PMC10077775_01
Right distal humerus fracture undergoing PHB. Ans showing probe placements and needle insertions in supine position (a) Probe on the ventral surface of arm 6 cm [blue dotted line] proximal to the elbow crease, with needle inserted from lateral to medial; (b) Schematic explains the compartment, relation of nerve to inter-muscular space; (c) Ultrasound image illustrating the needle tip placement [broad white arrows] and spread of local anesthetic [light blue] on anteromedial surface. (LA - local anesthetic); (d) Ultrasound image illustrating the needle tip placement [broad white arrows] and spread of local anesthetic [light blue] on anterolateral surface. LA - local anesthetic; (e) Probe placement, needle trajectory and LA spread with injections and LA spread posterior to humerus [light blue] and posterior brachial cutaneous nerve [PBCN] in the subcutaneous tissue. Yellow arrow depicts the site on injection. (LA - local anesthetic); (f) Average VAS [0-24th hour]; (g) Time to first analgesic for tramadol. McN - musculocutaneous nerve; RN - radial nerve; AM-NP - anteromedial needle positioning; AL-NP - anterolateral needle positioning; NP - needle positioning
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In the supine position, the linear array US probe was deployed on the ventral arm 6 cm proximal [Figure 1a] to the line joining the medial and lateral epicondyle (intercondylar line). The biceps, brachialis, proximal brachioradialis in the anterior compartment, and triceps in the posterior compartment were visualized [Figure 1b-schematic]. An echogenic needle was inserted from lateral to medial, through the biceps brachii muscle and the tip was positioned at the anteromedial [Figure 1c] and anterolateral [Figure 1d] aspect of humerus, 0.5 cm away from the bone. Three ml of 0.2% ropivacaine was injected in real time as the local anesthetic (LA) spread from the ventral to dorsal aspect at both sites [Figure 1c and d]. With the posterior surface of the humerus in vision, the needle was inserted from lateral to medial, through the triceps muscle and 0.2% ropivacaine 5 ml was injected 0.5 cm away from the bone as the needle withdrawn [Figure 1e]. The medial brachial cutaneous and posterior brachial cutaneous nerves [Figure 1e] were blocked separately in the subcutaneous tissues. Median of VAS after 24 hours was 3 (IQR-O to 4) [Figure 1f] and the mean time to first analgesia (TTFA) was 425.417 +- 229.005 min [Figure 1g].