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
Tips:An easy way to locate the
Interscalene nerve, sympathetic blockade (Horner’s
interscalene site is to scan up from the syndrome) or epidural spread. C7 tranverse process
shoulder, proximal suprac lavic ular re gion; the distinc tive
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
superficial to the artery. against pneumothorax. anterior
scalene SCA
Target:Using an in-plane needle Avoid: Pneumothorax: avoid needle
approach from the lateral end of tip penetrating beyond the first rib - it middle scalene
1st rib brachial plexus
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 pec major
artery. essential; the pectoral muscles help
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 cephalad

Axillary Identify: The axillary artery and veins Tips: Scan distally to confirm each
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 V
U
(musculocutaneous, median, ulnar, radial n dives deep towards the M
radial) will lie above that tendon. The medial border of humerus with the MC AA R V

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 targetAvoid: Intravascular injection (multiple
Axillary each nerve in turn (we block them in vessels) - watch the ultrasound for
triceps
elbow, forearm, order: MC, R, U, M to preserve the injectate spread with each injection;
hand surgery ultrasound view). avoid intrafascicular nerve trauma. cephalad caudad

Peripheral Nerves

Radial brachial artery Median Ulnar

ulnar nerve
radial nerve median
nerve

humerus medial
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
median 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.

Palmar Dorsal
Lower lateral cutaneous n. Lower lateral cutaneous n.
Radial n. of arm (Radial n.) of arm (Radial n.) Radial n.

Median n. Lateral cutaneous n. of forearm Axillary n. Axillary n. Lateral cutaneous n. of forearm Median n.
(Musculocutaneous n.) (Musculocutaneous n.)

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.)
Z9030239 07/22

*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.