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Distal radius and proximal humerus fractures

kmurp

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My partner texted me about a patient with this combo of fractures asking which block(s) would I do for this case. My thoughts were ISB or superior trunk plus SCB or ISB/Superior trunk plus radial nerve just above the elbow. I’d be interested in opinions.
 

vector2

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My partner texted me about a patient with this combo of fractures asking which block(s) would I do for this case. My thoughts were ISB or superior trunk plus SCB or ISB/Superior trunk plus radial nerve just above the elbow. I’d be interested in opinions.

Depending on how proximal the humerus is I think you have to hit C5-C7 cause the incisions might encroach on axillary and suprascapular nerve distributions. And usually for distal radius you have to hit median and radial nerves. I think you're better off just splitting a reasonable volume between both complete ISB and SCB just to make sure you have overlapping coverage and no hotspots.


 
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BLADEMDA

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I would choose a supraclavicuar block here. An interscalene block would work also provided local was deposited all along the nerve roots including C7. There may be some pain/pressure during the case from the C8 dermatome as well but that should be covered with a LMA

If in the pacu the patient had any shoulder pain I’d place another 10 Mls of local near C5 or C6. Typically, this isn’t necessary with a well placed SCB.
 
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Ronin786

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No the thumb is usually the weakest part of the block
1589959935160.png

"Sensory distribution of the interscalene brachial plexus block (in red). Ulnar nerve distribution area (C8-T1) can also be accomplished by using larger volume (e.g. 15-20 ml) and using low interscalene block where the injection occurs between the ISB and supraclavicular block."


The ulnar nerve has much more of a contribution from C8-T1 than the radial nerve.
 
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vector2

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View attachment 306912

"Sensory distribution of the interscalene brachial plexus block (in red). Ulnar nerve distribution area (C8-T1) can also be accomplished by using larger volume (e.g. 15-20 ml) and using low interscalene block where the injection occurs between the ISB and supraclavicular block."


The ulnar nerve has much more of a contribution from C8-T1 than the radial nerve.

ISB may work for distal radius, esp when supplemented by the anesthetic. I'm just saying that the radial nerve does have contributions from lower roots (not to mention the deltoid from the axillary n. if we havent forgotten about the humerus) in case someone had a low volume C5-7 ISB in mind. Additionally, if the fracture is very close to the articular parts and then rest of the wrist joint then I would feel uncomfortable not just covering the entire wrist from the getgo.

11487tn.jpg
 
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AdmiralChz

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Why would you do an interscalene block which might cover what you need versus a supraclavicular which you are virtually guaranteed a complete block? Overthinking going on here.

Also given the injury, the orthos around here would request GA anyways. What mechanism caused a prox humerus and distal radius fractures?
 
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MirrorTodd

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Why would you do an interscalene block which might cover what you need versus a supraclavicular which you are virtually guaranteed a complete block? Overthinking going on here.

Also given the injury, the orthos around here would request GA anyways. What mechanism caused a prox humerus and distal radius fractures?
I'm sure the guy was just standing on the corner minding his own business.
 
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caligas

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Why would you do an interscalene block which might cover what you need versus a supraclavicular which you are virtually guaranteed a complete block? Overthinking going on here.

Also given the injury, the orthos around here would request GA anyways. What mechanism caused a prox humerus and distal radius fractures?

honest answer is that I’ve done hundreds of ISBs and only dozens of SCBs, but sounds like I should shift my thinking. That’s why I surf here everyday.
 
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BLADEMDA

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An Interscalene block, even a low one near C7, will miss C8 about 10-15 percent of the time. Hence, if you need to block C8 or T1 then an interscalene block is a poor choice vs a supraclavicular or infraclavicular block.

For a radius fracture C7 needs to be blocked so a low interscalene should work most of the time. Still, I rarely ever do an ISB for distal extremity surgery any longer as we have ultrasound which makes the other brachial plexus blocks easy to perform.


c7 dermatome
 

BLADEMDA

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Here is a real image of the dermatomes. The typical incision for an ORIF of a radius involves C7. So, a "low" ISB which blocks C7 is required for good postop pain relief. I prefer a Supraclavicular block which is a superior block for distal upper extremity surgery while also providing very good post op analgesia for a proximal humerus fracture.

1590009898033.png
 
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