Thermal Imaging to Predict Failed Supraclavicular Brachial Plexus Block: A Prospective Observational Study

The aim of this study was to compare the combined ultrasound-guided supraclavicular brachial plexus block (SCB) and distal median, radial, and ulnar nerve blocks, with the supraclavicular block alone. Sixty-two patients undergoing upper extremity surgery were randomized to supraclavicular only (Group S, n=31) or supraclavicular+distal (Group SD, n=31) group. Patients in Group S received 32mL of 1.5% lidocaine+epinephrine 5µg/mL, while those in Group SD received 20mL of 1.5% lidocaine+epinephrine 5µg/mL followed by distal median, radial, and ulnar nerve blocks using equal volumes of 2% lidocaine+0.5% levobupivacaine (4mL/nerve). Sensory and motor blocks of the ulnar, median, radial and musculocutaneous nerves were assessed every 5min starting at the 10th minute. The imaging, needling and performance times were recorded. Also, the onset and anesthesia-related times, need for analgesic and first analgesic times, were noted. In Group SD, the anesthesia onset [15 (10-25) vs. 20 (15-30) min, p<0.001] and anesthesia related times [16.6 (10.7-28.2) vs. 22 (15.9-33.7) min, p<0.001] were significantly shorter than those of Group S. Additionally, the analgesic requirement was lower in Group SD (56.7 vs. 88.5%, p=0.009), while among the patients who required analgesic, the first analgesic time was longer in Group SD in comparison to Group S [625 (347-1764) vs. 315 (233-746) min p<0.001]. The addition of distal median, radial, and ulnar nerve blocks to SCB shortens anesthesia-related time and anesthesia onset time when compared with a SCB alone.

A misdiagnosis of multifocal motor neuropathy

Summary An analysis has been made of the incidence and distribution of the lesions occurring in 301 cases of peripheral nerve injuries. Reference should be made to the text for detailed information relating to the incidence and distribution of the lesions in individual nerves. The following significant points have emerged from this analysis: 1 In the upper limb injuries of single nerves outnumbered combined lesions by six to one. 2 Lesions in the upper limb were approximately three times as numerous as in the leg. 3 With the exception of brachial plexus lesions, gunshot lesions greatly outnumbered those due to other causes, though in the case of single lesions in the upper limb the former did not predominate to the extent that might be anticipated. 4 Gunshot lesions of the brachial plexus and those due to other causes occurred in about equal proportions, but whereas the former were three times as numerous on the right, the latter occurred twice as frequently on the left. 5 Gunshot lesions of the sciatic nerve were approximately nine times as numerous as those due to other causes, where, incidentally, the incidence was very low. 6 The percentage incidence of concomitant bone injury in the various lesions was as follows: radial, 52; median, 25; ulnar, 38; and sciatic, 37. 7 Lesions due to gunshot wounds: (a) Ulnar nerve lesions predominated. This nerve was more frequently the common factor in combined lesions than either the radial or median nerve. (b) Lesions of the radial, median and sciatic nerves occurred in about equal proportions. (c) The incidence was approximately the same on the two sides for the radial and median nerves, but was greater on the left for the ulnar, posterior interosseous and sciatic, and on the right for the brachial plexus. (d) Gunshot lesions, when totalled, occurred with equal frequency on the two sides in the upper limb, but in the leg they were twice as numerous on the left. (e) The number of radial nerve lesions, single and combined, associated with a fracture greatly exceeded that in which there was no bone injury, while the reverse obtained in the case of the median, ulnar and sciatic nerves. 8 Lesions due to other causes: (a) Lesions of the ulnar nerve were double those of the median or radial nerves, which were involved in about equal proportions. (b) In combined lesions the radial, median and ulnar nerves were involved in approximately equal proportions. (c) Lesions occurred more frequently on the right in the case of the radial, median and ulnar nerves and on the left in plexus lesions.

A Young Man With Acute-Onset Bilateral Arm Weakness After Traumatic Sciatic Neuropathy: A Clinical Vignette.

Objective To compare the anesthetic effects of interscalene brachial plexus combined with ulnar nerve and axillary brachial plexus block guided by nerve stimulator. Methods Eighty patients belonging to ASA Ⅰ or Ⅱ and undergoing replantation of severed palm or wrist were divided randomly into 2 groups, Each group had 40 patients. Nerve stimulator guided nerve block. Patients in groupⅠreceived interscalene brachial plexus combined with ulnar nerve block, and those in group Ⅱ received axillary brachial plexus block. The onset time, hold time, tourniquet tolerance of radial nerve, median nerve and ulnar nerve of two groups was recorded. The phrenic nerve block, Horner's syndrome and recurrent laryngeal nerve block was compared between two groups. Results The onset time of radial nerve, median nerve and ulnar nerve in group Ⅰ was (5.13 ± 0.76), (7.13 ± 1.04), (3.23 ± 0.62) min, in group Ⅱ was (9.23 ± 1.61), (12.35 ± 1.76), (8.83 ± 1.13) min, and there were significant differences (P < 0.05). The excellent rates of sensory block of radial nerve, median nerve and ulnar nerve in group Ⅰ were 90.0% (36/40), 85.0% (34/40), 97.5% (39/40), in group Ⅱ were 72.5% (29/40), 65.0%(26/40), 70.0%(28/40), and there were significant differences (P < 0.05). The full rates of motor block of radial nerve, median nerve and ulnar nerve in group Ⅰwere 75.0%(30/40), 37.5%(27/40), 80.0%(32/40), in group Ⅱ were 47.5%(19/40), 40.0%(16/40), 45.0%(18/40), and there were significant differences (P < 0.05). The tourniquet tolerance rate in group Ⅰ was significantly higher than that in group Ⅱ: 90.0%(36/40) vs. 62.5%(25/40), P < 0.05. In group Ⅰ, phrenic nerve block occurred in 2 patients, and Horner syndrome occurred in 1 patient. None had laryngeal recurrent nerve block in both group. Conclusions The interscalene brachial plexus combined with ulnar nerve block guided by nerve stimulator is more suitable for a long time microsurgery of the palm or wrist, because it takes action faster, has better sensory and motor block effects, improves the rate of tourniquet tolerance without increasing untoward reaction. Key words: Brachial plexus; Anesthetics, local; Ulnar nerve; Nerve stimulator

Familiarity with the localization of the nerves in the neurovascular bundle that constitutes the axillary segment of the brachial plexus (BP) is important when applying ultrasound (US)-guided block anesthesia. Therefore in this study we aimed to delineate the anatomy of the median, radial, and ulnar nerves of the BP at the axilla with US and electrical stimulation. The study included 60 patients who were scheduled to undergo upper-arm surgery with axillary block anesthesia. Prior to anesthesia, ulnar, radial, and median nerves were localized with US using a 12-h quadrant identification system that placed the axillary artery (AA) in the middle. The nerves were then functionally tested using a neurostimulator. The radial nerve was mainly located in the 4-6 o'clock arc (posterior and posteromedial to AA) in 50 (83 %) of patients. Ulnar nerve was mainly at the 12-3 o'clock arc (anteromedial to AA) in 51 (85 %) of patients. Ulnar nerve showed a second peak at 9-10 o'clock quadrant (anterolateral to AA) in 11 % (7) of patients. Median nerve location was most common in the 12 and 9 o'clock arc (anterior and anterolateral to AA) in 53 (88 %) of the patients. Ultrasound is a useful tool for depicting BP anatomy in the axillary fossa prior to block anesthesia. Median, ulnar, and radial nerves form a highly consistent triangular pattern around the axillary artery that is easily recognizable with US.

Variant location of the musculocutaneous nerve during axillary nerve block

Single infraclavicular injection

P-NU003. Estimation of cross-sectional area reference values of nerves in the upper and lower extremities using ultrasonography in the Indian population

The ulnar nerve upper limb neurodynamic test (ULNT3) uses upper limb positioning to investigate symptoms arising from the ulnar nerve. It is proposed to selectively increase tension of the nerve; however, this property of the test is not well established. The aim of this study was to determine the upper limb position that results in: (1) the greatest tension of the ulnar nerve and (2) the greatest difference in tension between the ulnar nerve and the other 2 major nerves of the upper limb: median and radial. This was an observational cadaver study. Tension (in newtons) of the ulnar, median, and radial nerves was measured simultaneously using 3 buckle force transducers in 5 upper limb positions in 10 embalmed human cadavers (N=20 limbs). Repeated-measures analysis of variance (ANOVA) with Bonferroni post hoc tests determined differences in tension among nerves and among limb positions. The addition of shoulder horizontal abduction (H.Abd; 12.62 N; 95% confidence interval [95% CI]=10.76, 14.47) and combined shoulder abduction and internal rotation (H.Abd+IR; 11.86 N; 95% CI=9.96, 13.77) to ULNT3 (scapular depression, shoulder abduction and external rotation, elbow flexion, forearm pronation, and wrist and finger extension) produced significantly greater ulnar nerve tension compared with the ULNT3 alone (8.71 N; 95% CI=7.25, 10.17). The ULNT3+H.Abd test demonstrated the greatest difference in tension among nerves (mean difference between ulnar and median nerves=11.87 N; 95% CI=9.80, 13.92; mean difference between ulnar and radial nerves=8.47 N; 95% CI=6.41, 10.53). These results pertain only to the biomechanical plausibility of the ulnar nerve neurodynamic test and do not account for other factors that may affect the clinical application of this test. The ULNT3+H.Abd is a biomechanically plausible test for detecting peripheral neuropathic pain related to the ulnar nerve. In situations where the shoulder complex will not tolerate the combination of shoulder external rotation in abduction, performing upper limb neurodynamic tests with internal rotation instead of external rotation is a biomechanically plausible alternative.

Throughout the glabrous representation in Area 3b, electrical stimulation of the dominant (median or ulnar) input produces robust, short-latency excitation, evident as a net extracellular "sink" in the Lamina 4 current source density (CSD) accompanied by action potentials. Stimulation of the collocated nondominant (radial nerve) input produces a subtle short-latency response in the Lamina 4 CSD unaccompanied by action potentials and followed by a clear excitatory response 12-15 ms later. Laminar response profiles for both inputs have a "feedforward" pattern, with initial activation in Lamina 4, followed by extragranular laminae. Such corepresentation of nondominant radial nerve inputs with the dominant (median or ulnar nerve) inputs in the glabrous hand surface representation provides a likely mechanism for reorganization after median nerve section in adult primates. To investigate this, we conducted repeated recordings using an implanted linear multi-electrode array straddling the cortical laminae at a site in "median nerve cortex" (i.e., at a site with a cutaneous receptive field on the volar surface of D2 and thus with its dominant afferent input conveyed by the median nerve) in an adult squirrel monkey. We characterized the baseline responses to median, radial, and ulnar nerve stimulation. We then cut the median nerve and semichronically monitored radial nerve, ulnar nerve and median nerve (proximal stump) evoked responses. The radial nerve response in median nerve cortex changed progressively during the weeks after median nerve transection, ultimately assuming the characteristics of the dominant nerve profile. During this time, median, and ulnar nerve profiles displayed little or no change.

SP47 Upper limb surgery: how do I do it?

SUMMARYCarpal tunnel syndrome is the most common upper extremity compression neuropathy caused by compression of the median nerve at the wrist. Along with motor and sensory fibers, sympathetic fibers also pass through the median nerve, playing an important role in the regulation of blood flow to the skin which interacts between the body interior and its environment. The aim of this study was to examine the preand postoperative correlation between skin temperature changes in the area innervated by compressed median nerve compared to the skin areas innervated by radial and ulnar nerve and median nerve of the unaffected hand. The study included 16 patients with carpal tunnel syndrome with an indication for open carpal tunnel decompression. Skin temperature was measured preoperatively, at 2-week, 2and 6-month follow-ups on the areas innervated by median, ulnar and radial nerve of the affected hand and median nerve of the non-affected hand. On the affected hand, median nerve innervated skin temperature showed maximum increase at 2-month follow-up before decreasing to a level higher than preoperatively. Radial nerve innervated skin temperature was lower than the preoperative value at 2-week follow-up, increasing to higher levels afterwards. Ulnar nerve temperature followed the curve of the median nerve innervated skin at all follow-ups. Unaffected median nerve innervated skin temperature increased at all follow-ups compared to the preoperative values. In conclusion, two or even five additional measurements should be made after at least one year. The results should be correlated with clinical and electromyoneurography recovery.

Objective: The purpose of this study was to assess the measurement of nerve gliding, resulting from joint motion and changes of upper extremity position. Methods: The upper extremities of ten fresh human cadavers were dissected to delineate relationship between the positioning of upper extremity and gliding distance of nerves. Nerve mobilization – stretching therapy (SMG) techniques are mentioned in the literature for each of the radial, medial and ulnar nerves. Nerve excursion secondary to motion of shoulder, elbow, wrist, and fingers was evaluated at the elbow via SMG application. Initially extremities and the head were positioned with anatomic position. For the median nerve, extremity position was elbow extension, forearm supination, wrist and finger extension. For the ulnar nerve upper extremity position was elbow flexion, full forearm pronation, and wrist and finger dorsiflexion. Finally, the excursion of the radial nerve was observed with the position of elbow extension, forearm pronation, wrist and finger palmar flexion. Results: The ulnar, radial and median nerves excursion were 13.5, 29.75 and 11.37 mm respectively. Conclusion: In this study, longitudinal excursion movement of radial, median and ulnar nerves was observed with movements of shoulder, elbow, wrist and finger joints in different positions. SMG techniques can contribute to the mobilization of nerve tissue in orthopedic rehabilitation.

The contribution of the intrinsic muscles to grip and pinch strength.