Lateral infraclavicular plexus block vs. axillary block for hand and forearm surgery

Abstract

Based on the safe landmark and feasibility of this procedure and the additional spectrum of nerve block achieved, the application of lateral infraclavicular technique has to be reconsidered in clinical practice.

The infraclavicular brachial plexus block by the coracoid approach is clinically effective: an observational study of 150 patients

“…Finger flexion is considered by Borgeat 10 as the motor response giving the best block results because, when this motor response is obtained, the needle is located approximately at the centre of the cords. We, and others, 3,16 10 mid distance from jugular notch to ventral acromial process, 1 cm caudal, needle 45° directed to axillary artery Rodriguez: 3 1.5 cm caudal and 1 cm medial to the coracoid process, needle perpendicular Whiffler: 5 needle perpendicular at a point medial and caudal to the coracoid process, on a line from the subclavian artery to the axillary artery Wilson: 6 2 cm caudal and medial to the coracoid process, needle perpendicular Kapral: 7 2-3 cm caudal to the coracoid process, needle perpendicular Koscielniak-Nielsen: 15 2-3 cm caudal to the coracoid process Mehrkens, 16 Kilka: 8 just under mid-clavicle, needle perpendicular Salazar: 9 junction 1/3 lateral-2/3 medial of the clavicle, 1 finger breadth below this point and medial to the coracoid, needle directed caudal, posterior and medial with this notion which is not consistently integrated in the literature. Even in a recent review article on neurostimulation, the authors stated (without the support of clinical data) that a musculocutaneous motor response is adequate while using the infraclavicular approach.…”

“…Several favourable characteristics of this approach can be highlighted: 1) contrary to the axillary block, the arm to be anesthetized does not need to be in a 90 abduction and a 90 elbow flexion. Arm positioning is thus less painful for patients with fractures; 7 2) the technique relies on the identification of the coracoid process, an easily palpable landmark, even in obese patients; 3) this single injection block is time efficient. It takes an average of five minutes to execute, which is shorter than that reported for the axillary multiple injection technique: eight minutes, 11 ten minutes; 12 4) this block gives excellent results with 91% of the patients having analgesia of the five terminal nerves distal to the elbow.…”

“…The optimal infraclavicular approach remains unclear. The vertical infraclavicular approach 8,16 seems to have gained in popularity in Central Europe, 7 but its more medial needle insertion site makes it less appealing because, theoretically, it carries a greater risk of pneumothorax. We report one case of pneumothorax (incidence 0.7%) in a thin, short stature 47 kg woman.…”

“…4 There have been, however, numerous descriptions of new infraclavicular approaches varying in their site of needle insertion, success and complication rate. [5][6][7][8][9][10] Wilson et al 6 described in 1998 an infraclavicular coracoid technique that we have since then adopted in our community hospital. The aim of their study was to use magnetic resonance imaging and cadaveric sections to establish the orientation and depth of needle placement required to reach the brachial plexus by this coracoid approach.…”

Upper Extremity Blocks

“…This block anesthetizes the axillary and musculocutaneous nerves more reliably than does the axillary approach. 67,68 Infraclavicular block techniques have the advantage of not requiring a specific arm position during placement, which is useful for patients with limited arm motion because of pain, casts, or dressings. 69 The infraclavicular approach is frequently used for continuous perineural catheter placement because the catheters reliably remain in place during use.…”