the supraclavicular nerve) to provide phrenic nerve sparing surgical block. SSN block may also be useful for diagnosis and treatment of chronic shoulder pain due to bursitis, arthritis, rotator cuff disorders, and degenerative shoulder joint disease [4,5].

Positioning — For the posterior approach to SSN block, the patient is placed in sitting position, with ipsilateral hand placed over the contralateral shoulder. This position moves the scapula laterally and provides more space for ultrasound scanning, and also moves the injection site laterally, away from thoracic cavity.

For the anterior approach to SSN block, the patient is positioned supine with the head of the patient rotated slightly to the contralateral side.

Ultrasound-guided suprascapular block — Suprascapular block can be performed with a posterior or an anterior approach. We suggest using ultrasound guidance for SSN block.

Anterior approach – A linear high frequency transducer is placed in the supraclavicular fossa just as it would be placed when performing a supraclavicular brachial plexus block. The subclavian artery and supraclavicular portion of the brachial plexus as well as the omohyoid muscle overlying these are identified. The SSN is located deep to the omohyoid muscle, superficial and lateral to the brachial plexus trunks. The needle is inserted in plane, from lateral to medial, targeting the SSN just underneath the omohyoid muscle and lateral to the brachial plexus. After negative aspiration for blood, 5 to 10 mL of LA is injected in 5-mL increments, with gentle aspiration between injections.

Posterior approach A linear high frequency transducer is placed on the scapula to obtain a transverse view of the suprascapular nerve and vessels. One end of the ultrasound transducer is placed over the scapular spine and the other end towards the coracoid process in position oblique the spine of the scapula in the suprascapular notch. This provides a transverse view of the nerve. First, the supraspinatus and overlying trapezius muscles are identified and the probe may be moved laterally to visualize the acromion as well. The lateral end of the transducer is then angled slightly anteriorly to visualize the suprascapular notch. The suprascapular artery (SSA) is seen superficial to SSN (sometimes, the superior transverse scapular ligament can be seen between the SSA and SSN). This supraspinous fossa is then followed posteriorly to the neck of the scapula, which leads more laterally and posteriorly to the spinoglenoid notch. It is best to perform the SSN block halfway between the scapular notch and the spinoglenoid notch. At this location, the SSA is lateral to the SSN. The needle is inserted in-plane from posteromedial to anterolateral, penetrating the trapezius and supraspinatus muscles until the needle is adjacent to the SSN and SSA. LA should be injected beneath the fascia of the supraspinatus muscle and not within the muscle itself. Hydrodissection can be used to confirm accurate placement of LA. After negative aspiration for blood, 5 to 8 mL of LA is injected in 3 to 5 mL increments, with gentle aspiration in-between injections.

Complications of suprascapular nerve block — Possible complications include pneumothorax and damage to the SSN or suprascapular vessels [6]. The SSN should not be targeted in the suprascapular notch because inadvertent needle advancement may puncture pleura anteriorly and result in pneumothorax. Concurrent radial nerve block may occur with greater volumes of LA, due to proximal spread to the posterior cord of the brachial plexus [7].

Axillary nerve block — The axillary nerve block is performed along with the SSN for analgesia for shoulder surgery.

Positioning — The patient is placed in a sitting or lateral decubitus position.

Ultrasound-guided axillary nerve block — The ultrasound transducer is placed over the posterior humerus in a long axis at the level of the posterior deltoid, 1 to 2 cm below the posterior shoulder capsule. This provides a short axis view of the AN and circumflex artery as a neurovascular bundle beneath the deltoid muscle. A 22-gauge needle is inserted in an in-plane technique. After negative aspiration for blood, 5 to 7 mL of LA is injected in divided doses, with gentle aspiration between injections, adjacent to the circumflex artery on artery on the posterior surface of the humerus to fill the space between the deltoid muscle and humerus.

Complications — AN block can be complicated by intravascular injection of LA.

Supraclavicular block — The supraclavicular approach blocks the brachial plexus at the level of the nerve trunks (upper, middle, and lower), where the nerves are packed closely together. Supraclavicular block provides a reliable, rapid onset and dense block for surgery of the distal two-thirds of the upper extremity, including those surgeries requiring an upper extremity tourniquet (eg, hand surgery) (figure 7). The technique for supraclavicular block is described in detail separately. (See "Supraclavicular block procedure guide".)

Infraclavicular block — The infraclavicular block anesthetizes the nerves of the brachial plexus at the level of the cords (lateral, posterior, and medial) (figure 5). Like the supraclavicular block, it provides anesthesia for surgeries of the distal two-thirds of the arm and consistently blocks the axillary and musculocutaneous nerves (figure 7) [8]. Compared with supraclavicular blocks, this approach is more often used for placement of indwelling catheters since the infraclavicular site provides improved efficacy [9], stable positioning, and easier catheter care. (See "Overview of peripheral nerve blocks", section on 'Continuous nerve block'.)

The technique for infraclavicular block is discussed separately. (See "Infraclavicular brachial plexus block procedure guide".)

Axillary block — The axillary block anesthetizes nerves of the brachial plexus at the level of the individual nerves (ie, median, radial, ulnar, and musculocutaneous nerves) and often requires multiple injections (figure 5 and figure 7). The musculocutaneous nerve in particular often needs to be targeted with a separate injection or else it can be spared. As with the other brachial plexus blocks described above, the intercostobrachial nerve, which innervates the upper arm where a tourniquet may be placed, is not part of the brachial plexus and must be blocked separately when an upper arm tourniquet is used (figure 3). (See 'Intercostobrachial nerve block' below.)

The technique for axillary block is discussed in detail separately. (See "Axillary block procedure guide".)

INTERCOSTOBRACHIAL NERVE BLOCK — Intercostobrachial nerve (ICBN) block may be performed in addition to brachial plexus block in order to provide complete anesthesia for medial upper arm surgery or for analgesia for use of an upper arm tourniquet (figure 8). The ICBN runs in the subcutaneous tissue of the medial upper arm (figure 9) and is blocked with a subcutaneous wheal of local anesthetic (LA).

The patient is positioned supine with the arm abducted in order to expose the axillary fossa.

A 25-gauge, 1.5-inch needle is inserted at the medial edge of the axillary crease using a shallow angle.

The needle is advanced subcutaneously across the medial aspect of the arm while injecting 5 to 10 mL of LA (figure 10).

WRIST BLOCKS — The ulnar, median, or radial nerves can be blocked at the level of the wrist for surgeries of the hand or fingers (figure 3 and figure 11 and figure 12). These blocks are usually performed by the surgeon or anesthesiologist as supplementation for incomplete brachial plexus blocks.

Only a small amount of local anesthetic (LA) is required to block each nerve (3 to 5 mL), and epinephrine should not be added to the anesthetic due to the risk of hand ischemia. The patient is positioned supine, with the arm abducted and the wrist supinated and in slight extension. Paresthesia during needle placement or injection warrants withdrawal and repositioning of the needle.

Radial nerve block — The radial nerve emerges between the brachioradialis tendon and the radius just proximal to the styloid process. The radial nerve can be blocked anatomically or with ultrasound guidance.

Anatomic placement – The needle is inserted subcutaneously just proximal to the styloid process of the radius, aiming medially, and, after negative aspiration, 3 to 5 mL of LA is injected (figure 11). The needle is then directed laterally, and an additional 3 to 5 mL of LA is infiltrated subcutaneously.

Ultrasound guidance – The radial nerve is difficult to visualize at the level of the wrist. However, if the transducer is moved proximally to the mid-forearm, the radial nerve can more easily be identified and blocked, lateral to the radial artery.

Median nerve block — The median nerve is located between the tendons of the flexor palmaris longus (between the flexor carpi ulnaris and radialis tendons) and the flexor carpi radialis (the most lateral tendon in the wrist). The flexor palmaris longus tendon may be identified by asking the patient to oppose the thumb and fifth finger with the wrist flexed. The median nerve can be blocked just lateral to this tendon. The needle is inserted between the two tendons until it pierces the fascia and advanced until contact is made with bone (figure 11). The needle should be redirected and LA injected in lateral and medial directions, in the same plane of depth, to increase the success rate of this block.

With ultrasound guidance, the median nerve can be visualized between the two tendons described above.

Ulnar nerve block — The ulnar nerve runs between the ulnar artery and flexor carpi ulnaris tendon (the most medial tendon in the wrist). This tendon is just superficial to the ulnar nerve. A needle is placed under the tendon, close to its attachment just above the styloid process of the ulna, and advanced 5 to 10 mm (figure 11). Three to 5 mL of LA is injected at this location. An additional 2 to 3 mL of LA may be injected subcutaneously above the tendon in order to anesthetize the cutaneous branches of the ulnar nerve.

When using ultrasound, the ulnar artery is identified, and the ulnar nerve is located medial to this vessel. Once identified, 3 to 5 mL of LA is injected to surround the nerve.

DIGITAL NERVE BLOCK (FINGER) — Digital nerve block is discussed in detail elsewhere. (See "Digital nerve block".)

DRUG CHOICES — Local anesthetics (LAs) are chosen according to the goal of the block (surgical anesthesia or analgesia) and the desired duration of the effect of the block (table 1). LAs and adjuvant drugs used for peripheral nerve blocks are discussed separately. (See "Overview of peripheral nerve blocks", section on 'Drugs'.)

Choices of LA for upper extremity blocks are as follows:

Surgical anesthesia only: 2% lidocaine or 1.5% mepivacaine

Postoperative analgesia: 0.25% bupivacaine or 0.5% ropivacaine

Surgical anesthesia and postoperative analgesia, either:

For rapid onset: Equal volumes of a short-acting LA (2% lidocaine or 1.5% mepivacaine) plus a long-acting LA (0.5% bupivacaine or 1% ropivacaine). Note that mixing local anesthetics results in onset and duration that are both intermediate between the two agents [10].

When rapid onset is not required (ie, 30 minutes for onset is acceptable): 0.5% bupivacaine or 0.5% ropivacaine

Perineural catheter infusion:

Inpatient: 0.1% bupivacaine or 0.2% ropivacaine, 5 to 10 mL/hour

Ambulatory surgery: 0.2% ropivacaine, 5 to 10 mL/hour

INTRAVENOUS REGIONAL ANESTHESIA (BIER BLOCK) — Intravenous regional anesthesia (IVRA), also called Bier block, is an alternative to peripheral nerve block for short (ie, 30 to 45 minutes) procedures on the hand and forearm (eg, carpal tunnel release, Dupuytren’s contracture release, reduction of wrist fracture). The technique involves placement of an IV catheter in the hand, exsanguination of the arm using an Esmarch bandage, inflation of a tourniquet, and then injection of local anesthetic through the IV catheter. The onset of anesthesia is almost immediate, and resolves very rapidly at the end of the procedure. Anesthesia lasts as long as the tourniquet is up, and is limited in duration by the short acting local anesthetic typically used (lidocaine) and the development of tourniquet pain.

IV regional anesthesia technique — The technique for IVRA of the upper extremity is as follows:

An IV for fluid and drug administration is placed in the nonoperative arm. A 20 to 22 gauge IV catheter is placed in the operative hand, flushed and capped. A double pneumatic tourniquet is placed high on the upper arm, padded with stockinette or cotton padding. The tourniquet can also be placed on the forearm for hand surgery.

The arm is raised for one to two minutes to allow passive exsanguination. An Esmarch bandage is wrapped tightly, in an overlapping spiral, from the fingers to the axilla.

The distal tourniquet is raised to 250 mmHg, or 100 mmHg above systolic blood pressure, followed by the proximal tourniquet. Each tourniquet should be tested sequentially by palpating the radial artery to confirm lack of a pulse. The distal cuff is released, and the Esmarch bandage is removed.

Local anesthetic (LA; 50 mL 0.5% lidocaine) is injected over at least 90 seconds via the indwelling IV in the operative hand. If a forearm tourniquet is used, 30 mL of 0.5% lidocaine is injected. Prilocaine is often used where it is available (outside the United States). Bupivacaine should not be used for IV regional anesthesia because of its potential for cardiotoxicity.

The IV catheter is removed and pressure applied to the IV site.

If tourniquet pain develops (often at 25 to 30 minutes after inflation), the alternate (distal) cuff is inflated, checked for functionality, and then the proximal cuff is deflated. This usually provides 15 to 30 minutes of comfort before tourniquet pain recurs (as the distal tourniquet is not inflated over an area that was previously uncuffed and therefore is anesthetized).

The tourniquet should be left inflated after injection of local anesthesia for at least 20 minutes, to avoid LA toxicity with deflation, though this recommendation is not evidence based. If the tourniquet must be deflated before 30 minutes, a gradual deflation/reinflation technique may be used (eg, 10 second deflation, followed by 1 minute reinflation), to prolong the washout of LA [11].

IVRA is less commonly used in the lower extremity for surgery on the ankle and foot. We avoid IVRA with a thigh cuff, because of the large volume of LA that would be required, almost universal incidence of leakage of LA across the tourniquet [12], and a high incidence of poor quality block [13]. For IVRA of the distal lower extremity, a double tourniquet is placed on the calf, and 30 to 50 mL of 0.5% lidocaine is injected into an IV catheter in the foot.

Side effects and complications of IV regional — Complications of IV regional anesthesia primarily involve local anesthetic systemic toxicity (LAST), usually as a result of technical error or cuff failure. Whereas LAST has been reported while the tourniquet is inflated, most events occur after deflation as a result of high systemic concentration of local anesthetic. Minor LAST events, including dizziness, blurred vision, facial numbness, tinnitus, and/or dysarthria, have been reported in up to 2 percent of patients who underwent IV regional with lidocaine or prilocaine [14,15]. Major LAST events, including seizures, cardiac arrest, and death have rarely been reported with the use of both lidocaine and bupivacaine [16].

Other reported complications include nerve damage, compartment syndrome, thrombophlebitis, and venous congestion of the limb [16,17].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Local and regional anesthesia" and "Society guideline links: Local anesthetic systemic toxicity".)

SUMMARY AND RECOMMENDATIONS

Brachial plexus blocks – The brachial plexus can be blocked at several levels (figure 5):

The interscalene block (at the level of the nerve roots) can be used for surgeries of the shoulder and proximal upper extremity (figure 6). (See "Interscalene block procedure guide".)

The supraclavicular block (at the level of the nerve trunks) and the infraclavicular block (at the level of the cords of the brachial plexus) can be used for surgery distal to the mid-humerus (figure 7). (See "Infraclavicular brachial plexus block procedure guide".)

The axillary block (at the level of the individual nerves) is used for surgery distal to the elbow (figure 7). (See "Axillary block procedure guide".)

Other blocks

Intercostobrachial nerve block may be necessary to provide complete coverage of an upper arm tourniquet following supraclavicular, infraclavicular, or axillary nerve block (figure 10 and figure 8). (See 'Intercostobrachial nerve block' above.)

The ulnar, median, or radial nerves can be blocked at the level of the forearm for surgeries of the hand or fingers (figure 11 and figure 12). (See 'Wrist blocks' above.)

Intravenous regional anesthesia (IVRA) is an alternative to peripheral nerve block for short (ie, 30 to 45 minutes) procedures on the hand and forearm (eg, carpal tunnel release, Dupuytren’s contracture release, reduction of wrist fracture). The technique involves placement of an IV catheter in the hand, exsanguination of the arm using an Esmarch bandage, inflation of a tourniquet, and then injection of local anesthetic through the IV catheter. (See 'Intravenous regional anesthesia (Bier block)' above.)

Guidance technique – We perform brachial plexus blocks using ultrasound guidance; we suggest use of ultrasound guidance for supraclavicular block to minimize the chance of vascular puncture and pneumothorax (Grade 2C). Others use nerve stimulation techniques for interscalene, infraclavicular, and axillary blocks. A transarterial technique can be used for axillary block. (See "Axillary block procedure guide" and "Interscalene block procedure guide" and "Infraclavicular brachial plexus block procedure guide".)

Continuous block – A perineural catheter may be placed for continuous infusion of local anesthetic (LA) for postoperative pain. Infraclavicular catheters are preferred over supraclavicular catheters for distal arm surgery. (See "Infraclavicular brachial plexus block procedure guide", section on 'Continuous infraclavicular block'.)

Complications – Pneumothorax is a possible complication with supraclavicular, and, rarely, infraclavicular and interscalene blocks. Side effects of these three blocks include phrenic nerve block, Horner syndrome, and hoarseness. (See "Interscalene block procedure guide", section on 'Complications' and "Infraclavicular brachial plexus block procedure guide", section on 'Side effects and complications'.)

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