Nadeau and associates (2013) reviewed the main US-guided approaches used for regional anesthesia of the upper limb. The anatomical configuration of the upper limb, with nerves often bundled around an artery, makes regional anesthesia of the arm both accessible and reliable. In-depth knowledge of upper limb anatomy is needed to match the blocked territory with the surgical area. The interscalene block is the approach most commonly used for shoulder surgery. Supra-clavicular, infra-clavicular, and axillary blocks are indicated for elbow and forearm surgery. Puncture techniques have evolved dramatically with US guidance. Instead of targeting the nerves directly, it is now recommended to look for diffusion areas. Typically, local anesthetics are deposited around vessels, often as a single injection. Phrenic nerve block can occur with the interscalene and supra-clavicular approaches. Ulnar nerve blockade is almost never achieved with the interscalene approach and not always present with a supra-clavicular block. If US guidance is used, the risk for pneumothorax with a supra-clavicular approach is reduced significantly. Nerve damage and vascular puncture are possible with all approaches. If an axillary approach is chosen, the consequences of vascular puncture can be minimized because this site is compressible. The authors concluded that upper limb regional anesthesia has gained in popularity because of its safety profile and effectiveness associated with US-guided techniques.
Satapathy and Coventry (2011) noted that the axillary approach to brachial plexus blockade provides satisfactory anesthesia for elbow, forearm, and hand surgery and also provides reliable cutaneous anesthesia of the inner upper arm including the medial cutaneous nerve of arm and intercostobrachial nerve, areas often missed with other approaches. In addition, the axillary approach remains the safest of the 4 main options, as it does not risk blockade of the phrenic nerve, nor does it have the potential to cause pneumothorax, making it an ideal option for day case surgery. Historically, single-injection techniques have not provided reliable blockade in the musculocutaneous and radial nerve territories, but success rates have greatly improved with multiple-injection techniques whether using nerve stimulation or US guidance. Complete, reliable, rapid, and safe blockade of the arm is now achievable. The authors concluded that axillary nerve block is a safe and effective regional anesthetic technique suitable for a wide variety of procedures, for both in-patient and out-patient care]; US guidance has allowed improved efficacy with smaller volumes of local anesthetic. Direct visualization of block performance and local anesthetic injection, though inherently safer, does not completely eliminate the risk of intra-vascular and intra-neural injection, and care should be continually exercised using standard safety precautions of slow, careful, fractionated injections to prevent and minimize the risks associated with the technique.
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Erdogmus et al (2021) stated that peripheral nerve blocks with the use of US allow visualization of both the structures and nerves and make the block administrations safe, quick, and comfortable. However, few publications concerning the minimum LA volume are capable of providing blocks. These researchers ascertained the minimum effective LA volume in brachial plexus blockage administrations with an axillary approach accompanied by US in hand, elbow, and forehand operations. The study included a total of 55 patients (classified as ASA I-II) who underwent hand surgery by administering US-guided axillary brachial plexus blockage. The ulnar, median, and radial nerves were located, and the minimum effective LA volume was examined starting with a total of 21-ml of bupivacaine 0.5 %. After accomplishing the blockage, the volume was decreased by 0.5 ml for each nerve. Block administration time, block onset times, anesthesia times, and time to 1st analgesic requirement were recorded. The minimum effective LA volume for each nerve was 2.5 ml for a total of 7.5 ml. In comparing block administration times, there were no differences between high or low volume groups. It was found that sensory block onset time was 17 mins for 7.5-ml and 11 mins for 21-ml; sensory block regression time was 6 hours for 7.5-ml and 10.4 hours for 21-ml, respectively. This regression was statistically significant. The 1st analgesic requirement was 5.8 to 16.6 hours, respectively, for each group. The authors concluded that in the administration of an US-guided axillary block, sufficient anesthesia can be achieved by administering 2.5-ml of bupivacaine 0.5 % for each nerve. However, it might be kept in mind that motor and sensory block onset time would be extended and regression time and time to the 1st analgesic requirement would be shorter with this volume. Furthermore, more advanced studies must be carried out for the determination of the optimum volume that can be used.
Milani and Lin (2018) noted that de Quervain tenosynovitis is a stenosing tenosynovitis of the 1st dorsal compartment of the wrist that could lead to painful functional impairment of the upper limb. This case presentation described a rare adverse effect of corticosteroid injection (CSI) involving local skin atrophy and hypo-pigmentation with proximal linear extension. In this case, hypo-pigmentation developed from the wrist to beyond the elbow after CSI with US guidance and targeted placement of the injectate in the extensor tendon sheath of the 1st dorsal compartment. Dermal complications of CSI were rare but notable and potentially disfiguring events that should be discussed with every patient during the informed consent process before soft tissue CSIs.
Buntragulpoontawee et al (2021) noted that peripheral nerve entrapment syndromes commonly result in pain, discomfort, and ensuing sensory and motor impairment. Many conservative measures have been proposed as treatment, local injection being one of those measures. Now with high-resolution US, anatomical details can be visualized allowing diagnosis and more accurate injection treatment. US-guided injection technique using a range of injectates to mechanically release and decompress the entrapped nerves has therefore developed called hydrodissection or perineural injection therapy. Several different injectates from normal saline, local anesthetics, corticosteroids, 5 % dextrose in water (D5W), and PRP are available and present clinical challenges when selecting agents regarding effectiveness and safety. In a systematic review, these investigators examined the clinical evidence and mechanism of different commonly used injectates for US-guided hydrodissection for the treatment of entrapment neuropathy. A total of 4 databases, including PubMed, Embase, Scopus, and Cochrane were systematically searched from the inception of the database up to August 22, 2020. Studies examining the safety and effectiveness of different commonly used injectates for US-guided hydrodissection entrapment neuropathy treatment were included. Injectate efficacy presented clinical effects on pain intensity, clinical symptoms/function, and physical performance, electrodiagnostic findings, and nerve CSAs. Safety outcomes and mechanism of action of each injectate were also described. From 10 US-guided hydrodissection studies, 9 studies were conducted in carpal tunnel syndrome (CTS) and 1 study was performed in ulnar neuropathy at the elbow. All studies compared different interventions with different comparisons. Injectates included normal saline, D5W, corticosteroids, local anesthetics, hyaluronidase, and PRP; 5 studies examined the use of PRP or PRP plus splinting comparisons. Both D5W and PRP showed a consistently favorable outcome than those in the control group or corticosteroids. The improved outcomes were also observed in comparison groups using injections with normal saline, local anesthetics, or corticosteroids, or splinting. No serious AEs were reported. Local steroid injection side effects were reported in only 1 study. The authors concluded that US-guided hydrodissection was a safe and effective treatment for peripheral nerve entrapment. Injectate selection should be considered based on the injectate mechanism, effectiveness, and safety profile.
The elbow specialists bring advanced diagnosis, treatment and care for upper extremity disorders. Specially trained and board-certified physicians and their support staff use procedures to diagnose, manage and correct conditions which can literally run from the fingertips to the elbow.
Treatment of the elbow is a highly specialized field that deals with a broad set of conditions and symptoms. Many of these are treated with non-surgical approaches such as medications, injections and therapy.
Through the intervention of our joint replacement specialists, pain-free everyday activities like walking, tennis, gardening, golf and playing with children are restored to patients who have had to limit or cease these activities as a result of the chronic and debilitating effects of their conditions.
Through the intervention of our Joint Replacement Specialists, pain-free everyday activities like walking, tennis, gardening, golf and playing with children are restored to patients who have had to limit or cease these activities as a result of the chronic and debilitating effects of their conditions.
But Rangers - with manager Steven Gerrard not in attendance after a recent Covid-19 outbreak at the Scottish Premiership champions - held on to move third in the table and open up a three-point lead over Celtic, who stay sixth. 2ff7e9595c
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