Bilateral wrist fractures and blocks

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Oggg

Oggg

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Healthy middle aged woman who fell off a bike and broke both wrists. Right handed. Right wrist hurts a little more. Dedicated boyfriend at home to take care of her. I discuss local vs various nerve block options. I recommend right brachial plexus block, GA, local to left wrist, and rescue block left arm only if needed. Pt is concerned about pain and wants bilateral blocks. I recommend a "light block" but tell her there's a risk that both her arms get paralyzed. She still wants both blocks.

Rt supraclav 30cc 0.3%ropiv w/decadron 5mg. Lt infraclav 30cc 0.3% ropiv w/decadron 5mg. GA. Zero narcotics. 0/10 pain in PACU. Totally paralyzed arms and fingers in PACU. Anyone surprised? I'm thinking I should have omitted the decadron and/or kept it at 0.2%ropiv.
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If analgesia is all you care about, 0.2% Ropivicaine will work just fine. I know we like to get all gung ho and blast in the 0.5% to provide a surgical block for hours and hours, but a more dilute solution can still provide long lasting pain relief.

The lady might not like the idea of pain, but with bilateral wrist fx's she's going to have some. You can't make a block last long enough on both arms for her to not hurt until she's healed weeks later.
 
I'm a REGIONAL ADVOCATE but this case screams blocking the right,

GENERAL ANESTHESIA AND DILAUDID IN THE PACU.

Pick your battles.
 
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What about individual blocks of the radial/ulnar/median nerves on the left post-op, when she can better tell you exactly what part hurts worst? When done under U/S at about the elbow, the nerves are easily visible and accessible. I had to rescue a supraclav the other day, when the pt had full sensation to the dorsum of her hand. The initial block was textbook, neither I nor my staff could figure out why we missed the distal radial nerve (excellent spread of local around the plexus up and down), but 10mL 0.5% bup deposited around the radial nerve took care of the problem.

I have put bilateral supraclav catheters in trauma patients with horrible injuries, and it does make overall care rather challenging (1:1 inpatient care, no PCA, or bolus on the catheters, etc), and wreaks havoc with their morale. Sometimes, though, you just have to do what will help the patient the most. It sounds like in your situation, she had an adequate support system available, and the single shot blocks are only temporary (even with the decadron, you shouldn't get more than a day of motor block with rop).

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psychbender said:
What about individual blocks of the radial/ulnar/median nerves on the left post-op, when she can better tell you exactly what part hurts worst? When done under U/S at about the elbow, the nerves are easily visible and accessible. I had to rescue a supraclav the other day, when the pt had full sensation to the dorsum of her hand. The initial block was textbook, neither I nor my staff could figure out why we missed the distal radial nerve (excellent spread of local around the plexus up and down), but 10mL 0.5% bup deposited around the radial nerve took care of the problem.

I have put bilateral supraclav catheters in trauma patients with horrible injuries, and it does make overall care rather challenging (1:1 inpatient care, no PCA, or bolus on the catheters, etc), and wreaks havoc with their morale. Sometimes, though, you just have to do what will help the patient the most. It sounds like in your situation, she had an adequate support system available, and the single shot blocks are only temporary (even with the decadron, you shouldn't get more than a day of motor block with rop).

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Click to expand...

Good post.

Selective terminal branches might work depending on the fracture. Or you can send her home with .1 % ropivicaine catheter. "Analgesic" not "Anesthetic doses". I wouldn't send bilateral blocks home due to possible phrenic dysfunction. Should still be able to move her arm without much motor block.

Bilateral motor blocks make #2 very difficult, embarrasing and just not worth it.
 
psychbender said:
What about individual blocks of the radial/ulnar/median nerves on the left post-op, when she can better tell you exactly what part hurts worst? When done under U/S at about the elbow, the nerves are easily visible and accessible. I had to rescue a supraclav the other day, when the pt had full sensation to the dorsum of her hand. The initial block was textbook, neither I nor my staff could figure out why we missed the distal radial nerve (excellent spread of local around the plexus up and down), but 10mL 0.5% bup deposited around the radial nerve took care of the problem.

I have put bilateral supraclav catheters in trauma patients with horrible injuries, and it does make overall care rather challenging (1:1 inpatient care, no PCA, or bolus on the catheters, etc), and wreaks havoc with their morale. Sometimes, though, you just have to do what will help the patient the most. It sounds like in your situation, she had an adequate support system available, and the single shot blocks are only temporary (even with the decadron, you shouldn't get more than a day of motor block with rop).

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Click to expand...

I've also performed rescue blocks under u/s. An additional 15 mls of local in the Supraclavicular or Infraclavicular region solves the problem. The Axillary approach to blocking the radial nerve is also quite easy.
 
1-s2.0-S0363502307008258-gr5.jpg
 
Do many of you do selective nerve blocks? I'm cautious about using Dexamethasone as an additive for selective nerve blocks. Remember small nerves are easy to elicit paresthesia so careful injection around the nerve (avoid touching the nerve).
 
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The radial nerve is easily seen as the deep andsuperficial branches between the brachioradialis and brachialis muscles at the elbow (Fig 4A) and wasconsistent across all volunteers. From the elbow levelthe nerve can be easily followed proximally up thearm where it usually divides approximately 2 cm to 3cm proximal to the elbow. The single radial nerve can beeasilyvisualized5cmproximaltotheelbowlateralto the humerus (Fig 4B). Traveling distal from theelbow it was only possible to follow the superficial branchoftheradialnerveasfarasthemidforearmin65% of volunteers (Fig 4C) and as far as the distalforearm (5 cm proximal to radial styloid where thenerve crosses anterior to the radius and then splitsinto small terminal branches) in 55% of volunteers
 
Oggg said:
Healthy middle aged woman who fell off a bike and broke both wrists. Right handed. Right wrist hurts a little more. Dedicated boyfriend at home to take care of her. I discuss local vs various nerve block options. I recommend right brachial plexus block, GA, local to left wrist, and rescue block left arm only if needed. Pt is concerned about pain and wants bilateral blocks. I recommend a "light block" but tell her there's a risk that both her arms get paralyzed. She still wants both blocks.

Rt supraclav 30cc 0.3%ropiv w/decadron 5mg. Lt infraclav 30cc 0.3% ropiv w/decadron 5mg. GA. Zero narcotics. 0/10 pain in PACU. Totally paralyzed arms and fingers in PACU. Anyone surprised? I'm thinking I should have omitted the decadron and/or kept it at 0.2%ropiv.
Click to expand...

I would block one arm with 0.3% Rop plus Decadron (4mg PF). GA with LMA. In PACU I would asses her motor block prior to consideration for a second nerve block. This way I could adjust her Rop concentration DOWN if needed.

Also, I would do Infraclavicular blocks (like you did) instead of Supraclavicular blocks to avoid Phrenic nerve block. Axillary blocks would be another alternative.

I'm not a big selective nerve block guy as my success is very high and I usually just rescue my partner's blocks with 15 cc of local via SCB or ICB approach. So far, 100% rescue with my approach.
 
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Oggg said:
Healthy middle aged woman who fell off a bike and broke both wrists. Right handed. Right wrist hurts a little more. Dedicated boyfriend at home to take care of her. I discuss local vs various nerve block options. I recommend right brachial plexus block, GA, local to left wrist, and rescue block left arm only if needed. Pt is concerned about pain and wants bilateral blocks. I recommend a "light block" but tell her there's a risk that both her arms get paralyzed. She still wants both blocks.

Rt supraclav 30cc 0.3%ropiv w/decadron 5mg. Lt infraclav 30cc 0.3% ropiv w/decadron 5mg. GA. Zero narcotics. 0/10 pain in PACU. Totally paralyzed arms and fingers in PACU. Anyone surprised? I'm thinking I should have omitted the decadron and/or kept it at 0.2%ropiv.
Click to expand...

Why did she need GA?
 
I had planned to do one block, GA then block the other arm in PACU if needed. Someone made a good point that you can titrate your block at that point.

I had thought about elbow blocks, but that is 3 injections and I thought I was being too crazy. Do you get any motor block with blocks at or just above the elbow? I would think you would maintain wrist flexor/extensors, as well as elbow and shoulder, but you'd lose intrinsically of the hand and abductors.
 
don't block the ulnar at the elbow, you are asking for a nerve injury
 
Mman said:
don't block the ulnar at the elbow, you are asking for a nerve injury
Click to expand...

Correct. Tight space... and the ulnar nerve is an uber big nerve.

Always surpises me how big that motha is when doing a cubital tunnel release.

For a wrist fracture you can do all terminal branch blocks below the elbow.
 
1. The ulnar nerve is highly visible above the elbow, above where the nerve dives down into the tunnel. I don't think there's anything wrong with that.
2. Distal to the elbow, I haven practiced mid forearm ultrasound guided nerve blocks. I have traced ulnar and radial nerves in this region but not with regularity. I don't remember tracing the median nerve down there (maybe start at carpal tunnel and scan proximally?).
 
We do a lot of infraclavs at my institution. By far our most common brachial plexus block.

We would probably do bilateral infraclavs with 2% lidocaine if surgical time would permit, or 0.5% ropiv or bupiv. Depending on weight, about 20-25ml per side, catheters on both sides. (Typically for a single side we'll do 30-40ml)

For forearm blocks, we do median and ulnar about mid-forearm. You can actually block both with just one needle and needle insertion site, if you wanna get fancy. Radial, we block at the elbow.

You might also need to block the medial antebrachial cutaneous and/or lateral antebrachial cutaneous.
 
BLADEMDA said:
Remember small nerves are easy to elicit paresthesia so careful injection around the nerve (avoid touching the nerve).
Click to expand...

+1

I had my colleague do a mid-forearm median nerve saline block via U/S on me today. I got an intense median nerve paresthesia as the needle simply approached the nerve and sheath. The needle wasn't in the nerve or even touching the sheath. I was really surprised a) how uncomfortable it was and b) how intense the sensation was even without physical contact.
 
Oggg said:
1. The ulnar nerve is highly visible above the elbow, above where the nerve dives down into the tunnel. I don't think there's anything wrong with that.
2. Distal to the elbow, I haven practiced mid forearm ultrasound guided nerve blocks. I have traced ulnar and radial nerves in this region but not with regularity. I don't remember tracing the median nerve down there (maybe start at carpal tunnel and scan proximally?).
Click to expand...

Ulnar, radial and median nerves are all visible below the elbow.

Median sticks out the most mid forearm... Pretty much smack in the middle.
 
Tracing the ulnar and radial up from the wrist is fairly easy. Use their respective arteries to find it and trace back. Good luck.
 
Oggg said:
Healthy middle aged woman who fell off a bike and broke both wrists. Right handed. Right wrist hurts a little more. Dedicated boyfriend at home to take care of her. I discuss local vs various nerve block options. I recommend right brachial plexus block, GA, local to left wrist, and rescue block left arm only if needed. Pt is concerned about pain and wants bilateral blocks. I recommend a "light block" but tell her there's a risk that both her arms get paralyzed. She still wants both blocks.

Rt supraclav 30cc 0.3%ropiv w/decadron 5mg. Lt infraclav 30cc 0.3% ropiv w/decadron 5mg. GA. Zero narcotics. 0/10 pain in PACU. Totally paralyzed arms and fingers in PACU. Anyone surprised? I'm thinking I should have omitted the decadron and/or kept it at 0.2%ropiv.
Click to expand...

Propofol + LMA. Screw all them fancy shmancy blocks.
 
fakin' the funk said:
+1

I had my colleague do a mid-forearm median nerve saline block via U/S on me today. I got an intense median nerve paresthesia as the needle simply approached the nerve and sheath. The needle wasn't in the nerve or even touching the sheath. I was really surprised a) how uncomfortable it was and b) how intense the sensation was even without physical contact.
Click to expand...

There are reports of Saline only nerve blocks (no local) causing motor and sensory loss (temporary)
Brain Ilfeld reported this last year. Be careful and stop monkeying around.
 
fakin' the funk said:
Who? Never heard of him.
Click to expand...

He's one of the pioneers of outpatient continuous peripheral nerve blocks.

Distal terminal nerve blockade is a great alternative to proximal brachial plexus block in some situations. All three nerves can be found relatively easily in the antecubital fossa (median nerve is the most medial structure, radial is "stellate" in appearance and lateral) and the epicondylar groove (ulnar) and then scanned distally to the forearm. It's great to be able to provide selective analgesia or anesthesia for specific hand/wrist injuries according to nerve distribution. Avoiding extremity motor-block is a bonus for the patient. Remember to use a blunt tipped needle for these blocks to reduce the likelihood of transfixing the nerve. Visualization is pretty easy given how superficial they are.
 
reanimatore said:
He's one of the pioneers of outpatient continuous peripheral nerve blocks.

Distal terminal nerve blockade is a great alternative to proximal brachial plexus block in some situations. All three nerves can be found relatively easily in the antecubital fossa (median nerve is the most medial structure, radial is "stellate" in appearance and lateral) and the epicondylar groove (ulnar) and then scanned distally to the forearm. It's great to be able to provide selective analgesia or anesthesia for specific hand/wrist injuries according to nerve distribution. Avoiding extremity motor-block is a bonus for the patient. Remember to use a blunt tipped needle for these blocks to reduce the likelihood of transfixing the nerve. Visualization is pretty easy given how superficial they are.
Click to expand...

Very easy to visualize. I can track them in most people in a few seconds. I'm still not a fan because of dysthesias. I've never had to rescue a median nerve but I have rescued the radial and ulnar nerve.
 
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