Infraclavicular Brachial Plexus

by Tom Fadial | Aug 22, 2021

$infraclavicular$

Indications

Upper extremity fractures
Lacerations or abscesses of upper arm

Contraindications

Infection overlying injection site
Allergy to local anesthetic
Vascular injury/injection: There are many large vessels that serve as landmarks so color doppler and negative aspirations are essential

Equipment

20-25cc of local anesthetic of choice
18-22G needle
Saline Flush
Cleansing solution
Ultrasound with high-frequency linear transducer
Ultrasound transducer sterile cover

Prepration

Position

The patient is positioned supine
Abduction of ipsilateral arm to 90° may aid nerve visualization

Ultrasound

Landmarks

The probe is placed in a parasagittal orientation between the midpoint of the clavicle and the coracoid process, just inferior to the clavicle.
The brachial plexus cords surround the axillary artery in a variable pattern but cannot always be individually visualized.

Technique

In-plane needle visualization
Enter in the parasagittal plane toward the posterior/dorsal aspect of the axillary artery
Inject local anesthetic in small aliquots just deep to the axillary artery

$Confirmation of ultrasound-guided infraclavicular brachial plexus injection with “double bubble” sign. The dashed line outlines the axillary artery as the top “bubble;” the accumulating local anesthetic after injection posterior/dorsal to the artery is the second “bubble.”$

Correct position can be demonstrated by obtaining the “double bubble” sign as local anesthetic spread in the periplexus space

Example

$Demonstration of the anatomy of the infraclavicular brachial plexus with the linear transducer in a parasagittal orientation just lateral to the mid-clavicular line. The pulsating subclavian artery can be seen surrounded by the brachial plexus (*). The hyperechoic clavicle is seen in short axis at the right of the image. Sliding pleura can be seen deep to the artery/brachial plexus.$