Clavicle Surgery Research Articles

Diaphragm-sparing brachial plexus blocks: a focused review of current evidence and their role during the COVID-19 pandemic.

Given that COVID-19 can severely impair lung function, regional anesthesia techniques avoiding phrenic nerve paralysis are relevant in the anesthetic management of suspected/confirmed COVID-19 patients requiring shoulder and clavicle surgical procedures. The objective of this review is to provide an overview of recently published studies examining ultrasound-guided diaphragm-sparing regional anesthesia techniques for the brachial plexus (BP) to favor their preferent use in patients at risk of respiratory function compromise. In the last 18 months, study findings on various diaphragm-sparing regional anesthesia techniques have demonstrated comparable block analgesic effectivity with a variable extent of phrenic nerve paralysis. The impact of hemi-diaphragmatic function impairment on clinical outcomes is yet to be established. Existing diaphragm-sparing brachial plexus regional anesthesia techniques used for shoulder and clavicle surgery may help minimize pulmonary complications by preserving lung function, especially in patients prone to respiratory compromise. Used as an anesthetic technique, they can reduce the risk of exposure of healthcare teams to aerosol-generating medical procedures (AGMPs), albeit posing an increased risk for hemi-diaphragmatic paralysis. Reducing the incidence of phrenic nerve involvement and obtaining opioid-sparing analgesia without jeopardizing efficacy should be prioritized goals of regional anesthesia practice during the COVID-19 pandemic.

PECS1 with superficial cervical plexus block for clavicle surgery analgesia.

PECS1 with superficial cervical plexus block for clavicle surgery analgesia.

Clavipectoral fascia plane block for analgesia after clavicle surgery

Clavipectoral fascia plane block for analgesia after clavicle surgery

Combined Interscalene and Superficial Cervical Plexus Block for Clavicle Surgery: Case Series

General Anesthesia is preferred over regional anesthesia in clavicle surgery. We report 3 cases of clavicle fracture which was performed under USG guided combined Interscalene and Superficial cervical plexus block. All the patients were comfortable and there was no need for additional analgesia. Thus regional anesthesia can be used as a sole anesthetic technique in patients with clavicle fracture and can be an alternative where general anaesthesia and its adverse effects needs to be avoided.
 Keywords: clavicle fracture; interscalene brachial plexus block; superficial cervical plexus block. Correspondance: Dr.

A Comparison of Combined Superficial Cervical Plexus Block and Interscalene Brachial Plexus Block with General Anesthesia for Clavicle Surgery: Pilot Trial

A Comparison of Combined Superficial Cervical Plexus Block and Interscalene Brachial Plexus Block with General Anesthesia for Clavicle Surgery: Pilot Trial

Ultrasound guided selective upper trunk block for clavicle surgery.

Ultrasound guided selective upper trunk block for clavicle surgery.

Comparison of Ultrasound Guided Interscalene and Supraclavicular Brachial Plexus Block for Clavicle Fracture Surgery

Introduction:The clavicle has dual nerve supply from the brachial plexus and cervical plexus. The interscalene brachial plexus block combined with superior cervical plexus block is frequently used for the clavicle surgery. This study was conducted to compare ineterscalene approach with the supraclavicular approach for brachial plexus block used for clavicle surgery Methodology:This was prospective comparative study conducted for two years in tertiary care hospital. Sixty patients with clavicle fracture with ASA I and II were randomly divided into two equal groups; ISBPB (interscalene approach) and SCBPB (supraclavicular approach). Both of these blocks were combined with superior cervical plexus block. Ultrasound was used to perform all the blocks. Primary outcome for the comparison was block characteristics, which included sensory and motor block onset, duration, and block satisfaction. The secondary variables used for comparison were analgesic properties and complications. Results: Supraclavicular brachial plexus had rapid onset of sensory and motor block and was statistically significant (P<0.05) as compared to interscalene approach. Similarly, SCBPB had significantly longer duration of sensory block (P=0.003). The duration of motor block was comparable between the blocks. The intraoperative pain score (VAS), requirement of rescue analgesia with in 24 hours of surgery and complications related with the procedures were comparable between the two groups. Majority of the patients were satisfied with either of the approach for brachial plexus block. Conclusion: Supraclavicular brachial plexus block combined with superior cervical plexus block provided equally effective and adequate anesthesia and analgesia for clavicle surgery with comparable complications as compared to interscalene approach.

Regional Anaesthesia in Clavicle Surgery

In routine practice, regional anaesthesia is less commonly used for clavicular fracture compared to general anaesthesia. We report two cases of clavicle fracture for which operative treatment was done under combined superficial cervical plexus and interscalene brachial plexus block. In both the cases combination of ropivacaine and dexmeditomidine was used for block. Both the patients exhibited comfort and there was no additional analgesic demand in both the cases. Thus combination of interscalene and superficial cervical plexus block can prove to be useful in patients with clavicle fracture where administration of general anaesthesia and its adverse effects could be avoided.

Extrafascial injection for interscalene brachial plexus block reduces respiratory complications compared with a conventional intrafascial injection: a randomized, controlled, double-blind trial

BackgroundHemidiaphragmatic paresis after ultrasound-guided interscalene brachial plexus block is reported to occur in up to 100% of patients. We tested the hypothesis that an injection lateral to the brachial plexus sheath reduces the incidence of hemidiaphragmatic paresis compared with a conventional intrafascial injection, while providing similar analgesia. MethodsForty ASA I-III patients undergoing elective shoulder and clavicle surgery under general anaesthesia were randomized to receive an ultrasound-guided interscalene brachial plexus block for analgesia, using 20 ml bupivacaine 0.5% with epinephrine 1:200 000 injected either between C5 and C6 within the interscalene groove (conventional intrafascial injection), or 4 mm lateral to the brachial plexus sheath (extrafascial injection). The primary outcome was incidence of hemidiaphragmatic paresis (diaphragmatic excursion reduction >75%), measured by M-mode ultrasonography, before and 30 min after the procedure. Secondary outcomes were forced vital capacity, forced expiratory volume in 1 s, and peak expiratory flow. Additional outcomes included time to first opioid request and pain scores at 24 h postoperatively (numeric rating scale, 0–10). ResultsThe incidences of hemidiaphragmatic paresis were 90% (95% CI: 68–99%) and 21% (95% CI: 6–46%) in the conventional and extrafascial injection groups, respectively (P<0.0001). Other respiratory outcomes were significantly better preserved in the extrafascial injection group. The mean time to first opioid request was similar between groups (conventional: 802 min [95% CI: 620–984 min]; extrafascial: 973 min [95% CI: 791–1155 min]; P+0.19) as were pain scores at 24 h postoperatively (conventional: 1.6 [95% CI: 0.9–2.2]; extrafascial: 1.6 [95% CI: 0.8–2.4]; P+0.97). ConclusionsUltrasound-guided interscalene brachial plexus block with an extrafascial injection reduces the incidence of hemidiaphragmatic paresis and impact on respiratory function while providing similar analgesia, when compared with a conventional injection. Clinical trial registrationNCT02074397.

Combined interscalene-superficial cervical plexus block for clavicle surgery: an easy technique to avoid general anesthesia

Combined interscalene-superficial cervical plexus block for clavicle surgery: an easy technique to avoid general anesthesia

Clavicle surgery - a rare cause of venous air embolism

1Pingtung Hospital, Ministry of Health and Welfare, Dept of Anaesthesiology, Pingtung City, Taiwan, Republic of China, 2Kaohsiung Medical University Hospital, Dept of Anaesthesiology, Kaohsiung City, Taiwan, Republic of China

Efficacy of ultrasound-guided combined C5 and superficial cervical plexus block in patients undergoing clavicle surgery

Objective To evaluate the efficacy of ultrasound-guided combined C5 and superficial cervical plexus block in patients undergoing clavicle surgery.Methods Sixty ASA physical status Ⅰ or Ⅱ patients,scheduled for elective clavicle surgery,were randomly divided into 2 groups (n =30 each) using a random number table:injection with 10 ml local anesthetic guided by ultrasound group (group U),and injection with 10 ml local anesthetic guided by anatomical landmark group (group A).A mixture of 0.375 ％ levobupivacaine and 1.0％ lidocaine was used.The time spent performing the block onset time of analgesia,onset time of analgesia in the medial border,midpoint and lateral border of the clavicle and duration of analgesia were measured.The effectiveness of block (excellent,good,failure) was assessed.The complications were observed.Results Compared with group A,the time spent performing the block was significantly prolonged,the onset time of analgesia in the lateral border and midpoint of the clavicle was shortened,the rate of excellent anesthesia was increased,and the duration of analgesia was prolonged in group U (P ＜ 0.05).No complications occurred in group U,while vascular puncture occurred in 3 cases,and one patient developed mild toxic reaction in group A.Conclusion Ultrasound-guided combined C5 and superficial cervical plexus block provides better block,with faster onset time of analgesia in the lateral border and midpoint of the clavicle,longer duration of analgesia and fewer complications as compared with that guided by anatomical landmarks in patients undergoing clavicle surgery. Key words: Ultrasonography ; Clavicle ; Brachial plexus ; Cervical plexus ; Nerve block

Fatal Air Embolus During Internal Fixation of the Clavicle: A Case Report.

Fractures of the clavicle constitute 2.6% of all adult fractures1. There is an increasing trend toward fixation of midshaft fractures, the most common subgroup2,3. Techniques include plate fixation, intramedullary screw fixation, and elastic nail osteosynthesis. Reported complications include wound dehiscence, infection, arterial injury4-7, and neurological injury8. An air embolus can occur as air enters from the surgical site into the venous system down a pressure gradient9. Diagnosis is difficult; outcomes range from subclinical to fatal and relate to the volume and rate of entrainment. An embolus can obstruct the right ventricular outflow and is associated with high mortality. It is particularly frequent with beach-chair positioning during posterior fossa neurosurgery10. To our knowledge, no prior report of this phenomenon exists in the context of clavicle surgery, despite the risks involved with patient positioning and surgical anatomy. We report a fatal case of air embolus secondary to subclavian vein injury during fixation of a midshaft clavicular fracture (performed by an independent surgeon) and suggest ways to prevent this complication. The family was informed that data concerning the case would be submitted for publication, and they provided consent. A thirty-four-year-old man fell from a boat and sustained an isolated displaced midshaft clavicular fracture. He was referred to an orthopaedic surgeon. Approximately six weeks later, he had no clinical or radiographic signs of healing, and he underwent open reduction and internal fixation. A general anesthetic was administered, and the airway was secured with a laryngeal mask. No nitrous oxide was used. A cervical block was administered. The patient was positioned without the head up, but a sandbag was placed under the affected shoulder. The clavicle was exposed with use of a straight incision in the line of the …

Fatal pulmonary embolism after surgery for a clavicle fracture: A case report

Patients undergoing upper extremity surgery generally have a low risk of pulmonary embolism. We encountered a rare case of fatal pulmonary embolism after surgical treatment of a clavicle fracture. A 46-year-old man fell off the roof of his car and suffered fractures of the left clavicle, temporal bone and ribs, as well as cerebral and lung contusions. He was admitted to a local hospital, and was later transferred to our hospital for surgical treatment of the clavicle fracture at 6 days after injury. He had no dyspnea and was ambulant. On day 7 after the injury, open reduction and internal fixation of the clavicle fracture using a plate and screws were performed under general anesthesia. Although surgery was uneventful, the patient had bradycardia postoperatively that progressed to cardiopulmonary arrest, which required resuscitation and intubation. Spontaneous cardiac output was restored 10 minutes after cardiac arrest, but the GCS score was E1V1M2. Enhanced CT of the chest revealed a 15 mm defect in the right pulmonary artery, leading to a diagnosis of pulmonary embolism. Thrombolytic therapy was started immediately. However, the patient’s condition worsened and he died 20 days postoperatively. We suggest that use of mechanical and chemical thromboprophylaxis should be considered for clavicle surgery.

‘Neck-Line’ Incision for Open Reduction and Internal Fixation of the Clavicle

Conventional incisions for clavicle surgery are made transversely along the clavicle. These often remain prominent. We propose a ‘neck-line’ incision (Fig. 1) closer to the sagittal plane, more aligned with Langer's lines, resulting in a more aesthetic outcome than conventional incisions. The cutaneous innervation of the clavicular region, via subclavicular branches (C4, C5), travels typically in the sagittal plane under the platysma; an incision closer to this plane may reduce postoperative sensory loss. The incision allows adequate exposure of the clavicle for surgical fixation due to tissue mobility, and patients can conceal the scar more effectively with their clothes. Figure 1 The ‘neck-line’ incision post surgery.