Infraclavicular Brachial Plexus

by | Aug 22, 2021


  • Upper extremity fractures
  • Lacerations or abscesses of upper arm


  • 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


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



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



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


  1. In-plane needle visualization
  2. Enter in the parasagittal plane toward the posterior/dorsal aspect of the axillary artery
  3. 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.”

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


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.



  1. Highland Ultrasound
  2. The POCUS Atlas