Abstract
The axillary approach to brachial plexus blockade provides satisfactory anaesthesia for elbow, forearm, and hand surgery and also provides reliable cutaneous anaesthesia of the inner upper arm including the medial cutaneous nerve of arm and intercostobrachial nerve, areas often missed with other approaches. In addition, the axillary approach remains the safest of the four main options, as it does not risk blockade of the phrenic nerve, nor does it have the potential to cause pneumothorax, making it an ideal option for day case surgery. Historically, single-injection techniques have not provided reliable blockade in the musculocutaneous and radial nerve territories, but success rates have greatly improved with multiple-injection techniques whether using nerve stimulation or ultrasound guidance. Complete, reliable, rapid, and safe blockade of the arm is now achievable, and the paper summarizes the current position with particular reference to ultrasound guidance.
Highlights
The axillary approach to brachial plexus was first demonstrated in 1884 by William Halsted when he injected cocaine under direct vision [1]
At the lateral border of the pectoralis minor muscle, the cords divide into terminal nerves of the brachial plexus: musculocutaneous, median, ulnar, radial, axillary, medial cutaneous nerve of arm (MCNA), and medial cutaneous nerve of forearm (MCNF), which along with the intercostobrachial nerve (ICB) provide the sensory and motor supply to the whole upper extremity (Figure 1)
A similar “donut” technique has been described by Imasogie et al [18], where the authors achieved successful block of the median, ulnar, and radial nerves by circumferential deposition of local anaesthetic around the axillary artery, instead of targeting them individually
Summary
The axillary approach to brachial plexus was first demonstrated in 1884 by William Halsted when he injected cocaine under direct vision [1]. The brachial plexus supplies the nerve supply to the upper limb and is formed by the ventral rami of the lower four cervical nerves and the first thoracic nerve It consists of roots, trunks, divisions, and cords. At the lateral border of the pectoralis minor muscle, the cords divide into terminal nerves of the brachial plexus: musculocutaneous, median, ulnar, radial, axillary, medial cutaneous nerve of arm (MCNA), and medial cutaneous nerve of forearm (MCNF), which along with the intercostobrachial nerve (ICB) provide the sensory and motor supply to the whole upper extremity (Figure 1). In relation to the axillary artery, the nerves are arranged as follows: (1) median-lateral and anterior, (2) ulnar-medial and anterior, and (3) radial-medial and posterior. The musculocutaneous nerve appears lateral and posterior to the artery
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