Regional Anaesthesia for Upper Limb

Interscalene Identify: 2-3 roots in a vertical helps to identify the correct level alignment between anterior and (symmetrical tubercles at C5, larger Sternomastoid middle scalene muscles; identify C5 & anterior tubercle at C6, no anterior C5 middle scalene C6 nerve roots; use doppler to check tubercle at C7). for vascular structures . C6 Avoid: The dorsal scapular nerve DSN Target: Using an in-plane approach (DSN) lies in the middle scalene anterior scalene from the posterior end of the probe muscle-avoid direct needle trauma; aim for the interscalene groove the vertebral artery lies deeper but C7 between the C5 and C6 roots. within needle range; large volume injections increase the risk of phrenic VA Interscalene Tips: An easy way to locate the nerve, sympathetic blockade (Horner’s interscalene site is to scan up from the syndrome) or epidural spread. C7 tranverse process shoulder, proximal supraclavicular region; the distinctive humerus surgery morphology of the transverse processes anterior posterior

Supraclavicular Identify: The subclavian artery lying Tips: Rotate the lateral end of the on the first rib with underlying pleura. probe a little posteriorly to optimise omohyoid suprascapular The brachial plexus appears as a the image; keep the 1st rib in view nerve honeycombed structure lateral and beyond the needle tip to protect anterior superficial to the artery. against pneumothorax. scalene SCA Target: Using an in-plane needle Avoid: Pneumothorax: avoid needle middle scalene approach from the lateral end of tip penetrating beyond the first rib - it 1st rib brachial plexes the probe. You may need to make is vital to keep the tip in view throughout. 2-3 injections in the brachial plexus sheath to ensure LA spread to all Supraclavicular components including the “corner pocket” between the artery and rib. humerus, elbow, pleura hand surgery medial lateral

Infraclavicular Identify: The pectoralis major & minor Tips: Arm abduction and external muscles, the axillary artery and vein, rotation improves the view and needle the 3 cords arranged around the access below the clavicle but is not artery. essential; the pectoral muscles help pec major to anchor nerve catheters at this site. Target: Using an in-plane approach pec minor from the cephalad end of the probe Avoid: Pneumothorax, blood vessel aim for the posterior cord deep to puncture (check for the cephalic vein medial the artery and check LA spread, joining the axillary vein). AA inject around the lateral cord on AV lateral Infraclavicular needle withdrawal, redirect the needle over the artery to the medial cord if posterior humerus, elbow, necessary. hand surgery caudad caphalad

Identify: The axillary artery and veins Tips: Scan distally to confirm each Axillary medial (often multiple). The conjoint tendon nerve identity (median n stays with cutaneous nerve of teres major and latissimus dorsi brachial artery, ulnar n moves medially V is important: the four target nerves and superficially to the cubital tunnel, biceps U V (musculocutaneous, median, ulnar, radial n dives deep towards the M V radial) will lie above that tendon. The medial border of humerus with the AA R medial cutaneous n of the forearm profunda brachii artery); a nerve lies between median and ulnar just stimulator can be used to confirm V conjoint tendon beneath the deep fascia. nerve identity; expect variation in the position of nerves. coracobrachialis Target: Using an in-plane approach from the lateral end of the probe target Avoid: Intravascular injection (multiple triceps Axillary each nerve in turn (we block them in vessels) - watch the ultrasound for elbow, forearm, order: MC, R, U, M to preserve the injectate spread with each injection; hand surgery ultrasound view). avoid intrafascicular nerve trauma. caphalad caudad

Peripheral nerves

Radial brachial artery Median Ulnar ulnar nerve radial nerve median nerve

medial humerus epicondyle lateral medial lateral medial medial lateral

Proximal: Flex the elbow, place the probe over the lower 1/3 of the Proximal: Extend the elbow, the nerve lies medial to the brachial artery just Proximal: On the medial side of the distal humerus, above the humerus in an axial plane, look for the rounded appearance of the nerve above the elbow skin crease. medial epicondyle, locate the nerve before the nerve enters the cubital looping around the distal humerus. tunnel. Do not block the nerve in the tunnel itself.

Radial Median ulnar nerve Ulnar radial nerve medial nerve ulnar artery

elbow joint

lateral medial lateral medial lateral medial Distal: Extend the elbow, place the probe over the lateral half of the Distal: At the mid-forearm level the nerve is a hyperechoic, honeycombed Distal: Nerve lies on the medial side of the ulnar artery. Starting at the wrist, elbow crease. The radial nerve here has a characteristic spindle shape (2 structure at the centre of 3 fascial planes. There may be an accompanying scan proximally until they separate. components + artery). artery which should be avoided.

Twitter YouTube Palmar Dorsal Lower lateral cutaneous n. Lower lateral cutaneous n. Radial n. of arm (Radial n.) of arm (Radial n.) Radial n. Get the Median n. Lateral cutaneous n. of forearm Axillary n. Axillary n. Lateral cutaneous n. of forearm Median n. APP (Musculocutaneous n.) (Musculocutaneous n.)

Android iPad iPhone Supraclavicular n. (Cervical plexus)

Intercostobrachial n. Ulnar n. Medial cutaneous n. Medial cutaneous n. Ulnar n. of arm of the forearm Medial cutaneous n. Medial cutaneous n. Posterior cutaneous n. Posterior cutaneous n. of the forearm of arm of arm (Radial n.) of the forearm (Radial n.) FOR FURTHER INFORMATION [email protected] · pajunk.com

*This poster is an educational aid. It should not be used as a sole source of information for a new technique. Variations in anatomy are to be expected and no responsibility can be accepted for the technical ability of the practioner and individual patient outcomes. Regional Anaesthesia for Lower Limb

Fascia iliaca Fascia iliaca – fractured neck of femur, femoral shaft, hip surgery Identify: Start with the probe in a sagittal plane above the muscle and beneath the fascia (and A just medial to the anterior superior iliac spine clearly beneath the circumflex artery). fascia iliaca and slide medially; note the deep circumflex iliac artery (a branch of external iliac) which Tips: Lateral tilt of the probe may improve lies superficial to the fascia 1-2cm above the the view and an assistant may be required to inguinal ligament and is a useful landmark. retract the abdomen in an obese patient. This suprainguinal parasagittal view demonstrates iliacus Target: Use an in-plane approach from the the muscle & fascia passing deep into the caudal end of the probe. The target is to pelvis - gravity aids the spread of LA towards deposit local anaesthetic on the belly the lumbar plexus (this approach is also of the iliacus muscle, beneath the fascia suitable to catheter placement). proximal to the inguinal ligament. Observe the spread of local anaesthetic proximally Avoid: Injection distal to the inguinal ligament. caphalad caudad

Femoral Femoral – femoral shaft, quadriceps mechanism, knee surgery Identify: The femoral artery, iliacus and Tips: Choose a proximal site before the nerve fascia lata psoas muscles and fascia iliaca. Identify the branches immediately below the inguinal fascia iliaca indentation between the two components of ligament (if the femoral artery has divided then A femoral nerve iliopsoas. The nerve lies lateral to the artery, you are too distal). The nerve is usually more V usually flattened between the fascia and visible following injection of LA. Quadriceps muscle and it can take on a variety of shapes. weakness will affect active rehabilitation and mobility. iliacus Target: Using an in-plane approach from the psoas lateral end of the probe, local anaesthetic Avoid: Superficial injection, distal injection, injection must be beneath the fascia iliaca; intravascular injection. ensure the spread of LA surrounds the nerve.

medial lateral

Adductor canal Adductor Canal – knee surgery, cruciate ligament repair, supplement to sciatic nerve block for distal lower limb surgery Identify: The femoral artery beneath the Tips: If necessary trace the femoral artery sartorius muscle. The saphenous nerve lies in down from the inguinal region to the medial sartorius the same fascial plane, anterolateral to the thigh, especially in larger patients. The true artery, accompanied by the nerve to vastus adductor canal starts where the medial medialis. border of sartorius crosses the medial border A of adductor longus. Above that level it is saphenous nerve Target: Using an in-plane approach from technically a femoral triangle block but the vastus medialis V the lateral end of the probe inject in the outcome is similar. fascial plane alongside the femoral artery if adductor the nerve itself is not clearly identified (it will Avoid: Intravascular injection, trauma to the longus be easier to see after injection). nerve supplying vastus medialis. antetior posterior

Subgluteal Subgluteal – a proximal approach to the sciatic nerve for surgery below the knee, an alternative to the popliteal approach when access is limited; the posterior cutaneous nerve of the thigh will not be blocked Identify: At this level the sciatic nerve lies the sciatic nerve. biceps femoris between biceps femoris laterally and semi- tendinosus medially. Deep to the nerve is the Tips: Trace the nerve up from the popliteal semitendinosus adductor magnus muscle and there is usually fossa if necessary; tilt the probe to optimize a clear fascial plane between this and the visibility (anisotropy). Track the spread of LA sciatic nerve proximally and distally to ensure complete superficial muscles. The nerve is rarely round, more femur usually flattened or triangular in cross section. coverage of the nerve. Block onset can be adductor magnus delayed dueto the size of the target . Target: Using an in-plane approach from the lateral end of the probe with a longer needle, Avoid: Check for arteries crossing obliquely aim for circumferential spread of LA around deep to the sciatic nerve. lateral medial

Popliteal Popliteal – procedures of the leg, ankle and foot Identify: At the level of the popliteal crease, Tips: Probe tilt is useful here to identify the common peroneal identify the popliteal artery and vein. The larger nerves (anisotropy); ankle flexion & extension tibial component lies just superficial to the demonstrates the “see-saw” sign where the 2 tibial vessels, the smaller common peroneal nerve components move around each other. Track biceps femoris semi will be lateral and more superficial. Scan up the spread of local anaesthetic distally after membranosus and down to find the point at which they join injection to assess coverage of both nerves. V to form the sciatic nerve. The lateral decubitus position is shown here A and is very stable but alternative positions Target: Inject between the two components are the prone or supine with leg elevation, at the point where they separate or target depending on patient factors. the two nerves individually more distally. Avoid: Inadequate needle length, direct nerve trauma, intravascular injection. lateral medial

Obturator Obturator- supplement for hip, knee or bladder surgery Identify: the femoral artery, then slide the Tips: Abduct and externally rotate the limb if probe medially to locate the pectineus muscle possible. Probe tilt is useful to highlight the adductor longus and the 3 layers of adductor muscles (longus, nerves. A linear ultrasound probe is sufficient femoral anterior brevis and magnus from superficial to deep). but a curvilinear can be required for a large vessels division The anterior and posterior divisions of the leg. A more proximal target can be achieved nerve appear as hyperechoic structures in the by tracking and tilting the probe in a cephalad adductor brevis intermuscular fascial planes as shown. direction - the divisions will unite deep to pectineus pectineus muscle and a single injection here Target: Using an-plane approach from the will result in a complete block including the posterior lateral end of the probe with a minimum 80mm branches to the hip joint. The knee is supplied division echogenic needle, make an injection in the by the posterior division. fascial plane for each division. The nerves will adductor magnus be more obvious following injection. Avoid: The needle entry point may overlie the lateral medial femoral vessels, avoid puncturing them.

Lumbar Plexus Anterior Iliohypogastric Posterior Twitter YouTube Ilioinguinal Iliohypogastric Femoral branch Dorsal rami S1-S3 Genitofemoral of genito femoral Get the Lateral cutaneous nerve of thigh Ilionguinal Lateral cutaneous Obturator Anterior cutaneous Lateral cutaneous nerve of thigh APP Femoral nerves of thigh nerve of thigh Saphenous Obturator Obturator Sacral Plexus Posterior cutaneous Android iPad iPhone Posterior Cutaneous nerve of thigh Anterior femoral nerve of thigh Calcaneal cutaneous Sciatic Tibial Medial plantar Lateral plantar Common peroneal Common peroneal Sural Superficial Saphenous Saphenous peroneal Common peroneal Superficial peroneal Deep peroneal Deep peroneal Sural Medial calcaneal FOR FURTHER INFORMATION [email protected] · pajunk.com

*This poster is an educational aid. It should not be used as a sole source of information for a new technique. Variations in anatomy are to be expected and no responsibility can be accepted for the technical ability of the practioner and individual patient outcomes. Regional Anaesthesia for Ankle

Tibial

Identify: From anterior to Tips: The nerve usually lies posterior: medial malleolus, posterior to the artery and tibialis V tibialis posterior, flexor digitorum 2 veins. A small ultrasound posteria V longus, artery, nerve, flexor probe is useful. A hallucis longus. flexor digitorum longus Avoid: Confusion with tendons Target: Surround the nerve which also exhibit anisotropy V with local anaesthetic, using on ultrasound (flex the ankle or an in-plane or out-of-plane scan proximally to distinguish approach depending on between them). Excessive flexor hallucis patient morphology. probe pressure, intravascular tibia longus injection.

antetior posterior

Saphenous

Identify: The long saphenous Tips: A venous tourniquet can vein which lies very superficially, be used to help identify the vein; V anterior to the medial malleolus; use minimal probe pressure saphenous the nerve accompanies the and minimal depth setting to nerve vein. avoid compressing the vessel. tibia Target: In the fascial plane Avoid: Excessive probe pressure, around the vein if the nerve is intravascular injection. not directly visible.

antetior posterior

Deep peroneal

Identify: The small dorsalis Tips: Use minimal probe pedis artery lies directly on pressure, minimal depth setting extensor tibialis the subcutaneous surface of and scan up and down hallucis longus anterior the tibia. The nerve crosses above the ankle to see the over the artery from medial to nerve crossing the artery. lateral and this is a reliable deep A sign. Avoid: Excessive probe pressure, peroneal nerve intravascular injection. tibia Target: The nerve as it lies alongside the artery either on its lateral or medial side.

lateral medial

Superfi cial peroneal

extensor Identify: The anterior border Tips: Scan up and down at a digitorum longus of the fibula in the lower third reasonable speed to identify of the leg has a characteristic the nerve above the bone and sickle shape on ultrasound. intermuscular septum. superfi cial The superficial peroneal nerve peroneus lies superficially and the sharp Avoid: Deep injection. longus peroneal nerve anterior border of the bone points to the intermuscular septum and the nerve. fibula Target: The nerve in the superficial tissues at any point in the leg.

posterior antetior

Sural

Identify: The short saphenous Tips: Use a venous tourniquet sural nerve vein runs vertically down the to help identify the short back of the calf; the sural nerve saphenous vein; flex the knee V accompanies the vein. to leave room for access with soleus the ultrasound probe. tendo Target: The nerve directly if it is achilles visible, otherwise the fascial Avoid: Excessive probe pressure, plane surrounding the vein(s). intravascular injection. flexor hallucis longus

lateral medial

Anterior Posterior Plantar Dorsal Twitter YouTube Femoral Sciatic Deep peroneal Saphenous Get the Medial Common plantar APP peroneal Tibial Common peroneal Sural

Android iPad iPhone Superficial Saphenous peroneal Superficial Calcaneal Sural Superficial peroneal peroneal Medial planter Deep peroneal Medial Saphenous Lateral plantar calcaneal Lateral plantar Sural Calcaneal Deep peroneal FOR FURTHER INFORMATION [email protected] · pajunk.com

*This poster is an educational aid. It should not be used as a sole source of information for a new technique. Variations in anatomy are to be expected and no responsibility can be accepted for the technical ability of the practioner and individual patient outcomes. Regional Anaesthesia for Trunk

Paravertebral Thoracic Paravertebral – surgery involving the breast, ribs and chest wall Identify: In a parasagittal plane identify the Tips: While maintaining the same probe ribs at the level you wish to block, then trace orientation, angle the caudad end of the medially until the bony shadow changes probe away from the mid line to improve the paraspinal muscles to the more superficial and squarer outline needle access past the rib and transverse of the transverse processes (described process below. superior costotranverse as tombstones). Tilt the probe laterally ligament to demonstrate the pleura and superior Avoid: Keep the needle tip in view at all times TP TP costo-transverse ligament in the same image. to avoid pneumothorax, never advance the needle if you cannot see the tip. pleura Target: The small triangular paravertebral space lies between the superior paravertebal space costo-transverse ligament and the pleura.

caphalad caudad

Erector spinae Erector Spinae Plane – thoracic and upper abdominal surgery, posterior rib fractures Identify: Count the spinous processes inserted too far - this acts as a safety net. Look to identify the correct spinal level. In the for free spread of local anaesthetic in the trapezius paramedian plane identify the corresponding fascial plane and use ultrasound to assess rhomboid major transverse process, overlying muscle layers the segmental spread up and down the spine. erector spinae and underlying pleura. target Avoid: Lateral injection - be sure to identify Target: Using an in-plane approach from the transverse processes not ribs. Calculate the T5 T6 cephalic end of the probe, the target is the maximum local anaesthetic dose and dilute pleura fascial plane deep to the erector spinae as necessary to achieve a suitable volume, muscle. especially with bilateral injections. This is a suitable site for catheter techniques for chest Tips: Choose a site where the needle track wall injuries. would hit the transverse process if it was caphalad caudad

PECS PECS – breast surgery Identify: Starting in the infraclavicular brachial Tips: A single needle path in plane from the plexus position in the deltopectoral groove, count medial end of the probe allows both targets pectoralis major the ribs down from the clavicle to identify the 3rd to be reached through one insertion point. This and 4th ribs, then rotate the probe towards the block relies on adequate volumes of local PECS I axilla. There are 3 muscle layers: pectoralis major anaesthetic for spread. lies superficially, the pectoralis minor is beneath pectoralis minor Avoid: Keep the 4th rib deep to the needle 3rd rib PECS II that and the intercostals are deepest, running path to act as a safety measure against between the ribs. Serratus anterior arises intercostals pneumothorax, ensure the safe dose of local 4th rib beneath the lateral border of pec minor. anaesthetic is not exceeded especially when Target: The PECS I injection is between pec performing bilateral blocks. Avoid the artery pleura major and pec minor; the PECS II includes a that runs in the PECS I plane (a pectoral branch second injection between pec minor and the of the thoracoacromial artery). intercostal muscles. medial lateral

Serratus anterior Serratus anterior plane – rib fractures, breast surgery, axillary surgery Identify: Starting with the probe in a Tips: This approach is also very suitable transverse plane in the midaxillary line, scan for insertion of a nerve catheter. This block target posteriorly until the latissimus dorsi muscle relies on adequate volume for spread eg latissimus dorsi appears. There is usually an artery in the 30ml of local anaesthetic. serratus anterior plane (a branch of the thoracodorsal artery). Avoid: Vascular puncture, intravascular serratus anterior injection, pneumothorax. 5th rib Target: The aim is to inject in the fascial plane between latissimus dorsi and serratus pleura anterior. intercortals

posterior antetior

Quadratus lumborum Quadratus Lumborum (transmuscular) – abdominal surgery Identify: With the patient in the lateral position, Tips: A curvilinear probe is required and the use a curvilinear probe in the posterior MSK preset may be best. Use an adequate axillary line between the costal margin depth initially to identify the vertebral outline. latissimus dorsi abdominal wall and the iliac crest. Identify the L4 vertebral The QL muscle attaches to the tips of L1-L4 muscles body then tilt the probe caudally to see the transverse processes. quadratus lumborum transverse process with the three muscle groups retro-renal fat forming the “shamrock sign” as illustrated. Avoid: Intramuscular injection - look for erector spinae fascial plane spread and adjust the needle target Target: Using a 100mm echogenic needle position if necessary. Avoid the lateral psoas and an in-plane approach from the posterior peritoneal recess and retro-renal fat. Adequate end of the probe, the target is the fascial plane spread depends on volume of injectate, L4

between quadratus lumborum and psoas typically 30ml each side. Vetroexceeding the tranverse process major. maximum dose for the individual patient. posterior antetior

TAP Transversus Abdominis Plane – abdominal surgery Identify: The 3 muscle layers of the abdominal 100mm needle is appropriate. The block wall (external oblique, internal oblique; can be performed unilaterally or bilaterally, external oblique transversus abdominis) and trace them back depending on surgical site, and adequate posteriorly to the termination of transversus volume is required for spread eg 20-30ml abdominis. each side. Visceral pain will not be blocked by a TAP block. For surgery above the internal oblique Target: Beneath the fascial layer between umbilicus use the quadratus lumborum block. target the internal oblique and tranversus abdominis muscles near the posterior limit of the transversus muscle. Avoid: Intravascular injection - check for small tranversalis vessels with doppler prior to injection; avoid transversus abdominis fascia Tips: The posterior target site is generally the intraperitoneal injection; be aware of total most effective and because of the tangential local anaesthetic dose. antetior posterior peritoneum approach through the abdominal wall a

Cervical plexus Supraclavicular nerves Twitter YouTube Supraclavicular nerves

T2 – 12 segmental nerves Lateral cutaneous T2 Get the branches (lat cut T3 Lateral Anterior T4 cutaneous APP branch of T2 = inter- T5 branches costobrachial) cutaneous T6 branches T7 Anterior cutaneous T8 Android iPad iPhone branches T9 T10 T 11 Lateral cutaneous Lumbar plexus Iliohypogastric T 12 nerves of thigh Ilioinguinal L1 Genitofemoral Ilioingunal nerve Lateral cutaneous nerve Femoral branch of of thigh genitofemoral nerve FOR FURTHER INFORMATION [email protected] · pajunk.com

*This poster is an educational aid. It should not be used as a sole source of information for a new technique. Variations in anatomy are to be expected and no responsibility can be accepted for the technical ability of the practioner and individual patient outcomes.

PA_GuRu_Trunk_RZ.indd 1 01.09.2020 08:50:20