consideration for a successful block involves interscalene block ( isb ) for surgeries on the shoulders and arms ; supraclavicular block for surgeries on the elbows and forearms ; and axillary block for surgeries on the hands and peripheries . such a preference is considered based upon the segmental nerve supply and the possibility of effective blockade of the involved region . surgeries on the clavicle are not as common . in fact , most descriptions of regional analgesia for upper limb include techniques for shoulder and below . for an effective blockade of nociceptive input , for surgeries on the clavicle , one has to consider the variability in its nerve supply when compared to other upper limb structures . previous reports suggest that the predominant nerve supply for distal clavicle is possibly from superficial cervical plexus ( scp ) and c5 nerve root , through suprascapular nerve and its branches . in view of this , one can aim for a selective regional block to avoid the side - effects and hazards of an isb . we would like to report two cases of open clavicular surgeries , which were managed with a selective c5 nerve root block and scp block , along with general anaesthesia ( ga ) . a 50-year - old obese woman had sustained a fall resulting in fracture of the left clavicle 6 months ago and was being treated conservatively . considering her comorbidities , we opted for a selective regional analgesia , along with ga . scp block and a selective c5 nerve root block were performed . for the actual surgery , without any other premedication , patient was induced with 100 mcg of intravenous ( iv ) fentanyl , 200 mg of propofol and 60 mg of rocuronium . patient was kept intubated throughout the surgery . since the surgical dissection was in close proximity to the pleura , respiratory pressures were closely monitored . patient required no analgesic supplementation during the surgery , apart from the 100 mcg of iv fentanyl given before the intubation . a 37-year - old man had a long history of right clavicular pain resulting from multiple injuries . he continued to have pain despite two previous surgeries on his clavicle , complicated with a history of recent injury . weighing 78 kg , he had a history of smoking , daily marijuana use , known stevens - johnson syndrome with skin sloughing , and a daily morphine intake of 45 mg , 3 times daily . he was asked to continue with his regular dose of morphine even on the day of surgery . scp block and a selective c5 nerve root block on the right side were performed . patient was induced with 150 mg of propofol , 75 mcg of fentanyl and intubated using 50 mg of rocuronium . there were no signs indicative of inadequate analgesia and hence required no supplementation of intraoperative analgesics . for both patients , an informed consent which included an explanation regarding the ultrasound ( us ) guided regional blocks , were obtained . they were sedated with 2 mg of midazolam before the blocks and were provided oxygen supplementation through nasal prongs . they were monitored with continuous noninvasive blood pressure ( nibp ) and o2 saturation in the block room . we used a high frequency linear probe ( ge ultrasound , logiq - e machine ) , with a 50 mm echostim needle ( benlan , ontario , canada ) . scp block was performed with patient 's head turned to the opposite side . at the posterior border of sternocleidomastoid , around the midpoint between c6 and mastoid process , the needle was placed just underneath the muscle , in an in - plane approach , and 8 ml of 0.5% ropivacaine was injected with good visualisation - observed as a sausage under the posterior border of the sternocleidomastoid . the selective c5 nerve root block was performed in an in - plane approach as described by narouze et al . identification of c5 was done by comparing it with the anterior and posterior tubercles of c6 and c7 transverse processes . the c7 has a rudimentary anterior tubercle and a prominent posterior tubercle [ figure 1a ] . the vertebral artery travels antero - posteriorly and enters the foramen tranversarium at c6 , to lie medial and anterior to the nerve root . the c6 transverse process has a prominent anterior tubercle , which is well - known as chassaignac 's tubercle [ figure 1b ] . , with the c5 nerve root in between them , casting a hypoechoic shadow[figure 2a ] . the needle was placed with an in - plane approach , just below the nerve root and 2 ml of 0.5% ropivacaine was injected [ figure 2b ] . in both patients , ( a ) identification of c7 level : prominent posterior tubercle with almost no anterior tubercle . ( b ) identification of c6 level : prominent anterior tubercle ( chassaignac tubercle ) ( a ) identification of c5 nerve root with important vascular structures visualised in the medial aspect . ( b ) c5 nerve root between the  camel humps  formed by anterior and posterior tubercles - with the needle approaching from posterior both patients were monitored with 3-lead electrocardiography , o2 saturation and a continuous nibp throughout the procedure ; their vital signs were observed to be within normal ranges throughout . both were observed to be comfortable in the postoperative period with minimal pain , < 2/10 in numerical analogue scale , in recovery . in the first patient , a postoperative chest x - ray was ordered from the surgical team to rule out any pneumothorax due to the proximity of surgical site to the pleura . a 50-year - old obese woman had sustained a fall resulting in fracture of the left clavicle 6 months ago and was being treated conservatively . considering her comorbidities , we opted for a selective regional analgesia , along with ga . scp block and a selective c5 nerve root block were performed . for the actual surgery , without any other premedication , patient was induced with 100 mcg of intravenous ( iv ) fentanyl , 200 mg of propofol and 60 mg of rocuronium . patient was kept intubated throughout the surgery . since the surgical dissection was in close proximity to the pleura , respiratory pressures were closely monitored . patient required no analgesic supplementation during the surgery , apart from the 100 mcg of iv fentanyl given before the intubation . a 37-year - old man had a long history of right clavicular pain resulting from multiple injuries . he continued to have pain despite two previous surgeries on his clavicle , complicated with a history of recent injury . weighing 78 kg , he had a history of smoking , daily marijuana use , known stevens - johnson syndrome with skin sloughing , and a daily morphine intake of 45 mg , 3 times daily . he was asked to continue with his regular dose of morphine even on the day of surgery . scp block and a selective c5 nerve root block on the right side were performed . patient was induced with 150 mg of propofol , 75 mcg of fentanyl and intubated using 50 mg of rocuronium . there were no signs indicative of inadequate analgesia and hence required no supplementation of intraoperative analgesics . for both patients , an informed consent which included an explanation regarding the ultrasound ( us ) guided regional blocks , were obtained . they were sedated with 2 mg of midazolam before the blocks and were provided oxygen supplementation through nasal prongs . they were monitored with continuous noninvasive blood pressure ( nibp ) and o2 saturation in the block room . we used a high frequency linear probe ( ge ultrasound , logiq - e machine ) , with a 50 mm echostim needle ( benlan , ontario , canada ) . scp block was performed with patient 's head turned to the opposite side . at the posterior border of sternocleidomastoid , around the midpoint between c6 and mastoid process , the needle was placed just underneath the muscle , in an in - plane approach , and 8 ml of 0.5% ropivacaine was injected with good visualisation - observed as a sausage under the posterior border of the sternocleidomastoid . the selective c5 nerve root block was performed in an in - plane approach as described by narouze et al . identification of c5 was done by comparing it with the anterior and posterior tubercles of c6 and c7 transverse processes . the c7 has a rudimentary anterior tubercle and a prominent posterior tubercle [ figure 1a ] . the vertebral artery travels antero - posteriorly and enters the foramen tranversarium at c6 , to lie medial and anterior to the nerve root . the c6 transverse process has a prominent anterior tubercle , which is well - known as chassaignac 's tubercle [ figure 1b ] . , with the c5 nerve root in between them , casting a hypoechoic shadow[figure 2a ] . the needle was placed with an in - plane approach , just below the nerve root and 2 ml of 0.5% ropivacaine was injected [ figure 2b ] . in both patients , sensory block involving the clavicular area was confirmed using a pin prick . ( a ) identification of c7 level : prominent posterior tubercle with almost no anterior tubercle . ( b ) identification of c6 level : prominent anterior tubercle ( chassaignac tubercle ) ( a ) identification of c5 nerve root with important vascular structures visualised in the medial aspect . ( b ) c5 nerve root between the  camel humps  formed by anterior and posterior tubercles - with the needle approaching from posterior both patients were monitored with 3-lead electrocardiography , o2 saturation and a continuous nibp throughout the procedure ; their vital signs were observed to be within normal ranges throughout . both were observed to be comfortable in the postoperative period with minimal pain , < 2/10 in numerical analogue scale , in recovery . in the first patient , a postoperative chest x - ray was ordered from the surgical team to rule out any pneumothorax due to the proximity of surgical site to the pleura . our reports demonstrate that selective regional analgesia for surgeries involving clavicle is an acceptable technique and provides effective analgesia with limitation of side - effects . it does require considerable practice and skill in recognition of anatomical structures and placement of the needle . the skin and superficial fascia around the upper front of the chest is innervated from the scp . the plexus is formed by the anterior rami of c1-c4 nerve roots and gives rise to four terminal branches : greater auricular , lesser occipital , transverse cervical and suprascapular nerves . it has been shown that us guided scp can work well for acute clavicular fractures , performed in the emergency room . the shoulder joint complex ( comprised of glenohumeral , acromioclavicular and sternoclavicular joints ) itself is also innervated from the same nerve roots with predominant supply from suprascapular nerve arising from c5 . cervical plexus block alone has been reported to be effective for clavicular fracture ; however , it may not be sufficient to effectively block the deeper fibres innervating the bone , during and after surgery . kline et al . described the use of double catheters at cervical plexus and selective c5 nerve root for clavicle surgeries . the disadvantages of the isb include unwanted motor and sensory block of the upper extremity along with other recognised adverse effects . phrenic nerve originates predominantly from c4 nerve root and the incidence of phrenic nerve blockade could be nearly 100% when more than 20 ml of the solution is used . up to 8% of neurological symptoms , reported on the 8 postoperative day after shoulder surgery are attributed to it . the guidelines by american society of regional anaesthesia accord a clear recommendation regarding the use of isb . among the various strategies proposed to limit the respiratory impact of analgesic strategies to shoulder surgeries include supraclavicular nerve block and reduced volume of local anaesthetics . our report attempts to highlight that selective regional analgesia could be considered for patient specific management . blockade of c5 nerve root along with scp block can provide efficient analgesia for surgeries involving clavicle .
we report the anaesthetic management of two cases involving surgeries on the clavicle , performed under superficial cervical plexus block and selective c5 nerve root block under ultrasound ( us ) guidance , along with general anaesthesia . 
 regional analgesia for clavicular surgeries is challenging . 
 our patients also had significant comorbidities necessitating individualised approach . 
 the first patient had a history of emphysema , obesity , and was allergic to morphine and hydromorphone . 
 the second patient had clavicular arthritis and pain due to previous surgeries . 
 he had a history of smoking , stevens - johnson syndrome , along with daily marijuana and prescription opioid use . 
 both patients had an effective regional block and required minimal supplementation of analgesia , both being discharged on the same day . 
 interscalene block with its associated risks and complications may not be suitable for every patient . 
 this report highlights the importance of selective regional blockade and also the use of us guidance for an effective and safe block .