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53 Upper Extremity Blocks
Joseph M. Neal | Edward R. Mariano | Francis V. Salinas
Regional anesthetic approaches to the brachial plexus therefore be blocked separately if anesthesia of the medial
are a mainstay of surgical anesthesia practice and play an aspect of the upper part of the arm is desired. Therefore,
increasingly important role in postoperative analgesia. Well- basic knowledge of brachial plexus anatomy is crucial for
designed outcome studies have confirmed the benefits of understanding the advantages and limitations of the various
regional anesthesia in patients undergoing upper extrem- approaches to upper extremity regional anesthesia.
ity surgery. When compared with traditional opioid-based The functional neuroanatomy of the upper extremity is
postoperative analgesia for outpatient shoulder, arm, or critically important for determining selection of the block
hand surgery, single-injection regional anesthesia tech- and assessment. Motor function is generally well correlated
niques provide superior analgesia, reduce opioid-related with an observed motor response after electrical stimulation
side effects, improve patient satisfaction, and reduce the of a specific terminal nerve; for example, distal stimula-
number of unplanned admissions. Although these benefits tion of the radial nerve consistently elicits wrist and finger
are generally limited to the day of surgery, they nevertheless extension. In contrast, as one moves proximally along the
represent a valuable alternative to general anesthetic and brachial plexus, stimulation yields muscle movements of
postoperative opioid techniques.1-4 Furthermore, limited a mixed nature. As an example of this concept, electrical
comparative studies have shown that an interscalene or stimulation of the superior trunk during the interscalene
suprascapular block provides better analgesia than does approach results in mixed muscle stimulation that produces
an intra-articular injection or infusion of local anesthetic5,6 shoulder elevation (Table 53.1).
and without any risk for chondrolysis. Continuous perineural Sensory innervation of the upper extremity is inconsis-
catheter techniques provide superior analgesia for total tent and widely overlapping (Fig. 53.2). Certain areas of
shoulder arthroplasty and various ambulatory shoulder sur- the arm, such as the distal palmar aspect of the forearm,
geries. Similar to single-injection techniques, the prolonged have overlapping sensory innervation from the medial and
analgesia afforded by continuous perineural catheters is lateral antebrachial cutaneous nerves, plus occasional con-
associated with fewer opioid-related side effects and higher tributions from the median nerve. A practical implication of
patient satisfaction. What remains unclear is whether these this neuroanatomic overlap is that most areas of the upper
techniques substantially improve economic outcomes such extremity require anesthesia of two or more terminal nerves,
as faster rehabilitation or return to work.7-9 This chapter which supports the effectiveness of plexus-based regional
offers a brief review of brachial plexus anatomy and perti- anesthesia over multiple selective nerve blocks at the elbow
nent pharmacology, with a primary focus on the techniques or wrist. Furthermore, overlapping cutaneous sensory fields
and complications of upper extremity blocks. and motor function can be problematic for assessing anes-
thesia, which is best accomplished by testing end functions
that can be attributed only to a single nerve. The “four P’s”11
BRACHIAL PLEXUS ANATOMY is an example of such a tool (Table 53.2).
The brachial plexus is composed of the ventral primary

rami of cervical nerves C5 to C8 and thoracic nerve T1, PHARMACOLOGIC CONSIDERATIONS
with occasional contributions from C4 and T2 (Fig. 53.1).
Understanding the complex interdigitations that define the Selection of a local anesthetic for brachial plexus anesthesia
brachial plexus is important for two reasons. First, brachial is based on the expected duration of surgery and the optimal
plexus approaches are directed toward its various anatomic duration of postoperative analgesia. When considering
divisions. For example, the interscalene approach is directed block duration, anesthesiologists should be cognizant of the
toward the level of the distal roots and proximal trunks, expected degree of postoperative pain. For mildly painful
whereas the infraclavicular approach is directed toward the procedures, some patients may interpret prolonged arm
level of the cords. This anatomic subarchitecture, in turn, numbness as bothersome, whereas dense analgesia may
determines the expected motor response to peripheral nerve mask early signs of impaired circulation in crush injuries
stimulation and the distribution of anesthetic resulting from or surgeries with potential for the development of compart-
the particular approach. Second, supplemental procedures ment syndrome.12 Thus, selection of a local anesthetic for
are often necessary to anesthetize nerves that are distinct an upper extremity block is best individualized to achieve
from the brachial plexus or are intermediary branches. For specific therapeutic goals.
example, the intercostobrachial nerve is primarily derived Potency studies of long-acting local anesthetics applied
from T2, which is not part of the brachial plexus and must to the brachial plexus suggest that 0.5% bupivacaine is
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53 Upper Extremity Blocks

Joseph M. Neal | Edward R. Mariano | Francis V. Salinas

The brachial plexus is composed of the ventral primary

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