Users Online: 983 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  
Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 


RSACP wishes to inform that it shall be discontinuing the dispatch of print copy of JOACP to it's Life members. The print copy of JOACP will be posted only to those life members who send us a written confirmation for continuation of print copy.
Kindly email your affirmation for print copies to dranjugrewal@gmail.com preferably by 30th June 2019.

 

 
Table of Contents
REVIEW ARTICLE
Year : 2015  |  Volume : 31  |  Issue : 3  |  Page : 296-307

Ultrasound guided distal peripheral nerve block of the upper limb: A technical review


Department of Anesthesia, Toronto Western Hospital, Toronto, Canada

Date of Web Publication29-Jul-2015

Correspondence Address:
Herman Sehmbi
APT 2006, 10 Yonge Street, Toronto, Ontario M5E1R4
Canada
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.161654

Rights and Permissions
  Abstract 

Upper extremity surgery is commonly performed under regional anesthesia. The advent of ultrasonography has made performing upper extremity nerve blocks relatively easy with a high degree of reliability. The proximal approaches to brachial plexus block such as supraclavicular plexus block, infraclavicular plexus block, or the axillary block are favored for the most surgical procedures of distal upper extremity. Ultrasound guidance has however made distal nerve blocks of the upper limb a technically feasible, safe and efficacious option. In recent years, there has thus been a resurgence of distal peripheral nerve blocks to facilitate hand and wrist surgery. In this article, we review the technical aspects of performing the distal blocks of the upper extremity and highlight some of the clinical aspects of their usage.

Keywords: Distal, median, musculocutaneous, peripheral nerve blocks, radial, ulnar, ultrasound


How to cite this article:
Sehmbi H, Madjdpour C, Shah UJ, Chin KJ. Ultrasound guided distal peripheral nerve block of the upper limb: A technical review. J Anaesthesiol Clin Pharmacol 2015;31:296-307

How to cite this URL:
Sehmbi H, Madjdpour C, Shah UJ, Chin KJ. Ultrasound guided distal peripheral nerve block of the upper limb: A technical review. J Anaesthesiol Clin Pharmacol [serial online] 2015 [cited 2020 Jul 8];31:296-307. Available from: http://www.joacp.org/text.asp?2015/31/3/296/161654


  Introduction Top


Wrist and hand surgery are commonly performed under regional anesthesia. [1],[2] The advent of ultrasonography has made performing upper extremity nerve blocks relatively easier and increased their efficacy. [3] More proximal approaches such as supraclavicular plexus block, infraclavicular plexus block, or the axillary block are usually favored for surgical procedures of distal upper extremity. [4],[5],[6] Ultrasound guidance has however made distal nerve blocks of the upper limb a technically feasible, safe, and efficacious option. [7],[8],[9] In recent years, there has thus been a resurgence of distal peripheral nerve blocks to facilitate hand and wrist surgery. [10] In this article, we review the technical aspects of performing the distal blocks of the upper extremity and highlight some of the clinical aspects of their usage.


  Potential Benefits of Distal Nerve Blocks of Upper Extremity Top


A more distal approach involving the peripheral nerves of the upper extremity (radial, median, ulnar and musculocutaneous nerves) may offer several benefits. These include the following:

  1. Distal approaches to upper extremity block in general lie away from critical, more central structures such as the pleura, subclavian or axillary artery and the phrenic nerve and thus avoid the risk of inadvertent needle trauma to these structures.
  2. Distal peripheral nerve blocks allow preservation of proximal muscle function of the upper limb. The inability to use the affected limb due to the motor block of proximal and distal musculature has been shown to reduce patient satisfaction. [11] A recent randomized controlled trial comparing ultrasound guided supraclavicular plexus block with distal peripheral nerve blocks for outpatient hand surgery showed better strength preservation and greater patient satisfaction with distal blocks. [12]
  3. In conjunction with a proximal brachial plexus block (infraclavicular), distal nerve blocks of the upper limb have been shown to hasten block onset times and improve block consistency. [10]
  4. Combining a proximal brachial plexus block using a short acting local anesthetic and distal nerve blocks using a longer acting local anesthetic agent may prolong the analgesic component of the block while minimizing proximal muscle dysfunction. [13]
  5. Preservation of motor strength may also allow the patients to move affected digits when instructed to do so during the surgery. This may be vital during certain types of hand surgeries.



  Potential Limitations of Distal Nerve Blocks of Upper Extremity Top


  1. The cutaneous innervation of the upper arm is provided by the musculocutaneous nerve, medial cutaneous nerve of the arm, posterior cutaneous nerve of the arm, and intercostobrachial nerve. Distal nerve blocks will therefore not prevent tourniquet pain in an unsedated patient.
  2. Nerves originating proximally in the axilla such as the medial cutaneous nerve of the forearm and the musculocutaneous nerve (which gives rise to the lateral cutaneous nerve of the forearm) contribute to the cutaneous innervation of the forearm. Thus, distal nerve blocks may not always be sufficient for surgical procedures on the forearm.
  3. A distal approach to nerve block for the upper limb requires blockade of multiple nerves. This, therefore, involves multiple injections that may cause more patient discomfort.
  4. The peripheral nerves can be anisotropic, and scanning for them can be challenging initially. Experimenting with different degrees of probe tilt and scanning positions to find the best view is helpful.



  Recommended Applications of Distal Block Top


Distal blocks of the upper limb may be useful in the following circumstances:

  • Primary surgical anesthesia: For superficial or minor surgery of the distal upper limb that does not require the use of an arm tourniquet or profound muscle relaxation.
  • Secondary analgesia: To supplement a general anesthetic or a brachial plexus block performed using short-acting agents. In this instance, increased vigilance is required during block performance due to the reduced ability of the patient to report paresthesia or pain from neural trauma. Strategies to increase safety include the use of both peripheral nerve stimulator (PNS) and ultrasound, [14],[15] and injection pressure monitoring. [16],[17]
  • As rescue techniques for incomplete brachial plexus blocks.



  Required Equipment and Ergonomics Top


In general the following are required to perform the blocks:

  • Appropriate anesthetic equipment and personnel for sedation, monitoring, and oxygenation.
  • Ultrasound machine with high-frequency linear array transducer (10-15 MHz).
  • Sterile ultrasound probe cover or Tegaderm™ (3M, St. Paul, MN, USA) dressing.
  • Sterile ultrasound gel.
  • Sterile skin preparation (2% chlorhexidine or other appropriate disinfectant).
  • Local anesthetic for skin infiltration (usually 0.5-1 ml 2% lignocaine). It must be kept in mind that this would increase the number of needle pricks patient receives.
  • A 22 G, 50 mm short-bevel regional anesthesia block needle.
  • Sterile gloves.
  • Local anesthetic: Usually a volume of 3-5 ml suffice for each nerve. The objective is to achieve a circumferential spread of the local anesthetic around the nerve. While using a lower concentration (such as 0.25% bupivacaine) may suffice for analgesia, the duration may also be limited. Using a higher concentration (such as 0.5% bupivacaine) provides an anesthetic block, with a longer duration. Lignocaine may be used when a rapid onset is desired.
  • Ergonomics: We recommend that the operator stand on the side being blocked, with the ultrasound machine on the opposite side of the patient. This maintains an in-line orientation between the operator, the injection site, and the ultrasound screen.



  Specific Distal Nerve Blocks of the Upper Limb Top


Musculocutaneous nerve (C5, C6, and C7)

Brief anatomy

This nerve is a branch of the lateral cord of the brachial plexus, arising opposite the lower border of the pectoralis major. [18],[19] After penetrating the coracobrachialis muscle, the nerve passes obliquely between the biceps brachii and the brachialis innervating all three muscles, and supplying the elbow joint. It then emerges on the lateral side of the arm, pierces the deep fascia lateral to the tendon of the biceps brachii, and continues into the forearm as the lateral cutaneous nerve of the forearm. A schematic diagram is shown in [Figure 1].
Figure 1: Schematic diagram representing the course of musculocutaneous nerve

Click here to view


Patient position

The patient is positioned supine with the arm being blocked abducted away from the body at a right angle, and extended at the elbow. Alternatively, the abducted arm may be flexed at the elbow [Figure 2].
Figure 2: Patient position, scanning technique and in-plane needling for musculocutaneous nerve block

Click here to view


Scanning

A linear transducer is placed at the axilla to identify the axillary artery, above the teres major muscle. The coracobrachialis muscle lateral to the artery, and the biceps brachii further lateral is identified. The musculocutaneous nerve appears as a hyperechoic triangular or oval structure in the fascial plane between coracobrachialis and biceps brachii muscles [Figure 3].
Figure 3: Ultrasound scan of the musculocutaneous nerve

Click here to view


Injection

After raising a skin wheal using local anesthetic, a 22 G, 50 mm short bevel block needle is introduced in-plane in a lateral to medial direction (or out-of-plane depending on operator preference), aiming to enter the fascial plane next to the musculocutaneous nerve. If using a PNS, an evoked motor response constituting elbow flexion is obtained. After negative aspiration, local anesthetic is injected to encircle the nerve. Usually, a volume of 3-5 ml is sufficient for this [Figure 4] and [Figure 5].
Figure 4: In-plane needling for musculocutaneous nerve

Click here to view
Figure 5: Musculocutaneous nerve post injection

Click here to view


Radial nerve (C5, C6, C7, C8 and T1)

Brief anatomy

The radial nerve originates from the posterior cord of the brachial plexus (along with the axillary nerve) and enters the posterior compartment of the arm. [18],[19],[20] It then spirals obliquely over the posterior aspect of the humerus (in the spiral groove) to emerge on the lateral side of the humerus. It then pierces the lateral intermuscular septum to enter the anterior compartment of the arm. Here, it then descends between brachialis and brachioradialis and courses anterior to the lateral epicondyle, where it divides into superficial and deep branches. [Figure 6] illustrates a schematic representation of the course and the branches of the radial nerve.
Figure 6: Schematic diagram of the course and branches of the radial nerve

Click here to view


Patient position and scanning technique

The radial nerve may be blocked at the following two positions above the elbow joint:

  1. Just distal to the spiral groove - The arm is the best placed with shoulder adducted and internally rotated, and elbow flexed so that it lies on the chest. This allows the best access to the posterolateral aspect of the humerus [Figure 7]. A linear transducer is placed in the spiral groove to identify the humerus. Upon scanning distally, the radial nerve is usually seen as a triangular hyperechoic structure coming off the humerus [Figure 8]a. Blocking the radial nerve here maximizes the chances of involving both the deep and the superficial branches and is our preferred site of injection.
    Figure 7: Patient position and scanning technique for radial nerve block

    Click here to view
    Figure 8:

    Click here to view
  2. At the elbow - The patient is positioned supine, with the arm to be blocked kept straight in supination [Figure 7]. At first, the radial nerve is identified as above. On further scanning distally, it flattens out and comes to lie between the biceps and brachioradialis [Figure 8]b. Near the elbow joint, it is seen to branch out into its superficial and deep branches [Figure 8]c. This site may be chosen for simplicity, as the median nerve may also be blocked at the same level by moving the probe medially to identify the latter. However, care must be exercised to choose a point of injection before the bifurcation of the radial nerve to avoid missing one of the branches.


Injection

After raising a skin wheal using local anesthetic, a 22 G, 50 mm short bevel block needle is introduced in-plane (or out-of-plane) aiming to enter the fascial plane next to the radial nerve. If using a PNS, an evoked motor response constituting thumb and finger extension is obtained. An injection of 3-5 ml local anesthetic is made after negative aspiration to encircle the radial nerve [Figure 9], [Figure 10]a and b. Injection must not be made too close to the spiral groove to avoid pressure induced nerve damage.
Figure 9: In-plane needling for radial nerve block

Click here to view
Figure 10:

Click here to view


Ulnar nerve (C8, T1)

Brief anatomy

The ulnar nerve originates from the medial cord of the brachial plexus. [18],[19],[20] It descends in a subcutaneous plane, initially medial to the brachial artery, to emerge behind the medial epicondyle that seats the nerve. It enters the anterior (flexor) compartment of the forearm between the humeral and ulnar heads, lying under the aponeurosis of flexor carpi ulnaris. In the upper third of the forearm, the nerve is separated from the ulnar artery, but more distally it comes to lie adjacent to the medial side of the artery. This relationship is helpful in identifying the nerve. [Figure 11] illustrates a schematic representation of the course and the branches of the ulnar nerve.
Figure 11: Schematic diagram of the course and branches of the ulnar nerve

Click here to view


Patient position and scanning technique

The ulnar nerve may be blocked at the following two positions:

  1. The mid-humeral level - The patient is positioned supine with the arm being blocked abducted away from the body at a right angle, and extended (or flexed) at the elbow [Figure 12]. A linear transducer is placed in the axilla to identify the axillary artery. The ulnar nerve may be identified medial to it. As the artery is traced distally, the ulnar nerve is visible as a hyperechoic structure superficial and medial to the brachial artery at the mid-humeral level [Figure 13]. Blocking the ulnar nerve here covers the forearm muscles well and is the preferred approach for procedures on the forearm.
    Figure 12: Scanning for the ulnar nerve at mid-humerus

    Click here to view
    Figure 13: Ultrasound image of ulnar nerve at mid-humerus level. Ulnar nerve is typically seen away from the brachial artery

    Click here to view
  2. At mid-forearm level - The patient is positioned supine, with the arm being blocked kept straight and supinated [Figure 14]. A linear transducer is placed just above the wrist, on its medial aspect to identify the ulnar artery. Upon scanning proximally, the ulnar nerve is usually seen as an oval hyperechoic structure immediately medial to the artery [Figure 15]a. On further proximal scan up to the mid-forearm, the nerve is seen moving further away (medially) from the ulnar artery, to lie between the flexor carpi ulnaris above and flexor digitorum profundus deeper [Figure 15]b. Blocking the ulnar nerve here does not cover the forearm muscles well and is therefore primarily suitable for procedures on the hand.
    Figure 14: Patient position and scanning technique for ulnar nerve block

    Click here to view
    Figure 15:

    Click here to view


Injection

After raising a skin wheal using local anesthetic a 22 G, 50 mm short bevel block needle is introduced in-plane (or out-of-plane) aiming to enter the fascial plane next to the ulnar nerve. If using a PNS, an evoked motor response constituting thumb adduction and ring finger flexion is obtained. An injection of 3-5 ml local anesthetic is made after negative aspiration to cover the nerve circumferentially [Figure 16], [Figure 17]a and b.
Figure 16: In-plane needling for ulnar nerve block

Click here to view
Figure 17:

Click here to view


Median nerve (C5, C6, C7, C8 and T1)

Brief anatomy

The median nerve is formed by the lateral root of median (from the lateral cord) and the medial root of median nerve (from the medial cord) of the brachial plexus. [18],[19],[20] In the arm, it passes vertically downward lateral to the brachial artery. It crosses brachial artery anteriorly (or rarely posteriorly) to lie medial to it, just above the elbow joint. Here, it lies between biceps brachii and brachialis. In the forearm, passes between the two heads of pronator teres and then travels between flexor digitorum superficialis and flexor digitorum profundus. [Figure 18] illustrates a schematic representation of the course and the branches of median nerve.
Figure 18: Schematic diagram of the course and branches of the median nerve

Click here to view


Patient position and scanning technique

The median nerve may be blocked at the following positions:

  1. The mid-humeral level - The patient is positioned supine with the arm being blocked abducted away from the body at a right angle, and extended (or flexed) at the elbow [Figure 19]. A linear transducer is placed in the axilla to identify the axillary artery, with median nerve commonly located lateral to it. Upon distal scanning, the median nerve remains adjacent to the artery while the ulnar nerve moves further medially away from the artery [Figure 13]. This injection point allows both median and ulnar nerves to be blocked at the same level.
    Figure 19: Scanning for median nerve at the mid-humerus level

    Click here to view
  2. Above the elbow joint - The patient is positioned supine, with the arm being blocked kept straight and supinated [Figure 20]. A linear transducer is placed over the cubital fossa to identify the brachial artery. The median nerve can be seen as a round to oval hyperechoic structure medial or posterior to the brachial artery [Figure 21]a. The nerve can be blocked here.
    Figure 20: Patient position and scanning technique for median block at the cubital fossa and at the mid-forearm

    Click here to view
    Figure 21:

    Click here to view
  3. At the mid-forearm - The patient is positioned supine, with the arm being blocked kept straight and supinated [Figure 20]. A linear transducer is placed on the ventral aspect of the mid-forearm, where the median nerve is visible in the fascial plane between the flexor digitorum superficialis and flexor digitorum profundus. Another easy way to identify this plane is to identify the ulnar nerve at mid-forearm first (as described above). Upon moving the transducer laterally at this level, the median nerve can be identified in the fascial plane between the flexor digitorum superficialis and flexor digitorum profundus [Figure 21]b.


Injection

After raising a skin wheal using local anesthetic, a 22 G, 50 mm short bevel block needle is introduced in-plane (or out-of-plane) and aimed at the fascial plane next to the median nerve. Care is exercised not to puncture the brachial artery, which may be crossed from above or below to access the median nerve [Figure 22]a and b. If using a PNS, an evoked motor response constituting finger flexion is obtained. An injection of 3-5 ml local anesthetic is made after negative aspiration to cover the nerve circumferentially [Figure 23]a and b.
Figure 22:

Click here to view
Figure 23:

Click here to view


Medial antebrachial cutaneous nerve or medial cutaneous nerve of the forearm (C8-T1)

Brief anatomy

This nerve is a branch of the medial cord of the brachial plexus, arising medial to the axillary artery. Subsequently it gives a branch that pierces the fascia and supplies the skin over the biceps brachii muscle up to the elbow. The nerve lies medial to the brachial artery at mid-arm level and pierces the brachial fascia along with the basilic vein at the basilic hiatus. It then divides into anterior (volar) and posterior (ulnar) branches supplying the skin over the antero-medial and postero-medial aspect of the forearm respectively. [21],[22],[23]

Patient position

The patient is positioned supine with arm being blocked abducted away from the body at a right angle, and extended at the elbow. Alternatively, the abducted arm may be flexed at the elbow [Figure 24].
Figure 24: Patient position for medial antebrachial cutaneous nerve, lateral antebrachial cutaneous nerve and posterior antebrachial cutaneous nerve

Click here to view


Scanning

A linear transducer is placed at the mid-arm level (in short axis) to identify the biceps brachii muscle, brachial artery, median nerve (medial to the brachial a.), ulnar nerves (subcutaneous medially) and basilic vein (in the most superficial subcutaneous plane). The medial antebrachial cutaneous nerve (MACN) can be visualized as a hyperechoic oval immediately lateral to the basilic vein [Figure 25]a. Upon a distal scan, it can be seen dividing into its two branches, anterior and posterior [Figure 25]b. While the anterior branch moves laterally, the posterior branch passes under the vein to lie on its ulnar aspect. [24],[25]
Figure 25:

Click here to view


Injection

A 25-27 G hypodermic needle is introduced in-plane in a lateral to medial direction aiming to enter the fascial plane next to the basilic vein. After negative aspiration, 2-3 ml local anesthetic is injected to fill the fascial plane containing the MACN.

Lateral antebrachial cutaneous nerve or lateral cutaneous nerve of the forearm (C5, C6, C7)

Brief anatomy

In the arm, the musculocutaneous nerve pierces the coracobrachialis to descend in the plane between the brachialis and the biceps brachii muscles. After providing motor branches to these muscles, the nerve emerges lateral to the tendon of the biceps brachii muscle at the elbow, pierces the deep fascia distal to the interepicondylar line and continues as the lateral antebrachial cutaneous nerve (LACN). It usually lies medial to the cephalic vein and may divide into anterior (volar) and posterior (ulnar) branches supplying the skin over the antero-lateral and postero-lateral aspect of the forearm respectively. [26],[27]

Patient position

The patient is positioned supine with arm being blocked abducted away from the body at a right angle, and extended at the elbow [Figure 24].

Scanning

A linear transducer is placed above the elbow joint (in short axis) to identify the biceps brachii aponeurosis and the biceps tendon [Figure 26]a. The hyperechoic LACN is identified lateral to the tendon, and becomes subcutaneous upon distal scan. Here, it is seen under or medial to the cubital vein [Figure 26]b, and is seen dividing into an anterior (volar) and a posterior (ulnar) branch. [28],[29]
Figure 26:

Click here to view


Injection

A 25-27 G hypodermic needle is introduced in-plane, in a lateral to medial direction aiming to enter the fascial plane next to the cephalic vein. After negative aspiration, 2-3 ml local anesthetic is injected to fill the fascial plane containing the LACN.

Posterior antebrachial cutaneous nerve or posterior cutaneous nerve of the forearm (C5, C6, C7, C8)

Brief anatomy

After emerging from the spiral groove, the radial nerve pierces the lateral intermuscular septum to enter the anterior compartment of the arm. Along this course, both the inferior lateral cutaneous nerve of the arm and posterior cutaneous nerve of the forearm are given off. Thus, the posterior antebrachial cutaneous nerve (PACN) may be identified at the junction of triceps and brachioradialis in the superficial plane. It divides into an upper branch that supplies the lateral side of lower arm, and a lower branch that supplies the back of the forearm up to the wrist. [18],[30]

Patient position

The arm is the best placed with shoulder adducted and internally rotated, and elbow flexed, so that it lies on chest [Figure 24].

Scanning

A linear transducer is placed in the spiral groove (in short axis) to identify the radial nerve [Figure 27]a. Upon distal scanning, small hyperechoic nerve may be seen piercing the triceps to emerge superficially at the junction of the triceps and brachioradialis [Figure 27]b. It divides into an upper and a lower branch [Figure 27]c. [28],[30]
Figure 27:

Click here to view


Injection

A 25-27 G hypodermic needle is introduced in-plane, in an anterior to posterior direction aiming to enter the subcutaneous plane containing the nerve. After negative aspiration, 2-3 ml local anesthetic is injected to fill the fascial plane containing the PACN.


  Conclusion Top


The distal peripheral nerve blocks are relatively easy to perform using ultrasound guidance. These blocks are very useful as rescue blocks in the event of an incomplete anesthesia following brachial plexus blocks, or as standalone anesthetic or analgesic techniques. Good anatomical knowledge of their course and branches helps in their identification and selection for appropriate surgical procedures.


  Acknowledgments Top


All images in this manuscript have been taken from www.regionalfortrainees.com (courtesy of www.regionalfortrainees.com).

 
  References Top

1.
Maga JM, Cooper L, Gebhard RE. Outpatient regional anesthesia for upper extremity surgery update (2005 to present) distal to shoulder. Int Anesthesiol Clin 2012;50:47-55.  Back to cited text no. 1
    
2.
Lin E, Choi J, Hadzic A. Peripheral nerve blocks for outpatient surgery: Evidence-based indications. Curr Opin Anaesthesiol 2013;26:467-74.  Back to cited text no. 2
    
3.
Tran DQ, Pham K, Dugani S, Finlayson RJ. A prospective, randomized comparison between double-, triple-, and quadruple-injection ultrasound-guided axillary brachial plexus block. Reg Anesth Pain Med 2012;37:248-53.  Back to cited text no. 3
    
4.
Tsui BC, Doyle K, Chu K, Pillay J, Dillane D. Case series: Ultrasound-guided supraclavicular block using a curvilinear probe in 104 day-case hand surgery patients. Can J Anaesth 2009;56:46-51.  Back to cited text no. 4
    
5.
Chin KJ, Singh M, Velayutham V, Chee V. Infraclavicular brachial plexus block for regional anaesthesia of the lower arm. Anesth Analg 2010;111:1072.  Back to cited text no. 5
    
6.
Handoll HH, Koscielniak-Nielsen ZJ. Single, double or multiple injection techniques for axillary brachial plexus block for hand, wrist or forearm surgery. Cochrane Database Syst Rev 2006 Jan 25;(1):CD003842.  Back to cited text no. 6
    
7.
McCartney CJ, Xu D, Constantinescu C, Abbas S, Chan VW. Ultrasound examination of peripheral nerves in the forearm. Reg Anesth Pain Med 2007;32:434-9.  Back to cited text no. 7
    
8.
Foxall GL, Skinner D, Hardman JG, Bedforth NM. Ultrasound anatomy of the radial nerve in the distal upper arm. Reg Anesth Pain Med 2007;32:217-20.  Back to cited text no. 8
    
9.
Kathirgamanathan A, French J, Foxall GL, Hardman JG, Bedforth NM. Delineation of distal ulnar nerve anatomy using ultrasound in volunteers to identify an optimum approach for neural blockade. Eur J Anaesthesiol 2009;26:43-6.  Back to cited text no. 9
    
10.
Fredrickson MJ, Ting FS, Chinchanwala S, Boland MR. Concomitant infraclavicular plus distal median, radial, and ulnar nerve blockade accelerates upper extremity anaesthesia and improves block consistency compared with infraclavicular block alone. Br J Anaesth 2011;107:236-42.  Back to cited text no. 10
    
11.
Fredrickson MJ, Price DJ. Analgesic effectiveness of ropivacaine 0.2% vs 0.4% via an ultrasound-guided C5-6 root/superior trunk perineural ambulatory catheter. Br J Anaesth 2009;103:434-9.  Back to cited text no. 11
    
12.
Lam NC, Charles M, Mercer D, Soneru C, Dillow J, Jaime F, et al. A triple-masked, randomized controlled trial comparing ultrasound-guided brachial plexus and distal peripheral nerve block anesthesia for outpatient hand surgery. Anesthesiol Res Pract 2014;2014:324083.  Back to cited text no. 12
    
13.
Smith BE, Challands JF, Suchak M, Siggins D. Regional anaesthesia for surgery of the forearm and hand. A technique of combined supraclavicular and discrete blocks. Anaesthesia 1989;44:747-9.  Back to cited text no. 13
    
14.
Tsui BC, Pillay JJ, Chu KT, Dillane D. Electrical impedance to distinguish intraneural from extraneural needle placement in porcine nerves during direct exposure and ultrasound guidance. Anesthesiology 2008;109:479-83.  Back to cited text no. 14
    
15.
Dillane D, Tsui BC. Is there still a place for the use of nerve stimulation? Paediatr Anaesth 2012;22:102-8.  Back to cited text no. 15
    
16.
Gadsden J, McCally C, Hadzic A. Monitoring during peripheral nerve blockade. Curr Opin Anaesthesiol 2010;23:656-61.  Back to cited text no. 16
    
17.
Gadsden JC, Choi JJ, Lin E, Robinson A. Opening injection pressure consistently detects needle-nerve contact during ultrasound-guided interscalene brachial plexus block. Anesthesiology 2014;120:1246-53.  Back to cited text no. 17
    
18.
Stranding S, editor. Upper arm. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 40 th ed. London: Churchill Livingstone; 2008. p. 823-30.  Back to cited text no. 18
    
19.
Stranding S, editor. Forearm. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 40 th ed. London: Churchill Livingstone; 2008. p. 839-56.  Back to cited text no. 19
    
20.
Stranding S, editor. Wrist and hand. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 40 th ed. London: Churchill Livingstone; 2008. p. 857-98.  Back to cited text no. 20
    
21.
Viscomi CM, Reese J, Rathmell JP. Medial and lateral antebrachial cutaneous nerve blocks: An easily learned regional anesthetic for forearm arteriovenous fistula surgery. Reg Anesth 1996;21:2-5.  Back to cited text no. 21
    
22.
Masear VR, Meyer RD, Pichora DR. Surgical anatomy of the medial antebrachial cutaneous nerve. J Hand Surg Am 1989;14:267-71.  Back to cited text no. 22
    
23.
Thallaj A, Marhofer P, Kettner SC, Al-Majed M, Al-Ahaideb A, Moriggl B. High-resolution ultrasound accurately identifies the medial antebrachial cutaneous nerve at the midarm level: A clinical anatomic study. Reg Anesth Pain Med 2011;36:499-501.  Back to cited text no. 23
    
24.
Moritz T, Prosch H, Pivec CH, Sachs A, Pretterklieber ML, Kriechbaumer L, et al. High-resolution ultrasound visualization of the subcutaneous nerves of the forearm: A feasibility study in anatomic specimens. Muscle Nerve 2014;49:676-9.  Back to cited text no. 24
    
25.
Thallaj A. Ultrasound guidance of uncommon nerve blocks. Saudi J Anaesth 2011;5:392-4.  Back to cited text no. 25
[PUBMED]  Medknow Journal  
26.
Beldner S, Zlotolow DA, Melone CP Jr, Agnes AM, Jones MH. Anatomy of the lateral antebrachial cutaneous and superficial radial nerves in the forearm: A cadaveric and clinical study. J Hand Surg Am 2005;30:1226-30.  Back to cited text no. 26
    
27.
Wongkerdsook W, Agthong S, Amarase C, Yotnuengnit P, Huanmanop T, Chentanez V. Anatomy of the lateral antebrachial cutaneous nerve in relation to the lateral epicondyle and cephalic vein. Clin Anat 2011;24:56-61.  Back to cited text no. 27
    
28.
Blanco R, Gómez BM, González JM. Ultrasound appearance of the cutaneous nerves of the upper limb: A novel description in pain management. J Pain Relief 2012;1:e109.  Back to cited text no. 28
    
29.
Chiavaras MM, Jacobson JA, Billone L, Lawton JM, Lawton J. Sonography of the lateral antebrachial cutaneous nerve with magnetic resonance imaging and anatomic correlation. J Ultrasound Med 2014;33:1475-83.  Back to cited text no. 29
    
30.
Egeler C. Cutaneous Nerves of the Arm and Forearm-How Small Can We Go? Abstracts and Highlight Papers of the 32 nd Annual European Society of Regional Anaesthesia and Pain Therapy (ESRA) Congress 2013: Invited Speaker Highlight Papers; 2013. p. E1-259.  Back to cited text no. 30
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27]


This article has been cited by
1 Ultrasound-Guided Nerve Blocks as Analgesia for Nonoperative Management of Distal Radius Fractures–Two Consecutive Randomized Controlled Trials
Michiel Siebelt,Klaas A. Hartholt,Daniëlle F. M. van Winden,Femke Boot,Dafni Papathanasiou,Bas C. Verdouw,Mark R. de Vries,Nina M. Mathijssen,Gerald A. Kraan
Journal of Orthopaedic Trauma. 2019; 33(4): e124
[Pubmed] | [DOI]
2 Percutaneous cubital tunnel release with a dissection thread: a cadaveric study
Danqing Guo,Michel Kliot,Logan McCool,Alexander Senk,Brionn Tonkin,Danzhu Guo
Journal of Hand Surgery (European Volume). 2019; 44(9): 920
[Pubmed] | [DOI]
3 Proximal RUMM block in dogs: preliminary results of cadaveric and clinical study
Hamaseh Tayari,Pablo Otero,Alberto Rossetti,Gloria Breghi,Angela Briganti
Veterinary Anaesthesia and Analgesia. 2019;
[Pubmed] | [DOI]
4 Sonographic evaluation of uncommonly assessed upper extremity peripheral nerves: anatomy, technique, and clinical syndromes
Jonathan M. Youngner,Kulia Matsuo,Tom Grant,Ankur Garg,Jonathan Samet,Imran M. Omar
Skeletal Radiology. 2018;
[Pubmed] | [DOI]
5 Ultrasound and nerve stimulator guided peripheral nerve blocks of the upper and lower limbs
Svetlana Sreckovic
Serbian Journal of Anesthesia and Intensive Therapy. 2018; 40(1-2): 25
[Pubmed] | [DOI]
6 Low-concentration distal nerve blocks with 0.125% levobupivacaine versus systemic analgesia for ambulatory trapeziectomy performed under axillary block: a randomized controlled trial
Mireia Rodríguez Prieto,F. Javier González,Sergi Sabaté,Mercedes García,Claudia Lamas,Adriŕ Font,Marisa Moreno,Ignasi Proubasta,M. Ŕngels Gil De Bernabé,M. Victoria Moral,Rolf Hoffmann
Minerva Anestesiologica. 2018; 84(11)
[Pubmed] | [DOI]
7 Ultrasound-guided lower forearm median nerve block in open surgery for trigger thumb in 1- to 3-year-old children: A randomized trial
Wei Liu,Jianxia Liu,Xingqin Tan,Shouyong Wang,Adrian Bosenberg
Pediatric Anesthesia. 2017;
[Pubmed] | [DOI]
8 Upper extremity nerve block: how can benefit, duration, and safety be improved? An update
Metha Brattwall,Pether Jildenstĺl,Margareta Warrén Stomberg,Jan G. Jakobsson
F1000Research. 2016; 5: 907
[Pubmed] | [DOI]
9 Postoperative pain control after arthroscopic rotator cuff repair
Carlos A. Uquillas,Brian M. Capogna,William H. Rossy,Siddharth A. Mahure,Andrew S. Rokito
Journal of Shoulder and Elbow Surgery. 2016;
[Pubmed] | [DOI]
10 Ultrasound-Guided Ulnar Nerve Block for Boxer Fractures
Erden Erol Ünlüer,Arif Karagöz,Seran Ünlüer,Orhan Oyar,Ugur Özgürbüz
The American Journal of Emergency Medicine. 2016;
[Pubmed] | [DOI]
11 Easier and Safer Regional Anesthesia and Peripheral Nerve Block under Ultrasound Guidance
Young Hoon Jeon
The Korean Journal of Pain. 2016; 29(1): 1
[Pubmed] | [DOI]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
   Abstract
  Introduction
   Potential Benefi...
   Potential Limita...
   Recommended Appl...
   Required Equipme...
   Specific Distal ...
  Conclusion
  Acknowledgments
   References
   Article Figures

 Article Access Statistics
    Viewed9207    
    Printed75    
    Emailed0    
    PDF Downloaded2405    
    Comments [Add]    
    Cited by others 11    

Recommend this journal