Elbow Block

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Chapter 3 Elbow Block

Overview

The following five nerves are involved in an elbow block: radial, median, ulnar, medial antebrachial cutaneous, and lateral antebrachial cutaneous.

1. The radial and lateral antebrachial cutaneous nerves typically are blocked at the same time because of their proximity to one another.
2. The ulnar and medial antebrachial cutaneous nerves typically are blocked at the same time because of their proximity to one another.

Indications for use

A complete elbow block can be used when soft tissue procedures that cross dermatomal boundaries are performed.

Precautions

Intravascular and intranervous injection is of particular concern when injecting anesthetic around the elbow.

Pearls

1. The Median nerve lies Medial to the brachial artery.
2. To remember the order from lateral to medial, use the mnemonic “Break Right Through Both Military Police” for Brachioradialis, Radial nerve, biceps Tendon, Brachial artery, Median nerve, and Pronator teres.

Equipment

1. Antiseptic: Chlorhexidine prep stick or alcohol-soaked gauze
2. Syringe: 3 × 10 mL syringe
3. Needle:

a. Three large-bore, blunt-tipped, drawing-up needles
b. Three 1½-inch 25-gauge needles

4. Anesthetic:

a. Make sure that the dose of anesthetic is safe for the patient’s weight and health status.
b. Lidocaine: 15 mL of 1%
c. Bupivacaine: 15 mL of 0.5%

(1) Ulnar and medial antebracheal cutaneous nerves: 10 mL of anesthetic
(2) Median nerve: 5 mL of anesthetic
(3) Radial and lateral antebrachial cutaneous nerves: 10 mL of anesthetic

5. Sterile gloves
6. 4 × 4 inch gauze

Basic technique

1. Patient positioning: The patient should be seated and a bedside table should be available to position the extremity.

a. Ulnar nerve and medial antebrachial cutaneous nerve:

(1) Shoulder at 90 degrees of abduction and external rotation
(2) Elbow at 90 degrees of flexion

b. Median nerve:

(1) Shoulder at 45 degrees of abduction and maximal external rotation
(2) Elbow extended

c. Radial and lateral antebrachial cutaneous nerve:

(1) Shoulder at 45 degrees of abduction and maximal external rotation
(2) Elbow extended

2. Landmarks:

a. Ulnar and medial antebrachial cutaneous nerves:

(1) Medial epicondyle
(2) Olecranon (a line exists perpendicular to the epicondyle and olecranon)
(3) Injection of the ulnar nerve is carried out 1 cm proximal to the line between the medial epicondyle and olecranon.
(4) Injection of the medial antebrachial cutaneous nerve is carried out in a subcutaneous block anterior to the ulnar nerve.

b. Median nerve:

(1) Medial and lateral epicondyles: the line between the epicondyles is the intercondylar line
(2) Brachial artery
(3) Injection of the median nerve is carried out immediately medial to the brachial artery along the intercondylar line.

c. Radial and lateral antebrachial cutaneous nerve:

(1) Medial and lateral epicondyles: the line between the epicondyles is the intercondylar line
(2) Biceps tendon
(3) Injection of the radial and lateral antebrachial cutaneous nerves is carried out 2 cm lateral to the biceps tendon along the intercondylar line.

3. Steps

a. Block the ulnar and medial antebrachial cutaneous nerves.
b. Block the median nerve.
c. Block the radial and lateral antebrachial cutaneous nerve.

Detailed technique

Prepare Anesthetic

Three syringes should be prepared:

1. Two 10-mL syringes for the radial and lateral antebrachial cutaneous nerves and the ulnar and medial antebracheal cutaneous nerves
2. One 5-mL syringe for the medial nerve

Ulnar and Medial Antebrachial Cutaneous Nerves

1. Position the patient.
2. Palpate landmarks:

a. Mark the medial epicondyle and the olecranon.
b. Determine the location of the epicondylar-olecranon line.
c. Mark the injection site 1 cm proximal to the line.

3. Prepare the skin with an antiseptic solution.
4. Numb the skin with ethyl chloride (if desired).
5. Inject anesthetic (Figure 3-1):

a. Enter at a 30-degree angle to the skin.
b. Insert the needle tangentially along the ulnar nerve.
c. Maintain contact with the patient to ensure that no paresthesias are noted.
d. Aspirate the needle before injection to ensure that intravascular placement has been avoided.
e. Inject 5 mL of anesthetic immediately below the skin. Be vigilant for any warning signs of intravascular injection.
f. Redirect the needle anteriorly and advance subcutaneously to the hilt (Figure 3-2).
g. Withdraw the needle while injecting the remaining 5 mL of anesthetic.
6. Place a sterile bandage over the injection site.
image

Figure 3-1

image

Figure 3-2

Median Nerve

1. Position the patient.
2. Palpate landmarks:

a. Feel the medial and lateral epicondyles.
b. Mark the intercondylar line.
c. Palpate the brachial artery.
d. Mark the injection site immediately medial to the brachial artery.

3. Prepare the skin with an antiseptic solution.
4. Numb the skin with ethyl chloride (if desired).
5. Inject anesthetic (Figure 3-3):

a. Enter the skin directly over the nerve.
b. Insert the needle; aim slightly medially.
c. Maintain contact with the patient to ensure that no paresthesias are noted.
d. Aspirate the needle before injection to ensure that intravascular placement has been avoided.
e. Inject 3 to 5 mL of anesthetic at a depth of 0.5 to 1 cm. Be vigilant for any warning signs of intravascular injection.
6. Place a sterile bandage over the injection site.
image

Figure 3-3

Radial and Lateral Antebrachial Cutaneous Nerves

1. Position the patient.
2. Palpate landmarks:

a. Feel the medial and lateral epicondyles.
b. Mark the intercondylar line.
c. Palpate the biceps tendon.
d. Mark the injection site 2 cm lateral to the biceps tendon along the intercondylar line.

3. Prepare the skin with an antiseptic solution.
4. Numb the skin with ethyl chloride (if desired).
5. Inject anesthetic (Figure 3-4):

a. Enter the skin directly over the nerve.
b. Insert the needle; aim slightly laterally and proximally toward the lateral epicondyle.
c. Maintain contact with the patient to determine if paresthesias are noted.

(1) If paresthesias are elicited, withdraw the needle very slightly.
(2) If paresthesias are not elicited, advance the needle to bone.

d. Aspirate the needle before injection to ensure that intravascular placement has been avoided.
e. Inject 5 mL of anesthetic at a depth determined by the presence or absence of paresthesias. Be vigilant for any warning signs of intravascular injection.
f. Slowly withdraw the needle until it is in a subcutaneous position.
g. Inject 5 mL of anesthetic in a fan-shaped pattern.
6. Place a sterile bandage over the injection site.
image

Figure 3-4

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Chapter 3 Elbow Block

Overview

The following five nerves are involved in an elbow block: radial, median, ulnar, medial antebrachial cutaneous, and lateral antebrachial cutaneous.

1. The radial and lateral antebrachial cutaneous nerves typically are blocked at the same time because of their proximity to one another.
2. The ulnar and medial antebrachial cutaneous nerves typically are blocked at the same time because of their proximity to one another.

Indications for use

A complete elbow block can be used when soft tissue procedures that cross dermatomal boundaries are performed.

Precautions

Intravascular and intranervous injection is of particular concern when injecting anesthetic around the elbow.

Pearls

1. The Median nerve lies Medial to the brachial artery.
2. To remember the order from lateral to medial, use the mnemonic “Break Right Through Both Military Police” for Brachioradialis, Radial nerve, biceps Tendon, Brachial artery, Median nerve, and Pronator teres.

Equipment

1. Antiseptic: Chlorhexidine prep stick or alcohol-soaked gauze
2. Syringe: 3 × 10 mL syringe
3. Needle:

a. Three large-bore, blunt-tipped, drawing-up needles
b. Three 1½-inch 25-gauge needles

4. Anesthetic:

a. Make sure that the dose of anesthetic is safe for the patient’s weight and health status.
b. Lidocaine: 15 mL of 1%
c. Bupivacaine: 15 mL of 0.5%

(1) Ulnar and medial antebracheal cutaneous nerves: 10 mL of anesthetic
(2) Median nerve: 5 mL of anesthetic
(3) Radial and lateral antebrachial cutaneous nerves: 10 mL of anesthetic

5. Sterile gloves
6. 4 × 4 inch gauze

Basic technique

1. Patient positioning: The patient should be seated and a bedside table should be available to position the extremity.

a. Ulnar nerve and medial antebrachial cutaneous nerve:

(1) Shoulder at 90 degrees of abduction and external rotation
(2) Elbow at 90 degrees of flexion

b. Median nerve:

(1) Shoulder at 45 degrees of abduction and maximal external rotation
(2) Elbow extended

c. Radial and lateral antebrachial cutaneous nerve:

(1) Shoulder at 45 degrees of abduction and maximal external rotation
(2) Elbow extended

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