Study of Optimum Arm Position for Ultrasound Visualisation of the Brachial Plexus at the Axilla

Overview

Journal Anaesthesiol Intensive Ther

Date 2025 Feb 7

PMID 39917971

Authors

Shruti S Patil

Kiran A Gaikwad

Preeti S Rustagi

Affiliations

Soon will be listed here.

Abstract

Introduction: Visualisation and separate blockade of the four primary constituent nerves (radial, median, ulnar, musculocutaneous) increases the success rate of ultrasound-guided brachial plexus block at the axillary level. However, the upper limb is still positioned as if performing the landmark-oriented approach described by Winnie, with the shoulder and elbow at 90o. Thus, we aimed to find the optimum arm position for visualisation of the brachial plexus at the axilla using ultrasound.

Material And Methods: After the Institutional Ethics Committee's approval, this prospective observational study was conducted on 36 consenting individuals more than 18 years of age. The ultrasound probe was placed on a short axis at the intersection of the pectoralis major muscle and the biceps brachii muscle, with just enough probe pressure to cause light compression of veins. Each arm was placed in three different positions - shoulder at 90º and elbow at 90º, shoulder at 90º and elbow at 0º, and shoulder at 120º and elbow at 90º - in which the nerves were assessed using a six-point visibility scale. The path of each nerve was traced down for confirmation. Distance from the skin to axillary artery, skin to individual nerves, and artery to nerves was measured.

Results: Visibility scores of the individual nerves and the distances measured in the three positions were comparable ( P > 0.05). The skin artery and skin nerve distances were the shortest in the 120/90 position, and the radial nerve was more often located in this position.

Conclusions: Arm position with 120º shoulder and 90º elbow had favourable results. Further studies will confirm its clinical utility and block success rate.

References

Wong D, Gledhill S, Thomas R, Barrington M . Sonographic location of the radial nerve confirmed by nerve stimulation during axillary brachial plexus blockade. Reg Anesth Pain Med. 2009; 34(5):503-7. DOI: 10.1097/AAP.0b013e3181ae7323. View

Satapathy A, Coventry D . Axillary brachial plexus block. Anesthesiol Res Pract. 2011; 2011:173796. PMC: 3119420. DOI: 10.1155/2011/173796. View

Beheiry E . Anatomical variations of the median nerve distribution and communication in the arm. Folia Morphol (Warsz). 2004; 63(3):313-8. View

Sehmbi H, Madjdpour C, Shah U, Chin K . Ultrasound guided distal peripheral nerve block of the upper limb: A technical review. J Anaesthesiol Clin Pharmacol. 2015; 31(3):296-307. PMC: 4541174. DOI: 10.4103/0970-9185.161654. View

Bloc S, Mercadal L, Garnier T, Huynh D, Komly B, Leclerc P . Shoulder position influences the location of the musculocutaneous nerve in the axillary fossa. J Clin Anesth. 2016; 33:250-3. DOI: 10.1016/j.jclinane.2016.03.006. View

Bigeleisen P, Wilson M . A comparison of two techniques for ultrasound guided infraclavicular block. Br J Anaesth. 2006; 96(4):502-7. DOI: 10.1093/bja/ael024. View

Ustuner E, Yilmaz A, Ozgencil E, Okten F, Turhan S . Ultrasound anatomy of the brachial plexus nerves in the neurovascular bundle at the axilla in patients undergoing upper-extremity block anesthesia. Skeletal Radiol. 2013; 42(5):707-13. DOI: 10.1007/s00256-013-1578-7. View

Bruhn J, van Geffen G, Gielen M, Scheffer G . Visualization of the course of the sciatic nerve in adult volunteers by ultrasonography. Acta Anaesthesiol Scand. 2008; 52(9):1298-302. DOI: 10.1111/j.1399-6576.2008.01695.x. View

Retzl G, Kapral S, Greher M, Mauritz W . Ultrasonographic findings of the axillary part of the brachial plexus. Anesth Analg. 2001; 92(5):1271-5. DOI: 10.1097/00000539-200105000-00037. View

10.

Bargallo X, Carrera A, Sala-Blanch X, Santamaria G, Morro R, Llusa M . Ultrasound-anatomic correlation of the peripheral nerves of the upper limb. Surg Radiol Anat. 2009; 32(3):305-14. DOI: 10.1007/s00276-009-0583-y. View

11.

WINNIE A, Collins V . THE SUBCLAVIAN PERIVASCULAR TECHNIQUE OF BRACHIAL PLEXUS ANESTHESIA. Anesthesiology. 1964; 25:353-63. DOI: 10.1097/00000542-196405000-00014. View

12.

Remerand F, Laulan J, Couvret C, Palud M, Baud A, Velut S . Is the musculocutaneous nerve really in the coracobrachialis muscle when performing an axillary block? An ultrasound study. Anesth Analg. 2010; 110(6):1729-34. DOI: 10.1213/ANE.0b013e3181dc25c8. View

13.

Frkovic V, Ward C, Preckel B, Lirk P, Hollmann M, Stevens M . Influence of arm position on ultrasound visibility of the axillary brachial plexus. Eur J Anaesthesiol. 2015; 32(11):771-80. DOI: 10.1097/EJA.0000000000000293. View

14.

Spence B, Sites B, Beach M . Ultrasound-guided musculocutaneous nerve block: a description of a novel technique. Reg Anesth Pain Med. 2005; 30(2):198-201. DOI: 10.1016/j.rapm.2004.09.009. View

15.

Ruiz A, Sala X, Bargallo X, Hurtado P, Arguis M, Carrera A . The influence of arm abduction on the anatomic relations of infraclavicular brachial plexus: an ultrasound study. Anesth Analg. 2008; 108(1):364-6. DOI: 10.1213/ane.0b013e31818c94da. View

16.

Matsuda H, Oka Y, Takatsu S, Katsube R, Yoshida R, Oyama T . Ultrasound-guided block of selective branches of the brachial plexus for vascular access surgery in the forearm: a preliminary report. J Vasc Access. 2016; 17(3):284-90. DOI: 10.5301/jva.5000513. View

17.

Ozturk O, Tezcan A, Bilge A, Erdem E, Yagmurdur H, Dost B . Importance of the Upper Extremity Position for a Safe and Effective Axillary Block: a Comparative Study. Turk J Anaesthesiol Reanim. 2017; 45(3):164-168. PMC: 5512395. DOI: 10.5152/TJAR.2017.33349. View

18.

Loukas M, Aqueelah H . Musculocutaneous and median nerve connections within, proximal and distal to the coracobrachialis muscle. Folia Morphol (Warsz). 2005; 64(2):101-8. View

19.

Christophe J, Berthier F, Boillot A, Tatu L, Viennet A, Boichut N . Assessment of topographic brachial plexus nerves variations at the axilla using ultrasonography. Br J Anaesth. 2009; 103(4):606-12. DOI: 10.1093/bja/aep207. View