Purpose: Percutaneous transluminal angioplasty for forearm arteriovenous fistula stenosis is frequently associated with significant pain, which may hinder patient cooperation. Ultrasound-guided cutaneous nerve blocks were evaluated as an alternative analgesic method for percutaneous transluminal angioplasty in forearm arteriovenous fistula, with the aim of reducing pain without motor paralysis or systemic complications.Material and Methods: This retrospective, single-center study included 77 patients who underwent percutaneous transluminal angioplasty for forearm arteriovenous fistula stenosis with ultrasound-guided cutaneous nerve block using lidocaine in October 2024. Target nerves included the lateral antebrachial cutaneous nerves, the superficial branch of the radial nerve, and/or the medial antebrachial cutaneous nerves. We retrospectively collected data on block time, percutaneous transluminal angioplasty duration, lidocaine volume, complications, presence or absence of postanesthetic motor paralysis, and analgesic efficacy. Analgesic efficacy was graded as excellent, good, or poor, with “poor” defined as pain necessitating supplemental local infiltration anesthesia for adequate relief.Results: The mean block preparation time was 2.1 ± 0.5 min, and the percutaneous transluminal angioplasty duration was 27.3 ± 9.2 min. The mean volume of 1% lidocaine used was 2.6 ± 1.1 mL. Minor hematomas were observed in eight cases. No patient experienced postanesthetic motor paralysis. Analgesia was rated excellent in 57.1% of patients and good in 29.9%, while poor analgesia occurred in only 12.9%. A superficial branch of the radial nerve block improved outcomes in distal forearm lesions.Conclusions: Ultrasound-guided cutaneous nerve blocks provide rapid, effective, and motor-sparing analgesia for percutaneous transluminal angioplasty of forearm arteriovenous fistula stenosis, making them suitable for outpatient use and warranting further prospective evaluation.

ABSTRACTBackgroundThe initial treatment for distal forearm fractures, including Colles' fractures, involves closed reduction, for which effective pain management is essential. In Colles' fractures, achieving a satisfactory closed reduction may eliminate the need for surgical intervention. While ultrasound‐guided nerve blocks are effective, hematoma blocks (HB) are often favored due to their feasibility in the emergency care setting. Further research comparing treatment outcomes is warranted.MethodsIn a multicentre randomised controlled trial, adults with distal forearm fractures were assigned to either ultrasound‐guided blocks of the radial and median nerves (US) or HB for closed fracture reduction. The primary endpoint was satisfactory fracture reduction. Secondary endpoints were secondary fracture dislocation, self‐reported pain, and time spent in the emergency department.ResultsAmong 238 patients with Colles' fracture, 117 received US and 121 received HB. Satisfactory fracture reduction was achieved in 73 (62%) and 49 (40%) patients, respectively (p = 0.01). Surgical correction was conducted in 61 (52%) patients in the US group, contrasting 80 (66%) patients in the HB group (p = 0.03). During the fracture reduction, no difference in self‐reported pain was observed (p = 0.21) for patients with distal forearm fractures (n = 247). The median time from block application to fracture reduction was 45 min in the US group and 25 min in the HB group (p < 0.01).ConclusionUltrasound‐guided median and radial nerve blocks had a higher success rate for Colles' fracture reduction than the hematoma block group. The influence of anesthetic techniques on the eventual need for surgery requires further investigation.

This prospective, experimental, randomised, assessor-blinded cadaveric study was undertaken to describe the sono-anatomical features of the radial, ulnar, median and musculocutaneous (RUMM) nerves in rabbits and to develop and evaluate an ultrasound (US)-guided proximal RUMM block technique comparing a medial versus a lateral approach. A total of 13 adult rabbit cadavers were used. In Phase I of the study, four cadavers were used for anatomical dissection and to design and test a lateral and medial single injection point US-guided proximal RUMM block technique, while in Phase II, the medial and lateral approaches were randomly performed on nine cadavers administering 0.1 mL kg-1 injectate. After dissection, nerve staining was categorised as adequate (all nerves stained ≥4 mm) or inadequate (at least one nerve not stained or stained <4 mm). Staining spread was compared with Fisher's exact test, with p < 0.05 considered statistically significant. From Phase I, the axillary fascia containing all RUMM nerves was identified. The radial nerve exited the fascia right after the humeral head. In the lateral approach, the transducer was angled at 80° to the humerus longitudinal axis. In the medial approach, the transducer was placed perpendicularly to the humerus longitudinal axis. In both approaches, the brachial artery appeared as a rounded and anechoic structure, the musculocutaneous nerve as hypoechoic and oval and the radial nerve as a honeycomb, and the ulnar and median nerves were identified adjacent to each other. The radial nerve was selected as the injection point for both approaches using an in-plane technique. In Phase II, the injectate was found outside the axillary fascia in zero out of nine and five out of nine thoracic limbs, with an adequate staining in nine of nine and two of nine injections (p < 0.01) using the medial and lateral approach, respectively. Thus, a US-guided proximal RUMM block technique is feasible in rabbits, and the medial approach demonstrated evidence of a more consistent stain of the RUMM nerves.

Abstract Novel ultrasound‐guided local‐anaesthetic blocks have become increasingly popular due to improved visualisation of anatomical structures, needle and probe handling, reduced risk of neuronal or vascular damage, increased patient safety and enhanced block efficacy. The proximal‐RUMM block, targeting the radial (R), ulnar (U), median (M) and musculocutaneous (M) nerves, is well established for small animal forelimb surgeries distal to the mid‐humerus and is an effective regional anaesthetic technique in dogs. The classic medial approach to the proximal‐RUMM block can be challenging due to small muscle mass, superficial nerve locations and risk of inadvertent intrathoracic or intravascular injections. Therefore, a lateral approach to the proximal‐RUMM block has been suggested to be beneficial in small patients and has been previously documented in a small dog undergoing elbow surgery. This case report documents the use of a lateral approach for ultrasound‐guided proximal‐RUMM block in a 14.5 kg dog undergoing humeral condyle fracture repair.

Ultrasound-guided proximal radial, ulnar, median and musculocutaneous (RUMM) nerve block in rabbit (Oryctolagus cuniculus) cadavers: medial vs lateral approach

Peripheral nerve blocks effectively alleviate postoperative pain. Animal studies and human research suggest that opioid tolerance may reduce the effectiveness of local analgesics. The reduced effectiveness has been observed in opioid-tolerant humans and animals undergoing spinal and infiltration anaesthesia with both lidocaine and bupivacaine. However, the impact on peripheral nerve blocks in humans has not been evaluated. This study aims to assess the onset time and duration of a radial nerve block in opioid-tolerant individuals compared to opioid-naive individuals. We hypothesise that peripheral nerve blocks may be less effective in producing sensory and motor blockades in opioid-tolerant individuals compared to their opioid-naive counterparts. Twenty opioid-tolerant individuals will be matched by sex and age with opioid-naïve counterparts. Participants will receive an ultrasound-guided radial nerve block. The primary outcome is the difference in the duration of sensory nerve blockade between the two groups. The secondary outcomes include the onset time of sensory blockade, onset time of motor blockade, and difference in duration of motor nerve blockade. This study will compare the effectiveness of a peripheral nerve block between opioid-tolerant and opioid-naïve individuals. Any found differences could support a specific postoperative protocol for opioid-tolerant individuals regarding the use of peripheral nerve blocks.

Pediatric regional anesthesia has been driven by the gradual rise in the adoption of opioid-sparing strategies and the growing concern over the possible adverse effects of general anesthetics on neurodevelopment. Nonetheless, performing regional anesthesia studies in a pediatric population is challenging and accounts for the scarce evidence. This study aimed to review the scientific foundation of studies in cadavers to assess regional anesthesia techniques in children. We searched the following databases MEDLINE, EMBASE, and Web of Science. We included anatomical cadaver studies assessing peripheral nerve blocks in children. The core data collected from studies were included in tables and comprised block type, block evaluation, results, and conclusion. The search identified 2409 studies, of which, 16 were anatomical studies on the pediatric population. The techniques evaluated were the erector spinae plane block, ilioinguinal/iliohypogastric nerve block, sciatic nerve block, maxillary nerve block, paravertebral block, femoral nerve block, radial nerve block, greater occipital nerve block, infraclavicular brachial plexus block, and infraorbital nerve block. Regional anesthesia techniques are commonly performed in children, but the lack of anatomical studies may result in reservations regarding the dispersion and absorption of local anesthetics. Further anatomical research on pediatric regional anesthesia may guide the practice.

Background and Aim: Distal radius fractures are the most frequent upper extremity fractures in the whole population. The incidence of distal radius fractures is 195.2/100,000, and the rate is increasing. It can occur with low-energy trauma in the elderly associated with osteoporosis. The purpose of this study is to compare the two different treatment groups (1. Sedation analgesia, 2. Supracondylar radial nerve block) in terms of reduction in Visual Analogue Scale (VAS) score, the length of hospital stay, complications, side effects, patient-physician satisfaction, and the ease of application. Materials and Methods: Patients diagnosed with distal radius fracture were enrolled prospectively, to whom the study’s exclusion criteria do not apply. The patients included in the study were randomly separated into two groups. Ketofol was administered to the sedation and analgesia group’s patients at a dose of 0.5 mg/kg (ketamine 0.5 mg/kg, propofol 0.5 mg/kg) intravenously, and supracondylar radial nerve block was performed on the other group’s patients under ultrasound guidance. Results: There were 20 patients (6 male, 14 female) in the sedation and analgesia group and 21 patients (11 male, 10 female) in the supracondylar radial nerve block group. There was no significant difference between the groups regarding patient-physician satisfaction and complications. The length of hospital stay was significantly shorter in the supracondylar radial nerve block group (49.25 ± 4.05) compared with the sedation and analgesia group (125 ± 5.85) (p &lt; 0.01). The mean reduction VAS score in the block group was observed to be lower than the admission VAS score (p &lt; 0.01). Conclusion: Consequently, ultrasound-guided supracondylar radial nerve block would be a valuable alternative to procedural sedation analgesia and could become routine clinical practice in treating distal radius fractures.

Distal radius fractures are one of the most common upper extremity fractures, and their incidence continues to increase due to an aging population and an increase in osteoporosis. Various methods of analgesia for distal radius fractures have been described-including hematoma blocks and nerve blocks. Hematoma blocks are a simple and effective method of providing analgesia; nonetheless, their efficacy may be limited in some cases. On the other hand, nerve blocks provide more targeted analgesia and may be more effective in reducing pain during fracture reduction. This study aimed to compare the analgesic effectiveness of radial and median nerve blocks with hematoma blocks under ultrasound guidance in treating distal radius fractures. Also, this study aimed to compare the analgesia of radial and median nerve blocks with hematoma blocks under ultrasound guidance to reduce distal radius fractures. In this prospective trial, patients with distal radius fractures referring to 2 academic centers were placed into 2 randomized groups, including hematoma block, and radial median block, both of which were ultrasound-guided. The patient's pain levels were measured and recorded based on the visual analog scale before the block, 5, 10, and 15 minutes after the block, at the start of reduction, during reduction, and 5, 10, and 15 minutes after reduction. Patient satisfaction and physician satisfaction rates were assessed, and side effects were also observed for 1 week. Quantitative variables were reported as mean ± standard deviation, and number and frequency percentages were reported for qualitative variables. The Student t test and the chi-square test were used on a case-by-case basis. The significance level was set at P ˂ 0.05. In this study, 120 patients were included. The groups had no significant differences in pain reduction during the procedure. Analgesic medication was needed during the procedure for 17 patients; nerve blocks were applied for 6 patients, and hematoma blocks for 11 patients, which was statistically significant (P = 0.041). Satisfaction rates for patients and physicians performing the procedure were significantly higher in the nerve block group than in the hematoma block group ( P = 0.001; P ˂ 0.001, respectively). The results of this study suggest that ultrasound-guided radial and median nerve blocks can be used as alternative methods of analgesia with other techniques in the reduction of distal radius fractures in emergency departments.

BackgroundSuccessful brachial plexus blockade produces sympathetic blockade, resulting in increased skin temperature in the blocked segments. This study aimed to evaluate the accuracy of infrared thermography in predicting failed segmental supraclavicular brachial plexus block.MethodsThis prospective observational study included adult patients undergoing upper-limb surgery under supraclavicular brachial plexus block. Sensation was evaluated at the dermatomal distribution of the ulnar, median, and radial nerves. Block failure was defined as absence of complete sensory loss 30 min after block completion. Skin temperature was evaluated by infrared thermography at the dermatomal supply of the ulnar, median, and radial nerves at baseline, 5, 10, 15, and 20 min after block completion. The temperature change from the baseline measurement was calculated for each time point. Outcomes were the ability of temperature change at each site to predict failed block of the corresponding nerve using area under receiver-operating characteristic curve (AUC) analysis.ResultsEighty patients were available for the final analysis. The AUC (95% confidence interval [CI]) for the ability of temperature change at 5 min to predict failed ulnar, median, and radial nerve block was 0.79 (0.68–0.87), 0.77 (0.67–0.86), and 0.79 (0.69–0.88). The AUC (95% CI) increased progressively and reached its maximum values at 15 min (ulnar nerve 0.98 [0.92–1.00], median nerve 0.97 [0.90–0.99], radial nerve 0.96 [0.89–0.99]) with negative predictive value of 100%.ConclusionInfrared thermography of different skin segments provides an accurate tool for predicting failed supraclavicular brachial plexus block. Increased skin temperature at each segment can exclude block failure in the corresponding nerve with 100% accuracy.

This study retrospectively evaluated the fentanyl-sparing effect of ultrasound-guided proximal radial, ulnar, median, and musculocutaneous nerve (RUMM) block for radial and ulnar fracturerepair in dogs. Fentanyl was prepared for intraoperative analgesia in dogs, although proximal RUMM block was performed using 0.5% or 0.25% bupivacaine before surgery in the block group. Dogswithout a nerve block were assigned to the control group. The fentanyl dose in the block group [0.8 (0−1.9) μg/kg/hr] [median (interquartile range)] was significantly lower than in thecontrol group [8.4 (7.2−10) μg/kg/hr]. Surgery was performed without fentanyl in >50% of the dogs (5/7), using 0.5% bupivacaine. Ultrasound-guided proximal RUMM block can be useful as anintraoperative analgesic for radial and ulnar fracture repair in dogs.

Complex regional pain syndrome (CRPS) of upper limbs is one of the under-recognized painful disabling condition seen in many neurological conditions. To see the effectiveness of peripheral nerve blocks (PNB) along with intra-articular injection in shoulder joint in the improvement of pain, swelling and range of motion (ROM) of the upper limb in CRPS. It was a single-center, prospective study in male and female patients between 18 and 70 years with CRPS of the upper limb due to any etiology, within one year of illness. Single-dose of the intra-articular shoulder joint injection and peripheral nerve blocks at the wrist with steroid, 2% lignocaine, and sterile water was given. The primary outcome measure was a reduction in pain in the upper limb, assessed with a visual analog scale (VAS). Secondary outcome measures were an improvement in passive ROM of joints and a decrease in swelling of the hand. The significance of the P value was adjudged against an alpha of 0.05. Thirty-three patients (25 men), with a mean (SD) age of 55.2 (9.4) years, and mean (SD) duration of illness of 101.9 (76.8) days were included. After 1 week, there was a significant improvement (P < 0.05) in the ROM of joints. The decrease in pain scores on VAS [mean difference -5.1 (CI -5.7, -4.5)] and reduction in hand swelling [mean difference -0.9 (CI -1.1, -0.7)] was also significant. Peripheral median, radial, and ulnar nerve block at wrist along with intra-articular steroid injection in the shoulder joint is an effective method of management of CRPS of the upper limb.

The aim of this study was to evaluate an ultrasound-guided technique and the anatomical basis for radial, ulnar, musculocutaneous and median (RUMM) nerve block in dogs. The study was conducted in two phases. In phase 1, cadaver dissection (using 4 cadavers) for anatomical landmarks and ultrasound study of the axillary region were used to design and to perform the US-guided RUMM block. It was feasible to detect RUMM nerves using ultrasound. Success of this technique was considered based on the staining of all four nerves in cadavers by using 0.15 mL/kg of methylene blue solution for e” 2 cm. In phase 2 study, combined ultrasound/electrolocation-guided nerve blocks were performed sequentially. Orthopaedic thoracic limb surgery of eight client owned dogs underwent RUMM block, which was designed in phase 1, to provide analgesia by using 0.5% of ropivacaine (2 mg/kg body wt). Effectiveness of the block was considered when the rescue analgesic requirement was less during intraoperative period as well as postoperative pain score was d” 5/20 based on short form of Glasgow Composite Measure Pain Scale (SF-CGMPS).The roots of the RUMM and the axillary RUMM block were established by ultrasound in all eight dogs. The relationship between the four ventral nerve roots (C6, C7, C8, and T1) and the axillary vessels was confirmed by anatomical review. In 6/8 anaesthetized dogs, mean intraoperative opioid requirement was reduced and postoperatively, up to 8 hr all the 8 dogs had pain score of SF-GCMPS d” 5/20. The placement of local anaesthetic for the axillary RUMM using ultrasound-guided needle insertion was a precise procedure. The use of an in-plane needling approach of 0.5% ropivacaine at 2 mg/kg reduced the need of opioids during thoracic limb surgery, leading to postoperative analgesia for up to 8 hr after the peripheral nerve block was performed.

Does radial or median nerve blocks affect the area and blood flow of radial artery?

Background: The radial nerve is especially vulnerable to injury due to its location near the humerus. When acute pain becomes chronic and surgical repair is no longer an option, it is necessary to have non-opioid, nonpharmacological methods of pain relief. Case Report: A 63-year-old man presented with severe radial nerve neuralgia secondary to traumatic left upper extremity injury 40 years ago. After several unsuccessful surgical interventions and failing medication management, he was sent to pain management as a last resort prior to elective amputation of the left upper limb. After initial evaluation, the patient underwent a diagnostic ultrasound-guided radial nerve block at the midhumeral level with complete but short-lasting relief of his pain. Shortly after, we performed ultrasoundguided alcohol neurolysis of the radial nerve at the same level. This treatment resulted in 100% pain relief for 10 months with gradual resumption of pain to previous levels at 12 months post neurolysis. Conclusion: Alcohol neurolysis is an effective and viable option for the treatment of neuralgia resistant to other therapeutic modalities. To our knowledge, this is the first case report that describes the use of ultrasound to perform chemical neurolysis of the radial nerve. Key words: Alcohol neurolysis, chronic pain, nerve ablation, neuralgia, neurolysis, opioids, radial nerve, traumatic injury, ultrasound

Background: Distal radius fractures, the most prevalent of all fracture types, are often associated with severe pain and discomfort and treated with closed reduction and splinting. This study aimed to compare ultrasound-guided supracondylar radial nerve block with procedural sedation for the treatment of distal radius fractures in the emergency department. Methods: Patients with isolated distal radius fractures and limited displacement who met the inclusion criteria were randomly divided into two groups, an ultrasound-guided nerve block group and a procedural sedation group, which were compared in terms of managing patients with distal radius fractures. The number of patients in each group was 27. Results: The duration of the procedure was significantly shorter in the nerve block group than in the ketamine group (p &lt; 0.001). Physician and patient satisfaction were determined according to the unipolar Likert scale and unlike for patients (p = 0.001), no significant difference was noted between the two groups for the physicians (p = 0.619). Unlike nerve block, emergence reactions (p = 0.038) and vomiting (p = 0.009) occurred in the ketamine intervention. Conclusion: Ultrasound-guided supracondylar radial nerve block can be prescribed as an alternative method in minimal or non-displaced distal radius fractures instead of IV sedation due to fewer side effects and a shorter procedural duration.

Introduction: Upper limb nerve blocks are done commonly by brachial plexus (C5-T1) blocks via supraclavicular, infraclavicular approaches. Sometimes a single peripheral nerve needs additional block with local anaesthetic to achieve adequate block. Peripheral nerve blocks are useful for minor surgical procedures in a single nerve distribution. Aim: To study the course and clinical significance of the radial nerve in 50 cadaveric upper limbs. Materials and Methods: A cross-sectional study was conducted on 50 intact dissected upper limbs. The upper limbs were obtained from the Department of Anatomy, Sri Ramachandra Medical College from August 2020 to December 2020. Radial nerve was exposed by routine dissection in all the upper limbs and its entire course was studied and observed for any variation. The distance from the biceps tendon to the radial nerve at the elbow, distance of the radial nerve in the Lateral Intermuscular Septum (LIS) from the epicondyles at the elbow were measured. The results obtained were statistically analysed using Statistical Package for the Social Sciences (SPSS) version 16.0. Results: In present study, the mean distance of the radial nerve in the LIS to the medial epicondyle was 12.4±0.31 cm and to the lateral epicondyle was 12.1±0.28 cm. The mean distance from the biceps tendon to the radial nerve at the elbow was 1.75±0.22 cm. Conclusion: From the present study, it can be inferred that effective peripheral radial nerve block can be achieved by blocking the nerve 1.75 cm lateral to the biceps tendon at the elbow 3 cm above the elbow crease. This can be made comfortable to the patient and more precise by ultrasound localisation of the radial nerve.

A 26-day-old Pustertaler Sprinzer calf was referred to the ruminant clinic of the Veterinary University of Vienna for internal fixation of a suspected traumatic radius–ulnar fracture of the left forelimb....

Development of a lateral ultrasound-guided approach for the proximal radial, ulnar, median and musculocutaneous (RUMM) nerve block in cats

ObjectiveTo compare two needle insertion techniques in a novel lateral approach to the radial, ulnar, median and musculocutaneous (RUMM) nerve block in cat cadavers. Study designProspective, cadaveric experimental study. AnimalsA group of 18 feline cadavers. MethodsCadavers were divided into two groups. Both thoracic limbs of each cat were ‘blocked’ using the ‘in-plane’ (IP) or ‘out-of-plane’ (OP) ultrasound (US)-guided method. A single operator with limited experience performed all the techniques. Cadavers were placed in lateral recumbency and the uppermost limb was injected before turning to ‘block’ the contralateral limb in the same manner. The IP method consisted of tracking the triceps brachii muscle until the radial (R) nerve could be identified in the same field of view as the ulnar, median and musculocutaneous (UMM) nerve bundle. A needle was guided by US towards the R nerve and subsequently, methylene blue (0.4 mL) was instilled adjacent to it. The needle was retracted and redirected to the UMM nerve bundle, and another 0.4 mL dye was instilled. For the OP technique, the limb was pronated at a 45° angle. The nerves were then identified with the R nerve directly above UMM nerves. A needle was directed OP deep towards UMM nerves and dye (0.4 mL) was instilled. The needle was retracted superficially and 0.4 mL dye instilled next to the R nerve. After dissection, the nerves were assessed and ≥6 mm of staining was considered a successful technique. ResultsA total of 18 RUMM ‘blocks’ were performed IP and 18 were performed OP. The IP technique was more successful than the OP technique (R nerve p = 0.0339; UMM nerves p = 0.0352). Conclusions and clinical relevanceThe lateral approach to the RUMM was achievable in cat cadavers using both needle insertion techniques. The IP technique was significantly more successful than the OP technique.