This document describes the anatomy and techniques for performing brachial plexus and upper limb nerve blocks. It begins with an overview of the brachial plexus formation from C5-T1 nerve roots and its branches. Various approaches for blocking portions of the plexus are then outlined, including interscalene, supraclavicular, infraclavicular, axillary blocks. Selective nerve blocks of the median, ulnar, radial and digital nerves are also reviewed. Clinical indications and contraindications are provided for each technique.

1. BRACHIAL PLEXUS
& UPPER LIMB BLOCKS
Dr VEENA MOHAN
JR1 ANAESTHESIA

2. Network of nerves ..formed by ventral rami of C5-T1 innervate the
upper limb
COMPONENT PARTS
• ROOTS - Five ventral rami (C5 -T1 )
• TRUNKS – Upper, Middle, and Lower
• DIVISIONS – Anterior & Posterior from each trunk,
• CORDS – Lateral, Medial and Posterior
• BRANCHES

4. LOCATION
ROOT– leave the intervertebral foramina, converge to form trunks
TRUNKS –formed b/w scalene anterior & medius muscle, passed over
lateral border of 1st rib
under the clavicle ,it divides to form
DIVISIONS - behind clavicle
CORDS- formed below clavicle ,, arranged around 2nd part of Axillary
artery

5. • From the Roots
1.Dorsal Scapular nerve
Rhomboideus major and minor muscles
2.Long Thoracic nerve
serratus anterior
BRANCHES
the Upper Trunk
1. Nerve to subclavius muscle
2. Suprascapular nerve

6. BRACHIAL PLEXUS: NERVES FROM CORDS
Lateral cord(C5,C6,C7)
• Lateral pectoral: pectoralis major
• Lateral root of median
• Musculocutaneous : coracobrachalis, brachialis, biceps brachii
Medial cord(C8,T1)
• Medial pectoral : pectoral major & minor
• Medial root of median
• Medial cutaneous N of forearm
• Medial cutaneous N of arm
• Ulnar : intrinsic hand muscles except thenar & lateral 2 lumbricals
Posterior cord(C5,C6)
• Upper subscapular :subscapularis
• Thoracodorsal :latissimus dorsi
• Lower suscapular :subscapularis
• Axillary: deltoid, teres minor
• Radial: triceps, supinator, anconeus, extensor muscles of forearm & brachioradialis

9. LESIONS
KLUMPKE PARALYSIS
 partial palsy of the lower roots of the brachial plexus. C8 and T1
 Affects intrinsic muscles of the hand and the flexors of the wrist and fingers.
 the“claw hand”
forearm is supinated and the wrist and fingers are hyperextended with flexion
at interphalangeal and metacarpo phalangeal joints.

10. injury to the upper trunk C5-C6.
• loss of sensation in the arm
• paralysis & atrophy of the deltoid, biceps, and brachialis
• the arm hangs by the side and is rotated medially;
• the forearm is extended and pronated
• "waiter's tip hand."
ERB’S PALSY

11. ANESTHETIC
INTERVENTION

12. nerve block involving the injection of local anesthetic as close to
the nerve as possible for pain relief.
• Short surgical procedure
• Postoperative analgesia
ADVANTAGES
• avoids side effects nausea and vomiting,
• avoiding complications of general & central neuraxial
anesthesia
• In hemodynamically unstable patient
PERIPHERAL NERVE BLOCK

13. HOW TO LOCALISE THE NERVE
1.PARESTHESIA TECHNIQUE
Knowing anatomic relationship and surface landmarks
…..
block needles inserted
….
advanced towards the target nerve
……
When comes in contact
….
the paresthesia develops

14. 2.NERVE STIMULATOR TECHNIQUE
insulated needle with current at the tip.. attach to a nerve stimulator
0-5mA ,1-2Hz
The anode (+) …….to an electrode on the patient’s skin
The cathode (−)…….to the stimulating needle.
The needle is inserted… advanced near the nerve.
once proximity to the motor nerve…. muscle contraction is induced
A motor response at a current of 0.5 mA is can confirm the location
for the administration of the drug

15. 3. USG GUIDED
High frequency(1-20MHz) sound waves emitted from piezoelectric crystals…. pass through tissue…. return
signal to transducer….. create as electrical voltage…. converted to 2D image
HYPOECHOIC
• appear black
• Allow
Soundwave to
pass
TRANSDUCER
HIGH FREQUENCY
• high resolution
• clear image
• less penetration
• for superficial
structures
• Linear probe
LOW FREQUENCY
• poor image quality
• better tissue
penetration
• for deeper structures
• Curvilinear probe
HYPERECHOIC
appears white/brighter
reflects more
IMAGE

16. IN PLANE
parallel to the ultrasound waves
OUT OF PLANE
not parallel to ultrasound waves
TECHNIQUE

17. BRACHIAL PLEXUS BLOCK
a fascial sleeve enclose brachial plexus extending from IV foramen to upper arm
Inject LA into this sheath—block the brachial plexus
• Interscalene block
• Supraclavicular block
• Infraclavicular block
• Axillary block

18. 1.INTERSCALENE BLOCK
INDICATIONS
Surgery in shoulder, upperarm & forearm.
• Shoulder
• Distal clavicle
• Proximal Humerus
• Elbow
Postoperative analgesia for total shoulder arthroplasty
BLOCK: upper & middle trunk ....at interscalene groove.

19. PROCEDURE
1. Classic Technique (Winnie)
Supine position...
head to opp side.
..posterior border of SCM palpated..
..roll the finger posterolateraly from this border ...over
anterior scalenus muscle .
.. Reach interscalene groove....
Corresponds to C6..&..cricoid cartilage.

20. 22G short bevel needle inserted perpendicular to skin at the level of C6,,, in the groove
after a motor response is obtained in
• Pectoralis muscle
• Deltoid muscle
• Triceps muscle
• Biceps muscle
• Any twitch of the hand or forearm
LA is given
• movement of the diaphragm: needle is inserted too anteriorly
• Twitching of trapezius/ scapula…..more posteriorly

21. OTHER APPROACHES
2. BORGEAT MODIFIED LATERAL APPROACH
places the needle 0.5 cm more caudaL. The angulation of the needle is more
acute and thus away from the midline
facilitates Continuous perineural catheter placement
CLASSICAL WINNIE MODIFIED LATERAL

22. 3.USG GUIDED
Probe in supraclavicular fossa...visualise the
subclavian artery ...superolateral to it is brachial
plexus ( bunch of grapes) ....trace the plexus up to
neck to see them in interscalene groove.... Stoplight
sign

23. •COMPLICATIONS
• Ipsilateral diaphragmatic paresis
• Severe hypotension and bradycardia
(i.e., the Bezold- Jarisch reflex
• Inadvertent epidural or spinal block
• Nerve damage or neuritis
• intravascular injection with Seizure
 Horner’s syndrome.
• Puncture of the pleura -Pneumothorax.
• Hemothorax.
• HematomaandInfection.
CONTRAINDICATIONS
• Local infection
• Severe coagulopathy
• Local anesthetic allergy
• Patient refusal

24. 2.SUPRACLAVICULAR BLOCK
INDICATIONS
Surgery of elbow, forearm, hand
BLOCK
Distal trunk & proximal division
PROCEDURE
1.Plumbob technique
Patient position supine head away from the block site
asked to raise the head to identify lateral border of
sternocleidomastoid
Needle entered just above clavicle -- posterior border of the
muscle & direct towards the floor

25. 2. SUBCLAVIAN PERIVASCULAR APPROACH
Patient supine…, head turned only 30° to the opposite
side…..identify the interscalene groove….Follow down to the root
of the neck…..The subclavian artery is palpable……..
•Insert the needle at the lowest point of the interscalene groove
in the posterior part of the groove& posterior to the subclavian
artery if palpable ….Direct the needle parallel to the floor and
directly twitch should preferably be elicited in muscles below the
elbow i.e. flexors / extensors of wrist or fingers.

26. 3.USG GUIDED
patient’s head turned 30 degree to contralateral side
………linear high frequency probe in supraclavicular fossa &
angled to thorax….identify subclavian artery …….Brachial
plexus seen as hypoechoic ,superficial and lateral to
subclavian artery as honeycomb appearance
COMPLICATIONS
1. Pneumothorax
2. Phrenic nerve palsy
3. Horners syndrome
4. Neuropathy

27. 3 INFRACLAVICULAR BLOCK
INDICATION
surgery at distal to elbow
hand ,wrist
LEVEL OF BLOCK
at the level of cords
COMPLICATIONS
1. Vascular puncture
2. pneumothorax

28. TECHNIQUE
1 .CLASSICAL
identify coracoid process..... brachial plexus run Deep to coracoid process....
…around 2nd part of axillary artery b/w 3 &11 o’ clock position
….. insert the needle 2 cm medial and 2cm caudal to corocoid process…..
See for movememt of little finger, it moves
posteriorly : posterior cord stimulated
laterally: lateral cord stimulated
medially: medial cord stimulated
then LA is given

29. 2. USG guided
Use curvilinear transducer …. place it over 2 cm medial and 2 cm caudal to
coracoid process… Axillary Artery & vein seen… Cords seen around the artery
medial cord : b/w axillary artery & vein
lateral Cord : lateral to artery)
posterior cord : posteriolateral to the artery

30. 4 AXILLARY BLOCK
INDICATION
surgery to elbow & distal extremity
PROCEDURE
Patient is supine arm abducted 90 degree at shoulder,, flexed 90 degree at elbow ….
Arm lying across head
1.At Lateral border off pectoralis muscle cord forms terminal branches….. Palpate
axillary artery
Median nerve :superior ( wrist flexion ,thumb opposition, forearm pronation)
Ulnar nerve: inferior (wrist flexion,thumb adduction, 4th & 5th digit flexion)
Radial nerve: inferior posterior (digit wrist elbow–Extension, forearm supination

31. APPROCHES
1. TRANSARTERIAL: l identify axillary artery… give 30 to 40 ml LA in divided
doses posterior and anterior to the artery.
2. PERIVASCULAR: fanning small amount of LA inferior and superior to
axillary artery through constantly moving needle.
3. Parasthesia technique
4. Peripheral nerve stimulation technique

32. 5. Usg guided
Use high frequency linear transducer in proximal axilla….
…visualise axillary artery and nerves are identified around the artery
Contraindication
• local infection
• Neuropathy
• bleeding risk
• systemic toxicity
disadvantages
• requires the arm be abducted 90
degrees at the shoulder,
• musculocutaneous nerve has usually
split away from the
Others… requires a separate
block

33. MUSCULOCUTANEOUS NERVE BLOCK
Nerve is deep within coracobrachialis , cannot block in axillary block
2 ways
1. After axillary block
redirect needle more
superiorly and Pierce
coracobrachialis
muscle
2. At elbow
Identify insertion of biceps .
Nerve is superficial at intercondylar line.
Needle inserted 1-2 cm lateral to it.

34. 1.MEDIAN NERVE
COURSE
Enter arm…. run medial to brachial
artery ….enter anteriorcubital space
….give off motor branch to wrist &
finger flexors… reach wrist…lie behind
palmaris longus tendon in carpal
tunnel.
SELECTIVE NERVE BLOCK

35. Can block it
WRIST
identify palmers longus
( ask the patient to flex
against resistance)
Adjacent to it is median
nerve
ELBOW
Identify brachial artery medial
to it is median nerve

36. COURSE
Continuation of medial cord
In upper arm, medial to axillary and brachial artery
At elbow, pass under arcuate ligament
palpate proximal to medial epicondyle
At wrist,, lateral to FCU …medial to ulnar artery
2.ULNAR NERVE

37. TO BLOCK
ELBOW
22 g needle inserted to 1
fingerbreadth proximal to
arcuate ligament
elicit 4th or 5th digit
flexion or thumb
adduction
WRIST
insert needle
medial to ulnar
artery

38. 3.RADIAL NERVE
COURSE
from posterior cord in arm. Posteriorly pass .enter spiral groove & leaves it
Superficial branch
reach anatomic
snuffbox
• supply dorsal
lateral 3 ½ finger
• radial aspect of
dorsum of hand
Deep branch
innervate
extensor group
of muscles in
forearm

39. Block at
ELBOW
1. identify biceps tendon in
antecubital fossa
insert 22 g needle lateral to
tendon directed to lateral condyle
until wrist or finger extension is
elicited
2.With USG.. nerve identified
between biceps and
brachioradialis

40. Block at WRIST
Superficial branch lateral to artery

41. 4.DIGITAL NERVE BLOCK
• for minor operations on the fingers
• to supplement incomplete brachial plexus and terminal nerve blocks
Sensory innervation by 4 small digital nerves
that enter each digit at its base in each corner
At base of selected digit ,
medial & lateral aspect inject 2 -3ml LA injected

42. 5.SUPRACLAVICULAR NERVE BLOCK
C3- C4 ….
sensory innervation to cape of shoulder…
area from neck to deltoid & from 2nd rib anteriorly to top
of scapula posteriorly
Superficial cervical plexus block
5-10 ml LA s/c along posterior border of SCM
I

43. 6.SUPRASCAPULAR NERVE BLOCK
(C5–C6) branches from the supe-rior trunk
innervate posterior 2/3 of the shoulder joint, the acromioclavicular joint,
and the anterior axilla
suprascapular nerve is approached as it exits the supra-
scapular notch just above the scapular spine
Patient seated, line is drawn along the scapular spine and
then bi-sected by a second line drawn parallel to the
vertebral spine.
Needle entry is 2 cm along a third line that bisects the
upper
outer quadrant. The needle is directed parallel to the
vertebral .spine

44. 7.INTERCOSTOBRACHIAL NERVE
T2 ….cutaneous innervation to the medial aspect
of the
proximal arm
supine…arm abducted ,externally rotated.
Starting at the deltoid prominence and
proceeding inferiorly, a field block is performed
in a linear fashion
using 5 mL of LA, extending to the most inferior
aspect of the medial arm