Nerve Blocks: Part I. Upper Extremity

 

Am Fam Physician. 2020 Jun 1;101(11):654-664.

This is part I of a two-part article on nerve blocks. Part II, “Lower Extremity,” appears in this issue of AFP.

Author disclosure: No relevant financial affiliations.

Procedural anesthesia is administered by family physicians for a variety of conditions, including neuropathies, fracture reduction, foreign body removals, and complex wound management. A nerve block may be preferred because it provides effective regional anesthesia with less anesthetic. Nerve blocks require a thorough understanding of relevant anatomy, aiding the physician in optimizing the anesthesia effect while minimizing complications. Nerve blocks can be guided by bony landmarks, peripheral nerve stimulation, or ultrasonography. Ultrasound-guided nerve blocks are superior in decreasing procedural complications and procedure time. Physicians should be aware of these techniques to appropriately counsel their patients on procedural options. Nerve blocks of the ulnar, median, and radial nerves at the wrist and elbow provide effective anesthesia for a wide range of medical procedures in the upper extremity.

Family physicians use anesthesia via local, field, and nerve blocks to perform outpatient procedures. Local anesthesia is provided by infiltrating the anesthetic into the procedural field, whereas field blocks are performed by infiltrating the anesthetic around the procedural area leaving the procedural field undisturbed. A nerve block provides anesthesia to specific, innervated regions distal to the block. A nerve block may be preferred because it provides effective regional anesthesia with less anesthetic. Figure 1 illustrates cutaneous innervation of the upper extremity.1 This article, part I of a two-part series, discusses landmark and ultrasound-guided nerve blocks of the elbow and wrist. Part II, in this issue of American Family Physician, focuses on landmark and ultrasound-guided nerve blocks of the lower extremity.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

For improved outcomes and fewer complications, nerve blocks should be performed under ultrasound guidance.35

B

Consistent evidence from systematic reviews show ultrasound-guided nerve blocks are more effective with fewer complications compared with peripheral nerve stimulation guidance alone or with an anatomic landmark technique

Chlorhexidine should be used as a preoperative skin preparation before intact skin procedures.10

B

Comprehensive Cochrane review illustrates lower rates of surgical site infections compared with povidone-iodine paint

Lidocaine should be augmented with epinephrine to prolong the duration of anesthesia and reduce the risk of bleeding during procedures.21

B

Cochrane review of four low-quality randomized controlled trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

For improved outcomes and fewer complications, nerve blocks should be performed under ultrasound guidance.35

B

Consistent evidence from systematic reviews show ultrasound-guided nerve blocks are more effective with fewer complications compared with peripheral nerve stimulation guidance alone or with an anatomic landmark technique

Chlorhexidine should be used as a preoperative skin preparation before intact skin procedures.10

B

Comprehensive Cochrane review illustrates lower rates of surgical site infections compared with povidone-iodine paint

Lidocaine should be augmented with epinephrine to prolong the duration of anesthesia and reduce the risk of bleeding during procedures.21

B

Cochrane review of four low-quality randomized controlled trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

 Enlarge     Print

FIGURE 1.

Cutaneous innervation of the upper extremity.

Illustration by Renee Cannon

Adapted with permission from Neal S, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician. 2010;81(2):149.


FIGURE 1.

Cutaneous innervation of the upper extremity.

Illustration by Renee Cannon

Adapted with permission from Neal S, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician. 2010;81(2):149.

Nerve blocks are used when managing neuropathies, fracture reduction, foreign body removals, and complex wounds. Table 1 lists conditions that warrant consideration for upper extremity nerve blocks. Additionally, a nerve block can be a diagnostic aid by helping to determine the source of a patient's pain. For instance, pain relief after an ulnar

The Authors

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JACQUELINE L. YURGIL, DO, CAQSM, is a family and sports medicine physician at the Family Medicine Residency at Offutt Air Force Base, Neb. At the time this article was written, she was a sports medicine fellow at the Uniformed Services University of the Health Sciences, Bethesda, Md....

CHAD D. HULSOPPLE, DO, CAQSM, is assistant program director of the Sports Medicine Fellowship and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

JEFFREY C. LEGGIT, MD, CAQSM, is director of health care operations and an associate professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to Jeffrey C. Leggit, MD, CAQSM, 4301 Jones Bridge Rd., Bethesda, MD 20814 (email: jeff.leggit@usuhs.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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