Abstract
Purpose of the Review
Regional anesthesia has become a cornerstone in orthopedic surgeries due to its ability to provide precise, localized pain relief while minimizing the systemic risks associated with general anesthesia and opioid use. This review aims to provide a compact guide for anesthesia trainees and practicing anesthesiologists on the use of regional anesthesia techniques for upper and lower extremity procedures.
Summary
This guide outlines the main regional block options for orthopedic surgeries, detailing the targeted anatomy, common surgical indications, important adjacent structures, and potential complications for each technique. Key blocks for upper extremity surgeries include interscalene, supraclavicular, infraclavicular, axillary, and intercostobrachial blocks, while lower extremity techniques encompass femoral, adductor canal, sciatic, popliteal, and lumbar plexus blocks. Advances in ultrasound guidance have enhanced the safety and efficacy of these techniques, making them indispensable for modern anesthesiology practice. By mastering these approaches, providers can optimize patient outcomes, expand their skillset, and contribute to enhanced perioperative care in orthopedic surgery.
Keywords: Regional anesthesia, upper extremity surgery, brachial plexus, interscalene block, supraclavicular block, infraclavicular block, axillary block, intercostobrachial block, lower extremity surgery, femoral block, adductor canal, saphenous block, sciatic block, popliteal block, lumbar plexus block
Introduction
Regional anesthesia offers precise pain control, reduces opioid consumption, and can enhance postoperative recovery for patients undergoing orthopedic surgery for the upper and lower extremities.1 Key regional blocks enhance postoperative recovery by providing superior analgesia, enabling early mobilization, and reducing the likelihood of complications associated with general anesthesia, such as nausea, respiratory issues, and prolonged sedation. These benefits are particularly advantageous for patients undergoing surgeries on the upper and lower extremities, where focused nerve blocks can optimize outcomes while minimizing systemic risks. Advances in ultrasound guidance have significantly improved the safety and efficacy of these techniques, making them an essential skill for modern anesthesiologists.1–3
In this guide, we will discuss the essential regional anesthesia techniques for upper extremity surgeries, including interscalene, supraclavicular, infraclavicular, axillary, and intercostobrachial blocks, as well as those for lower extremity procedures, such as femoral, adductor canal, sciatic, popliteal, and lumbar plexus blocks. Each block will be analyzed in terms of its targeted anatomy, common surgical applications, and potential complications to provide a comprehensive understanding for anesthesiologists seeking to optimize perioperative pain management.
Techniques and Applications – Upper Extremity
1. Interscalene Block
Target: Roots/trunks of the brachial plexus (C5–C7)
Common Surgical Cases: Shoulder surgeries (e.g., rotator cuff repair, shoulder arthroscopy), proximal humerus fractures
Important Structures: Phrenic nerve (risk of hemidiaphragmatic paralysis), vertebral artery, recurrent laryngeal nerve
Complications: Respiratory complications (e.g., phrenic nerve block), Horner’s syndrome, vascular puncture, pneumothorax
2. Supraclavicular Block
Target: Trunks/divisions of the brachial plexus
Common Surgical Cases: Mid-humerus, elbow, forearm, and hand surgeries
Important Structures: Subclavian artery, pleura
Complications: Pneumothorax, vascular puncture
3. Infraclavicular Block
Target: Cords of the brachial plexus
Common Surgical Cases: Elbow, forearm, and hand surgeries
Important Structures: Axillary artery and vein, lung apex
Complications: Vascular puncture, pneumothorax
4. Axillary Block
Target: Branches of the brachial plexus
Common Surgical Cases: Forearm and hand surgeries
Important Structures: Axillary artery, radial, median, and ulnar nerves
Complications: Incomplete block, hematoma, nerve injury, infection
5. Intercostobrachial Block
Target: Intercostobrachial nerve (T2 and occasionally T1, not derived from brachial plexus); used as a supplement to brachial plexus blocks
Common Surgical Cases: Medial/posterior upper arm surgeries, anterior arthroscopic port, and upper extremity tourniquet pain
Important Structures: Axillary crease
Complications: Incomplete block, infection
Important considerations of each block are also listed in Table 1 below.
Table 1. This table summarizes the key characteristics of regional anesthesia blocks used for upper extremity surgeries. The columns detail the anatomical target, typical surgical indications, critical anatomical structures to consider, and potential complications. These blocks are highly effective for providing localized anesthesia and pain relief during upper extremity procedures.
| Block | Target | Common Surgical Cases | Important Structures | Complications |
|---|---|---|---|---|
| Interscalene Block | Roots and trunks of the brachial plexus (C5–C7) | Shoulder surgeries, proximal humerus fractures | Phrenic nerve, vertebral artery, recurrent laryngeal nerve | Respiratory issues, Horner’s syndrome, vascular puncture, pneumothorax |
| Supraclavicular Block | Trunks and divisions of the brachial plexus | Mid-humerus, elbow, forearm, and hand surgeries | Subclavian artery, pleura | Pneumothorax, vascular puncture |
| Infraclavicular Block | Cords of the brachial plexus | Elbow, forearm, and hand surgeries | Axillary artery and vein, lung apex | Vascular puncture, pneumothorax |
| Axillary Block | Branches of the brachial plexus | Forearm and hand surgeries | Axillary artery, radial, median, and ulnar nerves | Incomplete block, hematoma, nerve injury, infection |
| Intercostobrachial Block | Dermatomal innervation of the intercostobrachial nerve (medial/posterior upper arm) | Medial/posterior upper arm surgeries, tourniquet pain | Axillary crease | Incomplete block, infection |
Techniques and Applications – Lower Extremity
1. Femoral Nerve Block
Target: Femoral nerve in the inguinal region
Common Surgical Cases: Hip fractures, total knee arthroplasty, femoral shaft fractures
Important Structures: Femoral artery, femoral vein
Complications: Hematoma, nerve injury, infection, intravascular injection
2. Adductor Canal Block
Target: Saphenous nerve and branches of the femoral nerve within the adductor canal
Common Surgical Cases: Knee surgeries (particularly total knee arthroplasty), lower leg surgeries involving saphenous nerve distribution
Important Structures: Femoral artery, femoral vein, adductor muscles
Complications: Hematoma, limited coverage (suitable for distal knee anesthesia), infection, intravascular injection
3. Sciatic Nerve Block
Target: Sciatic nerve in the gluteal region, anterior thigh approach, or posterior thigh approach
Common Surgical Cases: Hip surgery, lower leg surgeries, foot and ankle surgeries
Important Structures: Gluteal arteries, ischial tuberosity, femoral shaft and lesser trochanter
Complications: Nerve injury, prolonged motor block, hematoma, infection
4. Popliteal Block (Sciatic Nerve at Popliteal Level)
Target: Sciatic nerve proximal to its division into the tibial and common peroneal nerves
Common Surgical Cases: Foot and ankle surgeries
Important Structures: Popliteal artery and vein
Complications: Nerve injury, vascular puncture, hematoma, infection, intravascular injection
5. Lumbar Plexus Block (Psoas Compartment Block)
Target: Lumbar plexus within the psoas major muscle
Common Surgical Cases: Hip surgeries, knee surgeries
Important Structures: Psoas muscle, lumbar vertebrae
Complications: Epidural spread, vascular injury, retroperitoneal hematoma, intravascular injection, infection
Important considerations of each block are also listed in the Table 2 below.
Table 2. This table outlines the regional anesthesia blocks commonly used for lower extremity surgeries. Each row describes the targeted nerve structure, types of surgeries the block is suitable for, significant anatomical landmarks, and possible complications. These techniques facilitate effective pain management while minimizing systemic side effects during lower extremity procedures.
| Block | Target | Common Surgical Cases | Important Structures | Complications |
|---|---|---|---|---|
| Femoral Nerve Block | Femoral nerve in the inguinal region | Hip fractures, total knee arthroplasty, femoral shaft fractures | Femoral artery, femoral vein | Hematoma, nerve injury, infection, intravascular injection |
| Adductor Canal Block | Saphenous nerve and branches of the femoral nerve within the adductor canal | Total knee arthroplasty, lower leg surgeries | Femoral artery, femoral vein, adductor muscles | Hematoma, limited coverage, infection, intravascular injection |
| Sciatic Nerve Block | Sciatic nerve in the gluteal region, anterior thigh, or posterior thigh | Hip surgery, lower leg surgeries, foot and ankle surgeries | Gluteal arteries, ischial tuberosity, femoral shaft, lesser trochanter | Nerve injury, prolonged motor block, hematoma, infection |
| Popliteal Block | Sciatic nerve proximal to its division into the tibial and common peroneal nerves | Foot and ankle surgeries | Popliteal artery and vein | Nerve injury, vascular puncture, hematoma, infection, intravascular injection |
| Lumbar Plexus Block | Lumbar plexus within the psoas major muscle | Hip surgeries, knee surgeries | Psoas muscle, lumbar vertebrae | Epidural spread, vascular injury, retroperitoneal hematoma, infection, intravascular injection |
Discussion
Regional anesthesia plays a significant role in orthopedic surgical practice, offering targeted pain relief, reducing the need for general anesthesia, and minimizing reliance on systemic opioids.4,5 The choice of regional anesthesia technique should align with the surgical site, patient-specific factors, and anticipated postoperative pain management needs. For upper extremity surgeries, the interscalene, supraclavicular, infraclavicular, axillary, and intercostobrachial blocks are essential for anesthesiologists to understand and master.1–4 Each technique targets distinct anatomical regions of the brachial plexus, with associated risks ranging from incomplete blocks to rare but serious complications such as pneumothorax or vascular injury. Similarly, lower extremity procedures benefit from regional techniques like femoral, adductor canal, sciatic, popliteal, and lumbar plexus blocks, which provide effective analgesia while minimizing systemic side effects.6–11
The advent of ultrasound guidance has revolutionized regional anesthesia by enhancing precision and safety. This advancement reduces the likelihood of complications, such as nerve injury and vascular puncture, and improves block efficacy. Furthermore, adjunctive agents like dexmedetomidine and dexamethasone have demonstrated the ability to prolong block duration, contributing to improved postoperative outcomes.12–15
Despite the numerous benefits, regional anesthesia is not without limitations. Providers must balance the risk of complications with patient-specific anatomical and clinical considerations. Effective implementation requires not only technical proficiency but also a thorough understanding of relevant anatomy and the ability to manage potential adverse events. This guide serves as a resource for trainees and practicing anesthesiologists looking to improve their regional anesthesia techniques and understanding.
Conclusion
Regional anesthesia remains a cornerstone in orthopedic surgical practice, offering precise, localized analgesia that enhances patient outcomes while minimizing the systemic side effects associated with general anesthesia and opioid use. For upper and lower extremity procedures, the selection of the appropriate block should be guided by the specific surgical site, patient anatomy, and clinical considerations. Mastery of these techniques requires an understanding of the anatomy, associated risks, and potential complications to ensure safety and efficacy. Advances in ultrasound-guided approaches have refined the precision and safety of these interventions, making them indispensable in modern anesthesia practice. By adopting these techniques, anesthesiologists can improve perioperative pain management, reduce recovery times, and contribute to the overall quality of patient care in orthopedic surgeries. This guide aims to serve as a valuable resource for trainees and practitioners striving to expand their skillset and optimize patient outcomes.
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