block for medial clavicular fracture?

[GA8314]

anyone have a good block for this? They can hurt really bad as my patient today (inhereted case from partner who didn't block preop). I did a post-op superficial cervical plexus and interscalene with some good success but at that point i had already thrown the kitchen sink at her so hard to tell with moving variables......

this was a fracture which was past the mid-clavicular line, medial....

anyone with good success with other blocks? parevertebrals? PECS2?

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[Scotty_G]

Medial clavicle is innervated by the cervical plexus. Superficial cervical plexus block is a simple block to do and you can basically do a high interscalene then move and deposit local under the SCM and cover majority of the clavicle. Most people will argue against u/s for the superficial cervical block and I agree it's not necessary. However, I combine the 2 blocks since I'm using the u/s anyway and it's just as fast.

 

[Maverikk]

Clavicle has a poorly described innervation in the regional literature and depends on which 1/3 you're talking about. I think the superficial cervical plexus contribution is what's often missed and not typically done in a busy ortho u/s regional practice. Here's what I've done before with good success: interscalene (as high up as you can go), then on the way out deposit a bit over the median scalene muscle where the superficial cervical plexus usually lies (sometimes you can catch a glimpse if you take your time and find it, but it's difficult). This has the advantage to of one block. No reason to do a supraclav after an interscalene in this situation, you're just getting further down the arm.

Edit: ha, two similar answers at the same time is always a good sign

 

[GA8314]

Thanks guys. Yes, I did the superficial cervical plexus(i mistyped supraclavicular) with the ISB. Got pretty good results, but as stated had already given toradol, Ofirmev, and Dilaudid.......Soooo there were a few confounding variables...

 

[dhb]

I go straight cervical plexus block superficial and deep with good results.

 

[GaseousClay]

I don't think block is necessary for any clavicle. Have not seen any patients in severe pain after this surgery when surgeon infiltrates local.

 

[dhb]

I don't think block is necessary for any clavicle. Have not seen any patients in severe pain after this surgery when surgeon infiltrates local.

I think a block is always superior to surgical infiltration.

 

[facted]

I don't think block is necessary for any clavicle. Have not seen any patients in severe pain after this surgery when surgeon infiltrates local.

Your surgeons must have the hands of God. Have seen patients in tons of pain without a block for clavicle. I also do interscalene and superficial cervical plexus.

 

[GassmanMD]

Superficial cervical plexus block.

 

[deleted171991]

Medial clavicle is innervated by the cervical plexus. Superficial cervical plexus block is a simple block to do and you can basically do a high interscalene then move and deposit local under the SCM and cover majority of the clavicle. Most people will argue against u/s for the superficial cervical block and I agree it's not necessary. However, I combine the 2 blocks since I'm using the u/s anyway and it's just as fast.

This is how close the superficial cervical plexus is to the brachial plexus:

Ultrasound-Guided Superficial Cervical Plexus Block - NYSORA The New York School of Regional Anesthesia

 

[turnupthevapor]

This is how close the superficial cervical plexus is to the brachial plexus:

Ultrasound-Guided Superficial Cervical Plexus Block - NYSORA The New York School of Regional Anesthesia

It is close.... You do pop through the investing fascia which envelopes and connects the trap to the SCM. The BP is wrapped with the paravetebral fascia (another deep cervical fascia sheath) so usually don't get a BP block if you do a superficial which has been renamed the intermediate cervical plexus block.

 

[turnupthevapor]

Question is, are the osteotomes to the medial clavicle supraclavicular n. or the T2 intercostal? I am not sure

 

[deleted171991]

Question is, are the osteotomes to the medial clavicle supraclavicular n. or the T2 intercostal? I am not sure

It took a 10 second Google search:
https://link.springer.com/content/pdf/10.1186/s40981-016-0061-6.pdf

We had to relieve the pain of the supraclavicular nerve and the fifth and sixth cervical nerves (C5 and C6) for the left clavicle fracture surgery. The most appropriate methods include both a left cervical plexus nerve block and a brachial plexus nerve block. However, since the cervical plexus nerve block is associated with a risk of phrenic nerve paralysis, we opted for a selective supraclavicular nerve block.

 

[GaseousClay]

Your surgeons must have the hands of God. Have seen patients in tons of pain without a block for clavicle. I also do interscalene and superficial cervical plexus.

I think interscalene for medial clavicle is good for billing purposes but not for pain control. Yes superficial cervical plexus will def help but a generous infiltration of local will definitely reach the nerves to the clavicle given how superficial they usually are. Our surgeons definitely do not have the gift of God haha

 

[GA8314]

I don't think block is necessary for any clavicle. Have not seen any patients in severe pain after this surgery when surgeon infiltrates local.

I have seen several patients in excruciating pain.

For the patient I described, the surgeon used a lot of LA infiltration...... So, not adequate at least for her.

 

[Metalblade]

A deep cervical plexus block, either the traditional approach or the Winnie approach (high interscalene with strap muscle twitch) will get the medial half of the clavicle. I'm not sure how to do this with Ultrasound. 30cc of chosen local. Then interscalene block with 10cc of local using US. Some of the local given at the cervical plexus makes it's way down to the brachial plexus so don't need to give much. Patient will get a numb face as well as a shoulder with this technique though. But I have found it to be the best block combo for a midclavicular fracture. Wont have to give any narcotic intra or post op.