Influencia de posición del brazo en adultos para abordaje de plexo braquial costoclavicular: estudio observacional / Influence of arm position in costoclavicular approach for brachial plexus block in adult patient: observational study

Resumen: Introducción: el bloqueo de plexo braquial con abordaje costoclavicular, ofrece ventajas como sitio de inyección único, sitio adecuado para colocación de catéter de analgesia continua. Objetivo: identificar la visibilidad de los tres cordones del plexo braquial en el espacio costoclavicular según la angulación del brazo. Material y métodos: se realizó un estudio observacional descriptivo y transversal; se incluyeron 99 pacientes entre 18 a 90 años de edad, en un período de dos meses. Se describieron variables continuas, se aplicó la prueba no paramétrica de Friedman para K muestras relacionadas, una regresión lineal para confirmar la correlación entre la distancia de la piel a plexo braquial, peso e índice de masa corporal (IMC). Resultados: se encontró una menor profundidad en relación piel plexo bajo abducción del brazo a una angulación de 90o y 110o, que permite la visualización sonoanatómica del plexo braquial a nivel costoclavicular con significancia estadística. El peso es un factor independiente que determina la distancia entre la profundidad piel plexo. Conclusiones: se determinó que el abordaje del bloqueo costoclavicular ecoguiado es anatómicamente factible con elevada eficacia clínica, el cual concluye ser un sitio anatómico innovador y seguro.

Abstract: Introduction: the brachial plexus block with a costoclavicular approach offers advantages as a single injection site, being a suitable site for continuous analgesia catheter placement. Objective: to identify the visibility of the 3 brachial plexus cords in the costoclavicular space according to the angulation of the arm. Material and methods: a descriptive and cross-sectional observational study was carried out; 99 healthy patients between 18 and 90 years of age were included, in a period of two months. Continuous variables were described, the nonparametric Friedman test was applied for K related samples, a linear regression was performed to confirm the correlation between the distance from the skin to the brachial plexus, weight and body mass index (BMI). Results: a smaller depth was found in relation to the skin plexus under abduction of the arm at an angulation of 90o and 110o, which allows an adequate sonoanatomical visualization of the brachial plexus at the costoclavicular level with statistical significance. Weight is an independent factor that determine the distance between the skin plexus depth. Conclusions: it was determined that the ultrasound-guided costoclavicular block approach is anatomically feasible with greater clinical efficacy, which concludes to be an innovative and safe anatomical site.

Ultrasound-guided continuous costoclavicular block through retrograde stimulating catheter technique for postoperative analgesia in shoulder surgery: a case series

Abstract In five patient undergoing surgery for proximal humerus fracture we investigated into postoperative analgesia provided by continuous costoclavicular block using continuous stimulating catheter. The postoperative pain scores were less than 4 in all patients except in two patients who required intravenous tramadol 50 mg as a rescue analgesic. The radiocontrast dye study executed in two patients revealed contiguous contrast spread through the brachial plexus sheath with the catheter tip in the interscalene space. We propose that a continuous costoclavicular block with a retrograde stimulating catheter is a feasible alternative regional anesthesia technique for postoperative analgesia in shoulder surgery.

Efectividad del bloqueo de plexo braquial con abordaje costoclavicular y factores que modifican la sonoanatomía en pacientes pediátricos / Effectiveness of brachial plexus block with costoclavicular approach and factors modifying sonoanatomy in pediatric patients

Resumen: El bloqueo de plexo braquial en pediatría se ha posicionado como una buena alternativa para procedimientos quirúrgicos de la extremidad superior, en especial a partir del advenimiento de la ultrasonografía. El objetivo del estudio fue evaluar la efectividad del bloqueo con el abordaje costoclavicular en la población pediátrica, comparar la sonoanatomía de la ventana costoclavicular con la coracoidea y determinar si la posición del brazo impacta en la imagen ultrasonográfica. Se evaluaron un total de ocho pacientes con fracturas de miembro superior. De los ocho pacientes, cinco eran de género masculino (62.5%), tres de género femenino (37.5%) con una edad promedio de 8.8 años. Se realizó rastreo ultrasonográfico comparando la sonoanatomía del abordaje costoclavicular y coracoideos, observando mejor los cordones del plexo braquial y estructuras vasculares con el abordaje costoclavicular. Con el brazo en abducción 90 y 110o se optimizó la visualización de las estructuras neurovasculares y mejoría en la calidad del bloqueo. La dosis de ropivacaína fue de 1.5 mg/kg entre el 0.3-0.5%, con un tiempo de bloqueo motor promedio de 6.4 horas, y bloqueo sensitivo promedio de 11 horas. No se presentaron complicaciones. En conclusión, el bloqueo de plexo braquial por vía costoclavicular en la población pediátrica es una técnica segura.

Abstract: Pediatric brachial plexus block has become a good alternative for upper extremity surgical procedures, especially since the advent of ultrasonography. The main aim of the study was to evaluate the effectiveness of the blockade with the costoclavicular approach in the pediatric population, and compare the sonoanatomy of the costoclavicular window with the coracoid one, and determinate if the position of the arm has an impact on the ultrasound image. A total of eight patients with upper limb fractures were evaluated. Of the eight patients, five were male (62.5%), three female (37.5%) with a mean age of 8.8 years. Ultrasonographic screening was performed comparing the sonoanatomy of the costoclavicular and coracoid approaches, better observing the brachial plexus cords and vascular structures with the costoclavicular approach. With the arm abducted 90 and 110o, a better visualization of the neurovascular structures and an improvement in the quality of the block was obtained. The ropivacaine dose was 1.5 mg/kg between 0.3-0.5%, with an average motor block time of 6.7 hours, and an average sensory block of 11.25 hours. There were not complications. In conclusion, the brachial plexus block via the costoclavicular approach in the pediatric population is a safe technique.

Efficacy of ultrasound-guided modified brachial plexus block at costoclavicular space for forearm surgery / 中华麻醉学杂志

Objective:To evaluate the efficacy of ultrasound-guided modified brachial plexus block at costoclavicular space (CCS) for forearm surgery.Methods:Eighty patients of both sexes, aged 18-75 yr, with body mass index of 18-30 kg/m 2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, scheduled for elective forearm surgery from September 2020 to May 2021 in our hospital, were randomized into 2 groups ( n=40 each) using a random number table method: single-injection control group (group C) and double-injection modified group (group T). Single-injection was performed in the anterior chamber of CCS in group C, double-injection was performed in the anterior and posterior chambers of CCS in group T, and the solution injected in both groups was a mixture (20 ml) of 1.0% lidocaine and 0.375% ropivacaine.The effect of block, onset time of block, completion time of block and duration of block for each nerve branch and anesthesia-related adverse reactions were recorded at 5, 10, 15, 20, 25 and 30 min after injection of local anesthesia. Results:Compared with group C, the rate of motor block of radial nerve at 5-20 min after injection of local anesthesia, the rate of sensory block of musculocutaneous nerve and radial nerve at 10 and 15 min after injection of local anesthesia, the rate of motor block of median nerve at 15-30 min after injection of local anesthesia and the rate of sensory and motor block of ulnar nerve at 20-30 min after injection of local anesthesia were significantly increased, and the onset time and completion time of block were shortened in group T ( P<0.05). There was no significant difference between the two groups in the duration of block and anesthesia-related adverse reactions ( P>0.05). Conclusions:Ultrasound-guided modified brachial plexus block at CCS provides better efficacy for forearm surgery.

Ultrasound-guided costoclavicular block as an alternative for upper limb anesthesia in obese patients / Bloqueio costoclavicular guiado por ultrassonografia como alternativa para anestesia de membro superior em paciente obeso

Abstract Background and objectives: Costoclavicular brachial plexus block is an anesthesia performed through the infraclavicular route described in the literature as a safe and effective route for upper limb anesthesia distal to the elbow. The following report describes the case of a patient whose traditional plexus blocking techniques presented ultrasound visualization difficulty, but the costoclavicular approach was easy to visualize for anesthetic blockade. Case report: A grade 3 obese patient scheduled for repair of left elbow fracture and dislocation. Ultrasound examination revealed a distorted anatomy of the supraclavicular region and the axillary region with skin lesions, which made it impossible to perform the blockade in these regions. It was decided to perform an infraclavicular plexus block at the costoclavicular space, where the brachial plexus structures are more superficial and closer together, supported by a muscular structure, lateral to all adjacent vascular structures and with full view of the pleura. The anesthetic block was effective to perform the procedure with a single injection and uneventfully. Conclusion: Costoclavicular brachial plexus block is a good alternative for upper limb anesthesia distal to the elbow, being a safe and effective option for patients who are obese or have other limitations to the use of other upper limb blocking techniques.

Resumo Justificativa e objetivos: O bloqueio de plexo braquial via costoclavicular é uma anestesia feita por via infraclavicular, já descrita na literatura como uma via segura e efetiva para anestesia de membro superior distal ao cotovelo. O relato a seguir trata de um paciente em que as técnicas tradicionais para bloqueio de plexo apresentavam dificuldade de visibilização à ultrassonografia, já a via costoclavicular foi de fácil visibilização para execução do bloqueio anestésico. Relato de caso: Paciente com obesidade grau 3 a ser submetido a correção de fratura e luxação de cotovelo esquerdo apresentava anatomia da região supraclavicular distorcida à avaliação ultrassonográfica e região axilar com lesões de pele, que impossibilitavam o bloqueio nessas regiões. Optou-se por fazer o bloqueio de plexo via infraclavicular no espaço costoclavicular, região onde as estruturas do plexo braquial estão mais superficiais e unidas, amparadas por uma estrutura muscular, laterais a todas as estruturas vasculares adjacentes e com a visibilização plena da pleura. O bloqueio anestésico foi efetivo para a realização do procedimento sob punção única em pele e sem intercorrências. Conclusão: O bloqueio de plexo braquial via costoclavicular é uma boa opção para anestesia de membro superior distal ao cotovelo, é uma opção segura e efetiva para pacientes obesos ou que tenham outras limitações à aplicação de outras técnicas de bloqueio de membro superior.

Comparison of the anesthetic effects between ultrasound-guided brachial plexus block via costoclavicular approach and ultrasound-guided infraclavicular brachial plexus block via coracoid approach in operations of forearm and hand / 临床麻醉学杂志

Objective To compare the effectiveness between ultrasound-guided brachial plexus block via costoclavicular approach and ultrasound-guided infraclavicular brachial plexus block via cora-coid approach.Methods Fifty-eight patients scheduled for forearm or hand surgery,33 males and 25 females,aged 18-70 years,ASA physical status Ⅰ-Ⅲ,were selected in this study.The patients were equally randomized into two groups:the group of brachial plexus block via costoclavicular approach (group A)and group of infraclavicular brachial plexus block via coracoid approach (group B).0.5 % ropivacaine 20 ml was used for local anesthetic.The anatomic depth of brachial plexus nerve,nerve block operation time,sensory and motor blockade situation were recorded.Results Ultrasonic ima-ging showed the brachial plexus was shallower in group A (2.0±1.2)cm than in group B (3.5± 1.8)cm (P<0.05).Nerve block operation time in group A (2.0±1.5)min was less than that in group B (4.0 ± 1.5 )min (P <0.05 ).After 5 minutes and 10 minutes of the local anesthetic inj ection,the sensory blockade rate of the median nerve,the ulnar nerve,the radial nerve and the muscle cutaneous nerve in group A was higher than in group B (P<0.05).After 10 minutes of the inj ection,the motor blockade rate for the ulnar nerve,the radial nerve and the muscle cutaneous nerve was higher in group A than in group B (P<0.05).There were no dyspnea,nausea,vomiting,tinni-tus and other adverse reactions in the two groups.Conclusion The ultrasound-guided costoclaviculari brachial plexus block is more shallower than the subclavicular plexus block in the anatomic depth,and the nerve-blocked-operating time is shorter;at the same time,the former’s sensory and motor block effects is faster than the later.

Costoclavicular Syndrome Secondary to Nonunion of a Displaced Fracture of the Clavicle, Misdiagnosed as a Simple Muscle Strain: A Case Report

Thoracic outlet syndrome is a relatively common disease. However, costoclavicular syndrome as a condition secondary to nonunion of a displaced fracture of the clavicle is very rare. Most clavicular fractures in adults are united with no or minimal persistent symptoms. Also, symptomatic nonunion of a displaced fracture of the clavicle is rare. A 55-year-old male initially presented with persistent forearm pain after slip-down was initially diagnosed with simple muscle strain. However, he was given a delayed diagnosis of costoclavicular syndrome, caused by compression of the subclavian artery due to trauma in the fibrotic nonunion of the right clavicle without apparent symptoms. We obtained satisfactory results by surgical treatment. Here we report this case with a review of the literature.

Coracoclavicular and costoclavicular joints at a common juncture: a rare phenomenon / Articulaciones coracoclavicular y costoclavicular en una unión común: un raro fenómeno

Movements at the human shoulder girdle are the result of complex interplay of glenohumeral, acromioclavicular, sternoclavicular and scapulothoracic articulations. Clavicle apart from articulating with the scapula and sternum is also connected with first rib by costoclavicular ligament and with coracoid process by coracoclavicular ligament. At times the area of attachment of these ligaments on clavicle, first rib and scapula show faceted apophysis suggesting the presence of additional diarthrodial articulations. Costoclavicular joint exists between clavicle and first rib and coracoclavicular joint between clavicle and coracoids process. Both these joints are described in the literature, but the concurrent occurrence of them in the same bone has not been reported yet. We found two clavicles, one of right and other of left side, both of them showed faceted apophysis for costoclavicular and coracoclavicular joint simultaneously, which is rare phenomenon.

Los movimientos de la cintura escapular humana son el resultado de la interacción compleja de las articulaciones glenohumeral, acromioclavicular, esternoclavicular y escapulotorácica. La clavícula, aparte de la articulación con la escápula y el esternón también está conectada con la primera costilla por el ligamento costoclavicular y con el proceso coracoides por el ligamento coracoclavicular. A veces la zona de unión de estos ligamentos de la clavícula, la primera costilla y la escápula muestran procesos facetarios que sugieren la presencia de nuevas articulaciones diartrodiales. La articulación costoclavicular existe entre la primera costilla y la clavícula y la articulación coracoclavicular entre la clavícula y proceso coracoides. Ambas articulaciones están descritas en la literatura, pero la aparición simultánea de ellas en el mismo hueso no se ha informado aún. Se encontraron dos clavículas, uno del lado derecho y otra del lado izquierdo, las dos presentaron procesos facetarios para las articulaciones costoclavicular y coracoclavicular simultáneamente, lo cual es un fenómeno raro.

Costoclavicular Syndrome: A Case Report

Costoclavicular syndrome is one of the four syndromes of thoracic outlet syndrome in which have similiar symptoms, and may result from cervical and thoracic scoliosis, formation of excessive callus or nonunion after fractures of clavicle or first rib. Conservative treatment may be offered. Surgical treatment includes scalenectomy with supraclavicular approach, transaxillary first rib resection with scalenectomy and correction of clavicular abnormality. The purpose of this paper is to evaluate the result of surgical intervention in costoclavicular syndrome of a 38-year old man with clavicular nonunion after an operation.