Interscalene brachial plexus block for surgical repair of clavicle fracture: a matched case-controlled study

Clavipectoral fascia plane block spread: an anatomical study

BACKGROUND

The clavipectoral fascia plane block (CPB) is a novel anesthetic management strategy proposed by Valdes-Vilches for clavicle fractures. This study aimed to investigate the distribution of the injected solution around the clavicle and the surrounding tissues.

METHODS

Twelve clavicle samples were acquired from six cadavers. CPB was conducted using a 20 mL solution comprising methylene blue and iodinated contrast agent to improve visibility of the injected substance's dispersion. Methylene blue spread was assessed through anatomical dissection across distinct planes (subcutaneous, superficial muscular, deep muscular, and periosteal layers of the clavicle) in five cadavers. For the purpose of comparing methylene blue distribution, CT scans were performed on three cadavers.

RESULTS

Methylene blue was detected in the medial, intermediate, and lateral supraclavicular nerves, as well as superficial muscles including the deltoid, trapezius, sternocleidomastoid, and pectoralis major. However, no staining was observed in the deep muscle plane, including the subclavius, pectoralis minor, and clavipectoral fascia (CPF). Anterosuperior periosteum exhibited staining in 54% of surface, while only 4% of the posteroinferior surface. CT images displayed contrast staining in anterosuperior periclavicular region, consistent with observations from sagittal sections and anatomical dissections.

CONCLUSION

The CPB effectively distributes the administered solution in the anterosuperior region of the clavicular periosteum, superficial muscular plane, and supraclavicular nerves. However, it does not affect the posteroinferior region of the clavicular periosteum or the deep muscular plane, including the CPF.

Femoral vs sciatic nerve block to provide analgesia after medial open wedge high tibial osteotomy in the setting of multimodal analgesia: A randomized, controlled, single-blinded trial

STUDY OBJECTIVE

Medial open wedge high tibial osteotomy (MOW HTO) is associated with moderate to severe postoperative pain. The proximal part of the tibia is innervated by branches from the femoral nerve anteriorly and the sciatic nerve posteriorly. There is a paucity of information regarding the optimal peripheral nerve block for postoperative analgesia with minimal impact on motor function. This study tested the hypothesis that a femoral nerve block provides superior analgesia to a sciatic nerve block after MOW HTO in the setting of multimodal analgesia.

DESIGN

Randomized controlled single-blind trial.

SETTING

Operating room, postoperative recovery area and ward, up to 6 postoperative months.

PATIENTS

Fifty patients undergoing MOW HTO.

INTERVENTIONS

Interventions were femoral or sciatic nerve block under ultrasound guidance. For each intervention, a total of 100 mg of ropivacaine was injected. Postoperative pain treatment followed a pre-defined protocol with intravenous patient-controlled analgesia of morphine, paracetamol, and ibuprofen.

MEASUREMENTS

The primary outcome was intravenous morphine consumption at 24 h postoperatively. Secondary outcomes included rest and dynamic pain scores (on a numeric rating scale out of 10) at 2, 24 and 48 h postoperatively. Functional outcomes included the Short Form-12, Knee injury and Osteoarthritis Outcome Score, and International Knee Documentation Committee (IKDC) scores measured at 6 months postoperatively.

MAIN RESULTS

Mean [95% confidence interval] i.v. morphine consumption at 24 postoperative hours were 24 mg [15 mg,33 mg] in the femoral nerve block group and 24 mg [16 mg,32 mg] in the sciatic nerve block group (p = 0.98). There were no significant differences in the secondary outcomes between groups.

CONCLUSIONS

This trial failed to demonstrate that a femoral nerve block provides superior analgesia to a sciatic nerve block after MOW HTO under general anesthesia in the setting of multimodal analgesia. There was no significant difference in quality of life and functional outcomes at 6 months postoperatively between groups. Trial registry number:Clinicaltrials.com - NCT05728294; Kofam.ch - SNCTP000003048 | BASEC2018-01774.

Peripheral regional anaesthesia and outcomes: a narrative review of the literature from 2013 to 2023

The use of peripheral regional anaesthesia continues to increase, yet the evidence supporting its use and impact on relevant outcomes often lacks scientific rigour, especially when considering the use of specific blocks for a particular surgical indication. In this narrative review, we consider the relevant literature in a 10-yr period from 2013. We performed a literature search (MEDLINE and EMBASE) for articles reporting randomised controlled trials and other comparative trials of peripheral regional anaesthetic blocks vs systemic analgesia in adult patients undergoing surgery. We evaluated measures of effective treatment and complications. A total of 128 studies met our inclusion criteria. There remains variability in the technical conduct of blocks and the outcomes used to evaluate them. There is a considerable body of evidence to support the use of interscalene blocks for shoulder surgery. Saphenous nerve (motor-sparing) blocks provide satisfactory analgesia after knee surgery and are preferred to femoral nerve blocks which are associated with falls when patients are mobilised early as part of enhanced recovery programmes. There are additional surgical indications where the efficacy of cervical plexus, intercostal nerve, and ilioinguinal/iliohypogastric nerve blocks have been demonstrated. In the past 10 yr, there has been a consolidation of the evidence indicating benefit of peripheral nerve blocks for specific indications. There remains great scope for rigorous, multicentre, randomised controlled trials of many peripheral nerve blocks. These would benefit from an agreed set of patient-centred outcomes.

Is local anesthesia or general anesthesia preferable for plate removal after clavicle fracture surgery under general anesthesia? A comparative study using a patient questionnaire

INTRODUCTION

Because we have a limited number of surgeries performed under general anesthesia, implant removal after plate fixation for clavicular fracture is often performed under local anesthesia. However, it is unclear whether local anesthesia or general anesthesia is preferred. Therefore, we conducted a questionnaire survey of patients who had undergone implant removal surgery under local or general anesthesia after clavicle fracture surgery to assess their impressions of each procedure and which anesthesia they would prefer if they were to undergo plate removal in the future.

MATERIALS AND METHODS

A questionnaire survey was conducted on 239 patients. Fifty-six patients who had undergone plate fixation of a clavicle fracture in whom plate removal was conducted under local anesthesia in a university hospital, and one hundred and eighty-three patients in whom plate removal was conducted under general anesthesia in a general hospital. All participants had undergone plate fixation for clavicle fractures under general anesthesia. The participants were asked to complete a questionnaire including a question on which method of anesthesia they would prefer should they have to undergo similar surgery in the future.

RESULTS

The patients of both groups responded that they would prefer the same method of anesthesia as before to be used (87.1 % of the patients who underwent plate removal under local anesthesia, 78.9 % of the patients underwent plate removal under general anesthesia), with no significant difference between the groups (p > 0.33).

CONCLUSIONS

Patients who underwent surgery under local anesthesia preferred local anesthesia if they were to undergo it next, even though most of them felt some pain. Though surgeons tend to focus only on the patient's distress during surgery, they also find that patients are often dissatisfied during the perioperative period, including bed rest and urinary catheters. Although clavicle plate removal may be performed under general anesthesia in many cases, it may be worth considering plate removal under local anesthesia to use general anesthesia surgery effectively, which is limited due to financial problems and facilities. Plate removal under local anesthesia was just as acceptable as general anesthesia for the patients.

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.

Ultrasound-guided clavipectoral fascia plane block for middle third clavicular fracture: A case series

BACKGROUND AND OBJECTIVE

Clavipectoral fascia plane block has been described as an anaesthetic and analgesic strategy for osteosynthesis of midclavicular fractures. However, to date, only isolated cases have been published. The aim of this study was to evaluate the anaesthetic and analgesic efficacy of this new approach in midclavicular fracture surgery in a large case series.

MATERIAL AND METHODS

Descriptive, observational study of 50 patients undergoing osteosynthesis of middle third clavicular fracture who received CPB block associated with supraclavicular nerve block. The primary objective was to assess pain on a VAS scale in the immediate postoperative period, and at 6, 12 and 24h. Secondary objectives were to determine the degree of intraoperative sedation, perioperative morphine consumption, need for rescue analgesia, unplanned general anaesthesia, presence of motor and sensory blockade, and diagnosis of diaphragmatic paralysis.

RESULTS

Postoperative pain was 1.04 (SD=1.26) in the immediate postoperative period; 1.24 (SD=1.42) at 6h; 1.34 (SD=1.92) at 12h; and 0.96 (SD=1.29) at 24h. Mean total intraoperative fentanyl dose was 0.88μg/kg. Postoperatively, nine patients (18%) requested rescue analgesia. There were no conversions to general anaesthesia, no motor or sensory blockade of upper extremities, and no hemidiaphragmatic paralysis.

CONCLUSIONS

Our series supports the anaesthetic and analgesic efficacy of CPB block for osteosynthesis of midclavicular fractures.

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.

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.

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

Background

Clavicular 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.

Objectives

We aimed to evaluate whether ultrasound-guided clavipectoral block [clavipectoral fascial plane block (CPB)] would be safe and effective in cases with clavicular fractures.

Methods

This 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.

Results

Despite 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.

Conclusions

CPB is a safe and effective regional technique that should be used for pain management after clavicular fixation 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

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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.

Innervation of the clavicle: a cadaveric investigation

BACKGROUND

This cadaveric study investigated the innervations of the clavicle and clavicular joints (ie, sternoclavicular and acromioclavicular joints).

METHODS

Twenty cadavers (40 clavicles) were dissected. A skin incision was made to permit exposure of the posterior cervical triangle and infraclavicular fossa. The platysma, sternocleidomastoid, and trapezius muscles were cleaned in order to identify the supraclavicular nerves. Subsequently, the suprascapular and subclavian nerves were localized after removal of the prevertebral layer of the deep cervical fascia. In the infraclavicular region, the pectoralis major and minor muscles were retracted laterally in order to visualize the lateral pectoral nerve. The contribution of all these nerves to the clavicular bone and joints were recorded.

RESULTS

Along their entire length, all clavicular specimens received contributions from the supraclavicular nerves. The latter innervated the cephalad and ventral aspects of the clavicular bone. The caudal and dorsal aspects of the clavicle were innervated by the subclavian nerve (middle and medial thirds). The lateral pectoral nerve supplied the caudad aspect of the clavicle (middle and lateral thirds). The sternoclavicular joint derived its innervation solely from the supraclavicular nerves whereas the acromioclavicular joint was supplied by the supraclavicular and lateral pectoral nerves.

CONCLUSION

The clavicle and clavicular joints are innervated by the subclavian, lateral pectoral, and supraclavicular nerves. Clinical trials are required to determine the relative importance and functional contribution of each nerve.

Ultrasound-Guided Clavipectoral Fascial Plane Block for Surgery Involving the Clavicle: A Case Series

The clavipectoral fascial plane block (CPB) is a novel regional anesthesia technique that has been utilized for clavicular fracture surgery. While the cutaneous innervation of the skin above the clavicle is well-known to be supplied by the supraclavicular nerve of the superficial cervical plexus (SCP), the sensory innervation of the clavicle itself is somewhat controversial. Despite this controversy, it has been hypothesized that the CPB is an effective regional anesthesia technique for peri-operative analgesia since the terminal branches of many of the sensory nerves like suprascapular, subclavian, lateral pectoral, and long thoracic nerves pass through the plane between the clavipectoral fascia and the clavicle itself.