Regional anesthesia for clavicle fracture surgery is safe and effective

Efficacy Comparison Between Interscalene Block with and Without Superficial Cervical Plexus Block for Anesthesia in Clavicle Surgery

Background

Clavicle fractures account for over one-third of shoulder injuries and up to 3.3% of all fractures in adults. While the majority of these fractures can be managed non-surgically, there are instances where surgical intervention is performed. Regional anesthesia (RA) can be a preferred alternative to general anesthesia (GA) to avoid complications and high costs in this surgery. Moreover, the identification of the most optimal approach for RA remains challenging.

Objectives

This study aimed to compare the efficacy of interscalene block (ISB) with and without superficial cervical plexus block (SCPB) as an anesthetic technique for clavicular fracture operation.

Methods

This double-blinded, non-inferiority clinical trial was conducted on 120 patients randomly divided into 2 groups: One receiving ISB and the other receiving ISB with SCPB. The primary outcome was defined as the conversion to GA. Various factors were recorded, including surgery duration, nerve block initiation, analgesics required in the postanesthesia care unit (PACU), and sedation during surgery. Pain was evaluated using the Visual Analog Scale (VAS) in PACU. SPSS version 26 was used for statistical analysis, performing descriptive analysis, Student's t-tests, and Mann-Whitney U tests to compare non-parametric variables between the 2 groups. Statistically significant results had a P value of less than 0.05.

Results

A total of 120 patients were randomly divided into 2 equal groups, each consisting of 50 males and 10 females. The mean age of intervention and case groups were 37.23 ± 13.30 and 38.43 ± 11.95 years, respectively. After performing statistical tests (Student's t-test and Mann-Whitney U test), there was no significant difference in the initiation time of nerve block, surgery initiation time, surgery duration, the amount of required sedation, VAS scores, and meperidine consumption (P > 0.05). None of the patients in both groups required conversion to GA.

Conclusions

The primary goal was achieved in all included cases, and no patients required conversion to GA. The efficacy of ISB is the same whether or not it is combined with a SCPB. Interscalene block is an alternative RA approach for clavicle fractures. Thus, ISB alone is as efficient as when used in combination with SCPB.

Continuous Interscalene Nerve Block for a Midshaft Clavicle Fracture: An Opioid-Sparing Postoperative Analgesic Strategy

Postoperative pain after surgical clavicle fixation is difficult to treat and often responds incompletely to opioid analgesics. Unfavorable side effects and the risk of misuse of opioid analgesics make regional anesthetic techniques an attractive strategy for treating clavicular pain. Literature on continuous nerve blocks with catheter placement for more prolonged pain control for clavicle fractures is scarce, while such techniques are common for other shoulder surgeries. This case report presents a successful continuous interscalene brachial plexus block (ISB) after surgical fixation of a midshaft clavicle fracture. The patient was discharged home on the day of the operation with a portable pump, which provided a local anesthetic infusion for five days postoperatively. The patient was very satisfied with her pain control and only required one dose of oral opioid analgesic postoperatively.

Effects of Intraoperative Local Pain Cocktail Injections on Early Function and Patient-Reported Outcomes: A Randomized Controlled Trial

OBJECTIVE

To determine whether a perioperative pain cocktail injection improves postoperative pain, ambulation distance, and long-term outcomes in patients with hip fracture.

DESIGN

Prospective, single-blinded, randomized controlled trial.

SETTING

Academic Medical Center.

PATIENTS/PARTICIPANTS

Patients with OTA/AO 31A1-3 and 31B1-3 fractures undergoing operative fixation, excluding arthroplasty.

INTERVENTION

Multimodal local injection of bupivacaine (Marcaine), morphine sulfate (Duramorph), ketorolac (Toradol) given at the fracture site at the time of hip fracture surgery (Hip Fracture Injection, HiFI).

MAIN OUTCOME MEASUREMENTS

Patient-reported pain, American Pain Society Patient Outcome Questionnaire (APS-POQ), narcotic usage, length of stay, postoperative ambulation, Short Musculoskeletal Function Assessment.

RESULTS

Seventy-five patients were in the treatment group and 109 in the control group. Patients in the HiFI group had a significant reduction in pain and narcotic usage compared with the control group on postoperative day (POD) 0 ( P < 0.01). Based on the APS-POQ, patients in the control group had a significantly harder time falling asleep, staying asleep, and experienced increased drowsiness on POD 1 ( P < 0.01). Patient ambulation distance was greater on POD 2 ( P < 0.01) and POD 3 ( P < 0.05) in the HiFI group. The control group experienced more major complications ( P < 0.05). At 6-week postop, patients in the treatment group reported significantly less pain, better ambulatory function, less insomnia, less depression, and better satisfaction than the control group as measured by the APS-POQ. The Short Musculoskeletal Function Assessment bothersome index was also significantly lower for patients in the HiFI group, P < 0.05.

CONCLUSIONS

Intraoperative HiFI not only improved early pain management and increased ambulation in patients undergoing hip fracture surgery while in the hospital, it was also associated with early improved health-related quality of life after discharge.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Could C3, 4, and 5 Nerve Root Block be a Better Alternative to Interscalene Block Plus Intermediate Cervical Plexus Block for Patients Undergoing Surgery for Midshaft and Medial Clavicle Fractures? A Randomized Controlled Trial

BACKGROUND

Variable innervation of the clavicle is a major challenge in surgery of clavicle fractures with patients under regional anesthesia. An interscalene block (ISB) combined with an intermediate cervical plexus block (ICPB) provides analgesia in clavicle fracture surgery, but this combination does not completely block sensation in the midshaft or medial clavicle. Cervical nerve root block is an alternative to deep cervical plexus block and has recently been used as an analgesic method in the neck and shoulder. Whether it should be used as an alternative for midshaft and medial clavicle fractures is unknown.

QUESTIONS/PURPOSES

In this randomized controlled trial, we compared a C3, 4, and 5 nerve root block to ISB combined with ICPB in surgery of midshaft and medial clavicle fractures in terms of the (1) proportion of patients achieving a sensory block that is sufficient for surgery, (2) onset time and duration of the block, and (3) effectiveness of postoperative analgesia, as measured by pain scores and consumption of analgesics.

METHODS

Between November 2021 and December 2021, we treated 154 patients for clavicle fractures. A total of 122 were potentially eligible, 91 of whom agreed to participate in this study. Twenty-nine patients were excluded because the patients chose general anesthesia or declined to undergo surgery. Ultimately, 62 patients were randomly allocated into the C3, 4, and 5 group or ISB + ICPB group, with 31 patients in each group; there were no dropouts. All patients were analyzed in the group they were randomized to under intention-to-treat principles. The assessor and patients were blinded to randomization throughout the trial. The two groups did not differ in any important ways, including age, gender, BMI, American Society of Anesthesiologists classification, and type of clavicle fracture. The two groups received either an ultrasound-guided C3, 4, and 5 nerve root block with 2, 3, and 5 mL of 0.5% ropivacaine or ultrasound-guided ISB with ICPB with 20 mL of 0.5% ropivacaine. The primary outcome was the proportion of patients in each group with a successful nerveba block who did not receive general anesthesia; this was defined as nerve block success. Secondary outcomes included the onset time and duration of the sensory block, defined as the onset to the moment when the patients felt pain and sought rescue analgesia; pain assessment in terms of the numeric rating scale (NRS) score (range 0 to 10) for pain after nerve block before and during surgery; and the median amount of sufentanil consumed intraoperatively and postoperatively in the recovery room. The dosing of sufentanil was determined by the assessor when the NRS score was 1 to 3 points. If the NRS score was more than 3 points, general anesthesia was administered as a rescue method. Complications after the two inventions such as toxic reaction, dyspnea, hoarseness, pneumothorax, and Horner syndrome were also recorded in this study.

RESULTS

A higher proportion of patients in the C3, 4, and 5 group had a successful nerve block than in the ISB + ICPB group (97% [30 of 31] versus 68% [21 of 31], risk ratio 6 [95% CI 1.5 to 37]; p < 0.01). The median onset time was 2.5 minutes (range 2.0 to 3.0 minutes) in the C3, 4, and 5 group and 12 minutes (range 9 to 16 minutes) in the ISB + ICPB group (difference of medians 10 minutes; p < 0.001). The sensory block duration was 10 ± 2 hours in the C3, 4, and 5 group and 8 ± 2 hours in the ISB + ICPB group (mean difference 2 hours [95% CI 1 to 3 hours]; p < 0.001). The median sufentanil consumption was lower in the C3, 4, 5 group than in the ISB + ICPB (median 5 µg [range 0.0 to 5.0 µg] versus median 0 µg [range 0.0 to 0.0 µg]; difference of medians 5.0 µg; p < 0.001). There were no differences between the two groups regarding NRS scores after nerve blocks and NRS score for incision and periosteum separation, with the minimum clinically important difference set at a 2-point difference (of 10). There were no severe complications in this study.

CONCLUSION

Based on our analysis of the data, a C3, 4, and 5 nerve root block was better than ISB combined with ICPB for surgery to treat medial shaft and medial clavicle fractures. When choosing the anesthesia method, however, the patient's basic physiologic condition and possible complications should be considered.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Regional Anesthetic and Analgesic Techniques for Clavicle Fractures and Clavicle Surgeries: Part 2-A Retrospective Study

Objective. Clavicle fracture fixation is commonly performed under general anesthesia due to the complex sensory innervation in this region which poses a challenge for anesthesiologists applying regional anesthetic (RA) techniques. In part 1 of this two-part study, we summarized the current literature describing various RA approaches in clavicle fractures and surgery. In our earlier scoping review, we surmised that a superficial or intermediate cervical plexus block (CPB) may provide analgesia for this procedure and, when combined with an interscalene brachial plexus block (ISB), can provide anesthesia to the clavicular region for surgical fixation. We performed a retrospective study, consolidating assumptions that were based on the results of our earlier scoping review. Methods. A retrospective study was conducted on 168 consecutive patients who underwent clavicle fixation surgery at a tertiary healthcare system in Singapore. We used a standardized pro forma to collate perioperative data from the electronic health records of both hospitals, including anesthetic technique, analgesic requirements, pain scores, and adverse events, up to the second postoperative day or up until discharge. Results. In our study, patients who received RA had significantly reduced pain scores and opioid requirements, compared to general anesthesia (GA) alone. Through subgroup analysis, differences were found in postoperative pain scores and opioid requirements in the following order: GA alone > GA with local infiltration analgesia > CPB > CPB plus ISB. All patients who received combined CPB and ISB had upper limb weakness in recovery, compared to none with CPB alone (p < 0.001). Of those who received an ISB either in isolation or combined with a CPB, four (9.3%) were reported to have dyspnea (within 24 h) and motor weakness that persisted beyond 12 h, compared to none for patients that received CPB alone. Conclusions. Addition of a CPB to GA for clavicle fracture fixation surgery is associated with reduced pain scores in the early postoperative period, with a lower opioid requirement compared to GA alone. In patients undergoing GA, the combination of a CPB with an ISB was associated with a small, although statistically significant, reduction in pain scores and opioid requirements compared to a CPB alone.

Outcomes After Orthopedic Trauma Surgery - What is the Role of the Anesthesia Choice?

The body of literature concerning the influence of anesthetic type on many perioperative outcomes has grown considerably in recent years. Most studies have suggested that particularly in orthopedic patients, regional anesthesia may be associated with improved perioperative outcomes. Orthopedic trauma presents itself as a field that might benefit from increased utilization of regional techniques with the goal to improve outcomes. This narrative review concludes that, indeed, regional anesthesia seems to provide benefits for morbidity, pain control, and improved return to function in hip fracture, rib fracture, and isolated extremity fracture patients.

Regional Anesthetic and Analgesic Techniques for Clavicle Fractures and Clavicle Surgeries: Part 1—A Scoping Review

Objective. Clavicle fractures are common injuries potentially associated with significant perioperative pain. However, this region’s complex sensory innervation poses a challenge for regional anesthetic or analgesic (RA) techniques. We conducted this scoping review to summarize the current literature, particularly with regards to motor-sparing techniques. Methods. A scoping review was carried out in accordance with the Joanna Briggs Institute’s framework. All articles describing the use of RA for clavicle fractures or surgery were included. PubMed^®, Ovid MEDLINE^®, EMBASE^®, Scopus^®, CINAHL^®, and the Cochrane database were searched without language restrictions. Results. Database searches identified 845 articles, 44 of which were included in this review, with a combined patient total of 3161. We included all peer-reviewed publications containing clinical data and summarized the findings. Conclusions. Current evidence of RA techniques in clavicle surgery is heterogeneous, with different approaches used to overcome the overlapping sensory innervation. The literature largely comprises case reports/series, with several randomized controlled trials. Intermediate cervical plexus block is the regional technique of choice for clavicle surgery, and can provide reliable surgical anesthesia when combined with an interscalene block. Cervical plexus block can provide motor-sparing analgesia following clavicle surgery. Promising alternatives include the clavipectoral block, which is a novel motor-sparing regional technique. Further studies are required to determine the efficacy and safety of various techniques.

Regional anesthesia as a safe anesthesia technique for clavicle surgery in a COVID-19 positive patient at rural setup: A case report

Introduction

Clavicle fractures are less commonly managed under regional anesthesia compared to general anesthesia. The study highlights the advantage of regional anesthesia in reducing the risk of aerosol generation and viral transmission during the times of COVID-19 and avoiding the complications associated with general anesthesia.

Presentation of case

We report a case of 42 years old COVID-19 positive male with a left clavicle fracture due to a fall from a tree, who was managed under regional anesthesia with open reduction and internal fixation. A combination of interscalene brachial plexus and superficial cervical plexus block was performed.

Discussion

The dual innervation of the clavicle makes combined interscalene brachial plexus and superficial cervical plexus block an effective method of anesthesia for clavicle surgery. It provides better analgesia, has fewer postoperative complications, less infection transmission via aerosol, and earlier hospital discharge as compared to general anesthesia.

Conclusion

Ultrasound-guided combined interscalene brachial plexus and superficial cervical plexus block can be used as a safe anesthetic technique in clavicle surgery.

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Clavicle fractures are less commonly managed under regional anesthesia.

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Regional anesthesia can be used as a safe anesthetic technique for clavicle surgery.

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It has better postoperative analgesia and fewer postoperative complications.

Awake Single-Stage Bilateral Clavicle Surgeries Under Bilateral Clavipectoral Fascial Plane Blocks: A Case Report and Review of Literature

The clavicle is a frequently fractured bone with an infrequent bilateral occurrence. Regional anesthesia (RA) for clavicle surgeries is always challenging due to its complex innervation arising from the two plexuses (cervical and brachial). Various RA techniques described for clavicle surgeries include plexus blocks, fascial plane blocks, and truncal blocks. Plexus blocks are associated with undesirable effects, such as phrenic nerve blockade and paralysis of the entire upper limb, limiting their application for bilateral regional clavicle surgeries. The clavipectoral fascial plane block (CPB) is a novel, procedure-specific, phrenic-sparing, and motor-sparing RA technique that can provide anesthesia or analgesia for clavicle surgeries. The decision to use the CPB and/or other RA techniques may depend on the site of clavicle injury or variations in clavicular innervation. We report a case of single-stage bilateral clavicle surgery successfully managed with a bilateral CPB alone using ultrasound guidance and landmark guidance separately. The patient was kept awake and comfortable throughout the surgery. In conclusion, CPB can be an effective alternate RA technique in avoiding undesired side effects of more proximal techniques such as phrenic nerve involvement and motor blockade of upper limbs. Landmark-guided CPB can be an alternative with equianalgesic efficacy as of ultrasound-guided CPB in resource-poor or emergency settings.

Regional anesthesia for nonunion surgery with iliac crest bone grafting results in an increase in same day discharge

INTRODUCTION

The purpose of this study was to evaluate the outcomes of fracture nonunion repair with autogenous iliac crest bone graft (ICBG) under regional anesthesia alone or in combination with other techniques compared to other anesthesia techniques.

MATERIALS AND METHODS

Overall, 137 patients were identified who underwent ICBG as part of a repair of a long bone fracture nonunion between January 1, 2013 and October 1, 2020. Surgical and anesthetic records were reviewed to classify patients by anesthesia type. General, spinal, and regional anesthetics were used as either the primary anesthetic or as a combination of regional nerve block with general or spinal anesthesia.

RESULTS

Administration of regional anesthesia alone or in combination with general or spinal anesthesia (RA) and general or spinal anesthesia only (GS) groups differed in nonunion site distribution (p < 0.001). RA patients were discharged the same day more often than GS patients (30.9% vs 10.0%, p = 0.009) and experienced fewer postoperative complications (p = 0.021). The RA group achieved union sooner than the GS group (by 5.3 ± 3.2 months vs. by 6.8 ± 3.2 months, p = 0.006). Mean morphine equivalent dose was similar between groups (p = 0.23). Regional anesthesia use increased from 2013 to 2020, and same day discharge surgeries simultaneously increased over the same time period.

CONCLUSION

Regional anesthesia use increased in nonunion repair surgery with ICBG from 2013 to 2020. This was associated with an increase in same day discharge, sooner time to union, and decreased postoperative complications. There was not a need for increased opioid prescription in patients that underwent regional anesthesia.

The emergency medicine management of clavicle fractures

BACKGROUND

Clavicle fractures are common. An emergency physician needs to understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, identify associated injuries, understand the difference between treating pediatric and adult patients, and have an approach to multimodal pain control. It is also important to understand when expert orthopedic consultation or referral is indicated.

OBJECTIVE OF THE REVIEW

To provide an evidence-based review of clavicle fracture management in the emergency department.

DISCUSSION

Clavicle fractures account for up to 4% of all fractures evaluated in the emergency department. They can be separated into midshaft, distal, and proximal fractures. They are also classified in terms of their degree of displacement, comminution and shortening. Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries. Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder. Nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling. Pediatric fractures are generally managed conservatively, with adolescents older than 9 years-old for girls and 12 years-old for boys being treated using algorithms that are similar to adults.

CONCLUSIONS

When encountering a patient with a clavicle fracture in the emergency department the fracture pattern will help determine whether emergent consultation or urgent referral is indicated. Most patients can be discharged safely with sling immobilization and appropriate outpatient follow-up.