ahm Archives of Hand and Microsurgery Arch Hand Microsurg 2586-3290 2586-3533 Korean Society for Surgery of the Hand; Korean Society for Microsurgery 10.12790/ahm.2019.24.2.152 ahm-24-152 Original Article Ultrasound-Guided Axillary Brachial Plexus Block Performed by OIrthopedic Surgeon for Distal Radius Fracture Surgery SunDoohoon LeeChul-Hyung KimCheol-U JungDeukhee AnChung-Han Department of Orthopedic Surgery, Daejeon Sun Hospital, Daejeon, Korea Corresponding author: Chul-Hyung Lee Department of Orthopedic Surgery, Daejeon Sun Hospital, 29 Mokjung-ro, Jung-gu, Daejeon 34811, Korea TEL: +82-42-220-8860, FAX: +82-42-220-8464, E-mail: mediiron@naver.com 012019 5012019 242 152161 21012019 31032019 31032019 Copyright © 2019 Korean Society for Surgery of the Hand; Korean Society for Microsurgery 2019 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose:

The purpose of this study was to evaluate the usefulness of ultrasound-guided axillary brachial plexus block performed by orthopedic surgeon as an anesthetic method for distal radius fracture surgery.

 Methods:

From October 2017 to October 2018, an ultrasound-guided axillary brachial plexus block was performed on 161 cases of distal radius fracture requiring surgery. The procedure was performed by orthopedic surgeons using solution (20 mL of lidocaine HCl in 2%, 20 mL of ropivacaine in 0.75%, and 10 mL of normal saline in 0.9%). The success rate of the anesthetic procedure, the duration of analgesic effect, and the complications were investigated. If the anesthesia induction failed, additional local anesthetic methods were performed stepwise and reassessment about whether the operation could proceed was made.

 Results:

Anesthesia was successful in 155 patients and the success rate was 96.3%. The duration of analgesic effect was 6 hours (3-10 hours). In 6 failed cases of anesthesia, local anesthesia was applied to the pain site in the operating room. In 5 cases, the operation was completed without discomfort. In 1 case complaining of pain around fracture site after the local anesthesia, ultrasound-guided radial nerve block was effective in controlling the pain.

 Conclusion:

In open surgery of distal radius fractures, an ultrasound-guided axillary brachial plexus block performed by orthopedic surgeon allows anesthesia with high success rates. Even if the surgical anesthesia is incomplete, it is expected that the surgery cab be completed safely if the nerve is identified and the stepwise additional local anesthesia method is performed.

 Distal radius fracture Orthopedic surgeon Ultrasound-guided axillary brachial plexus block Additional anesthesia REFERENCES Choi IG Choi YS Kim YH The effects of postoperative brachial plexus block using MgSO(4) on the postoperative pain after upper extremity surgery Korean J Pain. 20112415863 Sultan SF Iohom G Saunders J Shorten G A clinical assessment tool for ultrasound-guided axillary brachial plexus block Acta Anaesthesiol Scand. 20125661623 Kim CU Lee CH Yoon JY Rhee SK Ultrasound-guided axillary brachial plexus block, performed by orthopedic surgeons J Korean Orthop Assoc. 20185351321 Van de Pol GJ Koudstaal MJ Schuurman AH Bleys RL Innervation of the wrist joint and surgical perspectives of denervation J Hand Surg Am. 2006312834 Kang C Hwang DS Kim YM Ultrasound-guided femorosciatic nerve block by orthopaedist for ankle fracture operation J Korean Foot Ankle Soc. 201014906 Rah JH Kwon SM Cha JH Lee JP Kim JH The efficacy of ultrasound-guided brachial plexus block in trauma patients J Korean Soc Surg Hand. 201419138 Aysel I Topçu I Kurt FF Ultrasound guided brachial plexus block can be advantageous in patients with avulsion type upper extremity injuries Agri. 2013251456 Danelli G Fanelli A Ghisi D Ultrasound vs nerve stimulation multiple injection technique for posterior pop-liteal sciatic nerve block Anaesthesia. 20096463842 Walker KJ McGrattan K Aas-Eng K Smith AF Ultrasound guidance for peripheral nerve blockade Cochrane Database Syst Rev. 20097CD006459 Marhofer P Willschke H Kettner SC Ultrasound-guided upper extremity blocks - tips and tricks to improve the clinical practice Paediatr Anaesth. 2012226571 Jupiter JB Fernandez DL Toh CL Fellman T Ring D Operative treatment of volar intra-articular fractures of the distal end of the radius J Bone Joint Surg Am. 199678181728 Hohenberger GM Maier MJ Dolcet C Weiglein AH Schwarz A Matzi V Sensory nerve supply of the distal radioulnar joint with regard to wrist denervation J Hand Surg Eur Vol. 20174258691 Frenkel O Herring AA Fischer J Carnell J Nagdev A Supracondylar radial nerve block for treatment of distal radius fractures in the emergency department J Emerg Med. 2011413868 Bernucci F Gonzalez AP Finlayson RJ Tran DQ A prospective, randomized comparison between perivascular and perineural ultrasound-guided axillary brachial plexus block Reg Anesth Pain Med. 2012374737 Kang C Kim YM Hwang DS Kim JH Park JY Lee WY Ultrasound-guided femorosciatic nerve block J Korean Orthop US Soc. 20102748 McClure JH Ropivacaine Br J Anaesth. 1996763007 Stan TC Krantz MA Solomon DL Poulos JG Chaouki K The incidence of neurovascular complications follow-ing axillary brachial plexus block using a transarterial ap-proach. A prospective study of 1,000 consecutive patients Reg Anesth. 19952048692 Andersson A Akeson J Dahlin LB Efficacy and safety of axillary brachial plexus block for operations on the hand Scand J Plast Reconstr Surg Hand Surg. 2006402259 Ecoffey C Oger E Marchand-Maillet F Cimino Y Ran-nou JJ Beloeil H SOS French Regional Anaesthesia Hotline Complications associated with 27031 ultrasound-guided axillary brachial plexus blocks: a web-based survey of 36 French centres Eur J Anaesthesiol. 20143160610 Tetzlaff JE Walsh M Yoon HJ PH adjustment of mepi-vacaine decreases the incidence of tourniquet pain dur-ing axillary brachial plexus anaesthesia Can J Anaesth. 1993401336 Tetzlaff JE Yoon HJ Walsh M Regional anaesthetic technique and the incidence of tourniquet pain Can J Anaesth. 1993405915 Figures and Tables

Anesthetic preparation composed of lidocaine HCl 2% 20 mL, ropivacaine 0.75% 20 mL, 0.9% normal saline 10 mL, 50 mL syringe, 23-guage spinal needle, and intravenous extension line.

Patient position and the location of the probe for performing axillary brachial plexus block.

Ultrasound anatomy of the axilla. AA: axillary artery, CBM: coracobrachialis muscle, M: median nerve, MC: musculocutaneous nerve, R: radial nerve, U: ulnar nerve.

(A) In-plane needle approaching (arrowheads). (B) Complete block of the four nerves was performed. Hypoechoic areas surrounding each nerve was seen. CBM: coracobrachialis muscle, MC: musculocutaneous nerve, AA: axillary artery, M: median nerve, R: radial nerve, U: ulnar nerve.

Patient position (90 degree abduction and slightly internal rotation of the arm) and the location of the probe using aseptic cover and needle for performing radial nerve block.

The location of the ultrasound device and the position of the physician for performing radial nerve block.

(A) In-plane needle approaching (arrowheads) for performing radial nerve block. Radial nerve and humerus were seen. (B) The hypoechoic area of the local anesthetics was seen around the radial nerve after performing radial nerve block. R: radial nerve, LA: local anesthetics.

Flowchart of the supplemental local anesthesia for the distal radius fracture surgery. US-ABPB: ultrasound-guided axillary brachial plexus block, SA: surgical anesthesia, LA: local anesthesia, PFSI: peri-fracture site injection, US-RNB: ultra-sound-guided radial nerve block.

Demographic and clinical characteristics of patients (October 2017 to October 2018)

Variable Value
No. of patient 161
Sex (male:female) 37:124
Age (yr) 63.4 (23-78)
Fracture type (A:B:C)∗ 27:52:82
Injured side (dominant:non-dominant) 112:49

Values are presented as number only or mean (range).

This type was based on the AO/OTA classification.

Summary of the patients who failed the musculocutaneous nerve block

Age (yr)/ sex Anatomical variation of MCN Injection of supplemental LA at incision site (mL) VAS (before injection/ after injection)
57/male None 4 4/0
62/female None 5 5/0

MCN: musculocutaneous nerve, LA: local anesthetics, VAS: visual analogue scale.

Summary of the patients who failed the radial nerve block

Age (yr)/sex Method of the RNB First supplemental LA (PFSI) (mL) VAS (before PFSI/ after PFSI) Second supplemental LA (US-RNB) (mL) VAS (before US-RNB/ after US-RNB)
63/female PVB 10 5/1 - -
70/male PVB 10 7/1 - -
47/female PVB 10 7/2 - -
66/female PVB 10 7/5 4 5/1

RNB: radial nerve block, LA: local anesthetics, PFSI: peri-fracture site injection, VAS: visual analogue scale, US-RNB: ultrasound-guided radial nerve block, PVB: perivascular block.

Results of ultrasound-guided axillary brachial plexus block and tourniquet time (n=161)

Variable Value
Successful surgical anesthesia without supplementation 155 (96.3)
Needling time (min) 5.7 (3-10)
Time of analgesia (hr) 6 (3-10)
Complications 5 (3.1)
 Dizziness 2
 Nausea 3
Supplementation 6 (3.7)
 Incision site injection 2
 PFSI only 3
 US-RNB after PFSI 1
Tourniquet time (min) 55.3 (46-70)

Values are presented as number (%), mean (range), or number only.

PFSI: peri-fracture site injection, US-RNB: ultrasound-guided radial nerve block.