Clavicular Surgery Research Articles

Single injection technique with ultrasound-guided superficial cervical fascia block combined with brachial plexus block in clavicular surgery: a prospective randomized comparative trial

BackgroundTo investigate the effects of a single injection technique with ultrasound-guided superficial cervical fascia block combined with brachial plexus block in clavicular surgery.MethodsForty patients, 25 males and 15 females, aged 18–85 years with ASA class I or II underwent unilateral clavicular fracture internal fixation. The patients were randomly divided into a superficial cervical plexus block group (group S, n = 20) and a superficial cervical fascia block group (group F, n = 20). First, the brachial plexus of the intermuscular sulcus of all patients was blocked with an ultrasound-guided injection of one injection with 15ml 0.33% ropivacaine 15ml in both groups. Second, the superficial cervical plexus was blocked by another injection of 5-8ml 0.33% ropivacaine in group S, and the superficial cervical fascia was blocked by an injection with 5-8ml 0.33% ropivacaine in Group F. We evaluated operation time, onset time of anaesthesia, effective time and the grades of nerve block effect in the two groups. Additionally, we evaluated the incidences of local anaesthetic poisoning, hoarseness, dyspnoea, and postoperative nausea and vomiting, and the number of patients requiring remedial analgesia within 24 h. Repeated measurements were analysed by repeated data analysis of variance, and count data were compared by the χ2 test. A P value < 0.05 was considered statistically significant.ResultsThe operation time and onset time in Group F were significantly shorter than those in group S (P < 0.05); the effect of intraoperative block was better than that in group S (P < 0.05), and the effective time was significantly longer in group F than in group S (P < 0.05). However, no severe case of dyspnoea, local anaesthetic poisoning or hoarseness after anaesthesia occurred in either of two groups. There was no significant difference in the rate of postoperative salvage analgesia or that of postoperative nausea and vomiting between the two groups.ConclusionsThe application of the single injection technique with ultrasound-guided superficial cervical fascia block combined with brachial plexus block in clavicular surgery is beneficial because it shortens the operation time, has a faster onset, produces a more effective block and prolongs the longer analgesia time.Trial registrationChinese Clinical Trial Registry- ChiCTR2200064642(13/10/2022).

Ultrasonographic visualization of anatomical variations of the supraclavicular nerves.

Typical anatomy of the supraclavicular nerve (SCN) is described as originating from the cervical plexus and dividing into medial, intermediate, and lateral branches. The SCN is vulnerable to injury during clavicular surgery, leading to altered sensation post-operatively. There is also increasing interest in anesthetizing the SCN in shoulder or clavicular surgery. Utilizing a high-frequency (20 MHz) ultrasound probe, 20 healthy volunteers were scanned, giving data for 40 SCNs. For each nerve, anatomical course and branches were graphically plotted using a custom Python 3.8.12 program and Microsoft Excel. Of 40 nerves, only 19 (47.5%) demonstrated a typical course, with the rest showing considerable variability of branching patterns. Crossing branches (CBs) were found in 24 (60%) with a total of 54. Just over half (29, 54.7%) of these crossed the clavicle lateral to its midpoint, with 32 (59.6%) CBs having a diameter of ≥25% compared to that of the SCN main trunk. The distance from the mid-clavicular point at which the branches crossed the clavicle was recorded. This study demonstrated that over half the SCNs had atypical branching patterns with intra-volunteer variability. Preoperative mapping may be useful in preventing injury and subsequent numbness.

Ultrasound-guided superficial cervical plexus block combined with clavipectoral fascial plane block or interscalene brachial plexus block in clavicle surgery: a single-centre, double-blind, randomized controlled trial

The sensory innervation of the clavicle is complex, and the best regional block technology for clavicular surgery has yet to be determined. The purpose of this study was to compare the application of ultrasound-guided superficial cervical plexus block combined with clavipectoral fascial plane block verses interscalene brachial plexus block in clavicular surgery. Fifty patients undergoing internal fixation surgery for elective clavicle fractures were randomly divided into two groups (n = 25 for each group): group I and group II. Superficial cervical plexus block combined with clavipectoral fascial plane block was used in group I, and superficial cervical plexus block combined with interscalene brachial plexus block was used in group II. The primary outcome measure was the duration of analgesia. The duration of analgesia in group I was significantly longer than that in group II (P < 0.05). The modified Bromage scale function score in group II was lower than that in group I (P < 0.01). There was no significant difference in the skin acupuncture pain score 30 min after block and visual analog scale (VAS) scores at 6 and 12 h after surgery. However, the 24 h VAS score in group I was lower than that in group II (P < 0.05). The incidence of diaphragmatic paralysis was significantly increased in group II (P < 0.01). Ultrasound-guided superficial cervical plexus block combined with clavipectoral fascial plane block can be used for clavicular surgery. It has a long postoperative analgesia time, can retain the motor function of the involved upper limb and does not cause hemidiaphragmatic paresis.Clinical trial number and registry URL: Clinical Trials.gov; Trial registration number: ChiCTR2000039383; Date of registration: 25 October 2020.

Ultrasound-Guided Clavipectoral Block for Postoperative Analgesia of Clavicular Surgery: A Prospective Randomized Trial.

BackgroundClavicular fractures are commonly encountered in daily practice, and most cases are operated under general surgery. Until now, there has been a debate about the best approach to manage pain in such cases.ObjectivesWe aimed to evaluate whether ultrasound-guided clavipectoral block [clavipectoral fascial plane block (CPB)] would be safe and effective in cases with clavicular fractures.MethodsThis prospective randomized study included a total of 40 patients with clavicular fractures; they were divided into 2 groups. Group 1 included 20 cases who underwent CPB, and group 2 included 20 cases who underwent placebo block. Pain score, duration of analgesia, total analgesic consumption, and procedure-related complications were noted and recorded.ResultsDespite the comparable demographic data between the 2 groups, pain scores were significantly lower in group 1 than in group 2, starting from postanesthesia care unit (PACU) admission until 12 hours after the operation. Group 1 showed a significant reduction in 24-hour opioid consumption and significant prolongation of the duration of analgesia compared to the placebo. Patient satisfaction was significantly better in group 1 than in group 2. No block-related adverse events were recorded.ConclusionsCPB is a safe and effective regional technique that should be used for pain management after clavicular fixation surgery.

Ultrasound-Guided Clavipectoral Fascial Plane Block With Intermediate Cervical Plexus Block for Midshaft Clavicular Surgery: A Prospective Randomized Controlled Trial.

Regional anesthesia such as interscalene brachial plexus block (ISBPB) with intermediate cervical plexus block (ICPB) is generally a preferred choice for clavicular surgery. However, various studies have shown that these blocks, especially ISBPB, could cause phrenic nerve paralysis and decrease diaphragmatic motion. The study aimed to evaluate the efficacy of clavipectoral fascial plane block (CPB), an alternative technique to ISBPB, with ICPB, in reducing hemidiaphragmatic paralysis during midshaft clavicular surgery. Forty patients scheduled for right midshaft clavicular surgery were randomized (1:1) into an ultrasound-guided ISBPB with ICPB (BC) group or ultrasound-guided CPB with ICPB (CC) group. Five milliliter of 0.375% ropivacaine was used for ICPB, another 20 mL for ISBPB or CPB, and no administration of additional sedative or general anesthetic was planned. Primary outcome was measured by the incidence of hemidiaphragmatic paralysis using M-mode ultrasonography, while secondary outcomes were measured by bedside pulmonary function test, the success rate of block, the time required for the block procedure and onset of block, and motor block score in right upper extremity. In comparison with BC group, the incidence of hemidiaphragmatic paralysis postblock was decreased in CC group (50% vs 0%; P < .001), and measurement of bedside pulmonary function was significantly improved. There was a 100% success rate for anesthetic block in both BC and CC groups, and CC group showed lower motor block score in upper extremity and less block procedure time than BC group (7.1 ± 1.2 vs 3.2 ± 0.6 minutes; P < .001). Moreover, no significant differences were found between time of onset of block and other anesthetic complications in the 2 groups. Ultrasound-guided CPB with ICPB could significantly reduce hemidiaphragmatic paralysis and provide an adequate surgical anesthesia with fewer complications such as motor block in upper extremity during right midshaft clavicular surgery.

A Prospective Observational Study of the Efficacy of Combined Interscalene Block and Superficial Cervical Plexus Block using Peripheral Nerve Stimulator and Landmark-Based Technique, as a Sole Anesthetic for Surgeries on the Clavicle in the COVID-19 Pandemic.

Background:Fractures of the clavicle are usually operated under general anesthesia (GA) as they need dense anesthesia, and the airway is difficult to access intraoperatively. There is no established regional anesthesia (RA) technique for clavicular fractures, also as the innervation is contentious. Some studies have been done using RA techniques, but they are all small case numbers. RA is superior to GA in many ways, and we wished to avoid GA specifically during the COVID-19 pandemic.Aims:This study aimed to use a peripheral nerve stimulator and a landmark-based technique to give interscalene block (ISB) and superficial cervical plexus block (SCPB) as a sole anesthetic for clavicular fracture surgeries during the COVID-19 pandemic.Settings and Design:This was a prospective observational study in a tertiary care teaching hospital in eastern India.Materials and Methods:After approval from our ethics committee and informed consent, thirty patients of American Society of Anesthesiologists Class I or II, aged 18–65 years, after exclusion criteria were selected who had to undergo clavicular surgery. Three 10-mL syringes were made, each with 5 mL of 0.75% ropivacaine, 2 mL of 2% lignocaine with 1:200,000 adrenaline, and 3 mL of saline. Using the HNS Stimuplex (B. Braun Melsungen AG, Melsungen, Germany) nerve stimulator, 20 mL was given for an ISB and 5 mL for the SCPB. RA was considered successful if there was no conversion to GA and surgery could be performed.Results:With an onset time of 6.53 ± 2.17 min, good operating conditions were obtained in all our patients. Horner's syndrome was noted in two patients. Surgery was successfully carried out in all thirty patients under RA. Pain relief lasted postoperatively for 5 ± 0.92 h.Conclusion:ISB combined with SCPB is safe and effective as a sole anesthetic for clavicular surgery. We successfully avoided the use of a general anesthetic in these patients during the COVID-19 pandemic and gave them a safe and effective alternative.

Ultrasound-guided interscalene block combined with intermediate or superficial cervical plexus block for clavicle surgery: A randomised double blind study.

The complex innervation of the clavicle makes general anaesthesia a preferred technique for clavicular surgeries in current practice. The role and approach of regional anaesthesia remains unanswered. This study aims to delineate the relative effectiveness between interscalene brachial plexus block with either intermediate cervical plexus or superficial cervical plexus block (CPB) as the anaesthetics for clavicular surgery. A randomised, double-blind prospective study. Single-centre, tertiary care medical college and research institute. Fifty patients with American Society of Anesthesiologist's (ASA) grade I to III, aged 18 to 70 years, scheduled for clavicular surgery, during May 2018 to April 2019 were enrolled in this study. All patients received interscalene block with 10 ml of 0.5% bupivacaine. Patients were randomised to undergo additional ultrasound-guided intermediate CPB (Group-1) or superficial CPB (Group-2) with 10 ml of 0.5% bupivacaine. The block success rate, sensory block onset time, haemodynamic parameters, duration of postoperative analgesia and complications were noted. Categorical data were analysed using the chi-square test and Fisher's exact test. Continuous data were analysed using Student's t-test. In Group 1, block success was 100%. In Group 2, five patients failed to achieve adequate surgical anaesthesia (P = 0.02). The average sensory block onset time in Group 1 was 2.5 ± 0.4 min and was longer in Group 2, 4.3 ± 0.5 min (P < 0.001). There was no difference between the groups with respect to haemodynamic parameters and complications. The mean duration of postoperative analgesia was longer in Group 1 (7.5 ± 0.8 h) as compared with Group 2 (5.7 ± 0.4 h, P < 0.001). Ultrasound-guided combined interscalene and intermediate CPB had a better success rate, with faster sensory block onset time and prolonged postoperative analgesia as compared with interscalene and superficial CPB in patients undergoing clavicle surgery. Clinical trial registry of India (www.ctri.nic.in) - CTRI/2018/05/013785.

Utilization of regional anesthesia for open reduction and internal fixation of clavicular fractures is associated with increased same-day discharge and not readmissions

BackgroundRegional anesthesia is becoming increasingly used for analgesia in clavicular surgery. The purpose of the study is to examine same-day discharge and readmissions in patients with clavicular fractures receiving open...

Redefining clavipectoral fascial block for clavicular surgery: Response to Dr. Ince et al.

Redefining clavipectoral fascial block for clavicular surgery: Response to Dr. Ince et al.

Ultrasound-Guided Inter-scalene Brachial Plexus Block with Superficial Cervical Plexus Block Compared with General Anesthesia in Patients Undergoing Clavicular Surgery: A Comparative Analysis.

Background:General anesthesia is preferred for clavicular surgeries. With the advent of ultrasound-guided technology, interscalene brachial plexus block with superficial cervical nerve block has become a new option for providing intraoperative anesthesia and postoperative analgesia for surgeries of the clavicle.Aims and Objectives:The present study compares the ultrasound-guided interscalene brachial plexus nerve block combined with superficial cervical nerve block to general anesthesia in clavicular surgery.Settings and Design:This study was a randomized controlled trial in a tertiary care setting.Materials and Methods:A total of 60 patients between 18 and 60 years who were scheduled for clavicular surgeries were randomly and equally divided into Group B and Group G. Group B received ultrasound-guided interscalene brachial plexus block with superficial cervical nerve block. Group G received general anesthesia. Time duration between start of anesthesia to the incision time, intraoperative vitals, and time spent in postanesthesia care unit, postoperative pain scores, postoperative analgesic consumption, and complications were noted and compared.Statistical Analysis:Statistical analyses were done using SPSS software 20.0. Normality tests were applied, and accordingly, parametric and nonparametric tests were used to calculate the results.Results:The demographic data were comparable in both the groups. Time duration between start of anesthesia to the incision time was significantly more in Group B than in Group G. The time spent in postanesthesia care unit and postoperative pain scores were significantly more in Group G than Group B. Total postoperative opioid consumption was significantly less in Group B than in Group G.Conclusion:Ultrasound-guided interscalene brachial plexus block combined with superficial cervical nerve block is a safe and effective mode of anesthesia in comparison to general anesthesia for clavicle surgeries.

Disease and Illness

Commentary We are indebted to the surgeons who were curious enough to test their own biases. We are even more indebted to the patients who understand the value of clinical research enough to be randomly assigned to operative or nonoperative treatment so that future patients can make a more informed decision. As the authors point out, the key to interpreting this study is that the primary outcomes were the Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scores rather than fracture union. In spite of the fact that displaced clavicular fractures have difficulty healing and heal out of place without operative treatment (substantial disease or pathophysiology), patients treated with or without surgery have comparable arm-specific disability (comparable illness). Six (24%) of twenty-five nonoperatively treated fractures did not heal, but none of these patients had sufficient symptoms or disability to find surgery appealing. Three patients had symptoms related to malalignment of the fracture, and one underwent surgery. I can hear some of my American colleagues saying “Yeah. Maybe in Finland.” Finns may have exceptional adaptation and resilience—and if they do, we should make it a priority to figure out how to make these exceptional coping strategies accessible to all—but what I’ve always wondered in the United States is, “Where were all of the clavicular nonunions before?” I know that some will say that in the past, surgeons told patients with a clavicular nonunion that nothing could be done and left them to suffer. But I’ve met patients with clavicular nonunions that they were not aware of, and patients with diagnosed nonunions that were not very bothersome. On one visit to the Cleveland Museum of Natural History, 200 clavicles from about 100 years ago had been laid out, and I was impressed that about fifteen of them had fractures and there were two or three nonunions. I think that clavicular nonunion may pass my “cave person” rule. What happened to people with displaced clavicular fractures that failed to heal when there were no doctors to see them, no x-rays to image them, and no implants to fix them? I think it’s safe to say that “cave people” with clavicular nonunions were able to care for themselves well without any effect on life span. That’s not to say that clavicular nonunions don’t affect upper extremity use. Even though patients with nonunion did not request surgery, they did have greater symptoms and disability as measured by the DASH score. The problems associated with a clavicular nonunion seem too subtle on average to be measured by the Constant score, which primarily addresses motion and strength. I’d like to highlight a few other things. First, the handling of missing data is important as it can introduce bias. An initial analysis of the results from a recent Canadian Orthopaedic Trauma Society trial appeared to show a significant difference in union rate between treatment groups, but a reanalysis using last-carried-forward data showed no significant difference1. Researchers should always remember to specify how they will handle missing data prior to enrolling the first patient. Second, the clavicular surgery in this study was performed with subperiosteal stripping and fixation using a non-locked 3.5-mm reconstruction plate placed in the anterior position with at least three screws in each fragment. One plate bent and another broke, but both of these fractures healed. More data are needed to determine the degree to which muscle and periosteal attachments should be preserved and the optimal type and position of the plate, but the evidence to date suggests that technical details are relatively unimportant. Finally, substantial fracture displacement (dichotomized as a displacement of >1.5 bone widths) was the only risk factor for nonunion among nonoperatively treated fractures. Patients and surgeons should decide together how to treat a displaced clavicular fracture. I recommend the development of a decision aid in the form of a video or an interactive web site that presents the current best evidence to patients in a way that they can understand2. Patients can use this aid to clarify their treatment goals and preferences and come to a decision that suits them. Boiled down to one sentence, the best evidence to date is that fracture-healing will not occur in about one in four patients (one in four in this study) with a displaced diaphyseal fracture of the clavicle that is treated nonoperatively (the greater the displacement, the greater the risk), but—at least in Finland—most don’t have enough symptoms or disability to request later operative treatment.