Atlas of Peripheral Nerve Blocks and Anatomy for Orthopaedic Anesthesia

212 Pages·2007·76.06 MB·English

by  Andre P. Boezaart MD PhD

Atlas of Peripheral Nerve
Blocks and Anatomy
for Orthopaedic Anesthesia
André P. Boezaart
M.B.Ch.B., M.Prax.Med., DA (SA), FFA(CMSA),
M.Med. (Anaesth), Ph.D.
Professor of Anesthesia and Orthopaedic Surgery
Director of Acute Pain Medicine and Regional Anesthesia
University of Florida
Gainesville, Florida
Artwork by Mary K. Bryson, Bryson BioMedical
Illustrations
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1600 John F. Kennedy Blvd.
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ATLAS OF PERIPHERAL NERVE BLOCKS AND ANATOMY FOR ORTHOPAEDIC ANESTHESIA
Copyright © 2008 by Saunders, an imprint of Elsevier Inc. ISBN 978-1-4160-3941-9
Artwork prepared by Mary K. Bryson, Copyright © Bryson Biomedical Illustrations.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights
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NOTICE
Knowledge and best practice in this fi eld are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or
appropriate. Readers are advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to verify the recommended
dose or formula, the method and duration of administration, and contraindications. It is the
responsibility of the practitioner, relying on their own experience and knowledge of the patient, to
determine dosages and the best treatment for each individual patient. Neither the publisher nor the
author assumes any liability for any injury and/or damage to persons or property arising from this
publication.
Library of Congress Cataloging-in-Publication Data
Boezaart, André P.
Atlas of Peripheral Nerve Blocks and Anatomy for Orthopaedic Anesthesia / André P. Boezaart. – 1st ed.
p. ; cm. -- (Atlases of anesthesia techniques series)
Includes bibliographical references and index.
ISBN 978-1-4160-3941-9
1. Anesthesia in orthopedics--Atlases. 2. Conduction anesthesia--Atlases. 3. Nerve block--Atlases. I. Title.
II. Series.
[DNLM: 1. Anesthesia, Conduction—methods—Atlases. 2. Anesthetics, Local—Atlases. 3.
Musculoskeletal System—anatomy & histology—Atlases. 4. Nerve Block—methods—Atlases. WO 517
B673a 2007]
RD751.B64 2007
617.9’6747--dc22
2007007880
Executive Publisher: Natasha Andjelkovic
Multi-Media Producer: David Wisner
Project Manager: Mary Stermel
Design Direction: Karen O’Keefe Owens
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
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To Karin, my wife, with love and gratitude for her unwavering dedication to the care of
our children and for giving meaning to my life.
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P r e f a c e
The idea for this atlas followed the success of The nerve block of the specifi c areas. The blocks are
Primer of Regional Anesthesia Anatomy, which arranged from the upper extremity to the lower
was intended as an easily readable visual source extremity, starting with blocks above the clavicle
of the basic functional anatomy for regional and ending with ankle blocks and lumbar and
anesthesia. Its companion DVD contained videos thoracic paravertebral blocks. There are of course
of the motor responses following transcutaneous many more peripheral nerve blocks than those
stimulation of individual nerves (“nerve map- described in this atlas, but the main goal was to
ping”). To assist with this, medical illustrator focus on the most important, tested and tried
Mary Bryson painted the surface anatomy of the blocks rather than present an exhaustive array
nerves on a model, and the concepts of “nerve of blocks. This atlas is thus limited to peripheral
mapping” and dynamic functional anatomy were nerve blocks that are essential for orthopaedic
illustrated for all the nerves on this model. The surgery. Most of the blocks can also be applied
goal was to provide as much visual impact of to other types of surgery when appropriate. For
the static and dynamic anatomy as possible with example, continuous and single-injection tho-
minimum text. Mary received a Certifi cate of racic paravertebral block (described in Chapter
Merit from the Frank Netter Foundation of the 18) is more often used in thoracic and breast
Vesalius Trust for the illustrations she created for surgery than in orthopaedic surgery.
The Primer of Regional Anesthesia Anatomy. The fi nal chapter deals with pitfalls com-
This approach proved successful, and has monly encountered while performing periphe ral
been continued in this atlas, which is a natural nerve blocks. Recommendations in this chapter
continuation of The Primer and contains the are not strictly based on evidence published
relevant peripheral nerve blocks in the appro- in literature; rather, they represent my insight
priate anatomical context. Mary Bryson again and experience of many years of practicing
provided clear and beautiful illustrations of orthopaedic anesthesia and being an expert
the applied anatomy. Photographs of dedicated witness in medico-legal cases. The points are
cadaver dissections further illustrate the applied argued on the basis of anatomical principles,
anatomy, and clinical photographs show actual clinical experience, and known facts, which are
blocks performed on volunteers. All the blocks all referenced in the text. It is my sincere hope
discussed in this atlas were fi lmed while being that this will help practitioners avoid pitfalls and
demonstrated on volunteers and, with the func- inspire them to perform only blocks that are
tional dynamic anatomy movie clips, arranged on clearly indicated and in the best interest of their
the accompanying DVD. patients.
This atlas consists of chapters dealing fi rst
with the details of applied essential anatomy
followed by the single-injection and continuous André P. Boezaart
ix
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A c k n o w l e d g m e n t s
The idea for producing this atlas came from the many constructive debates about regional
colleagues who used The Primer of Regional anesthesia and acute pain management.
Anesthesia Anatomy and its companion DVD. I sincerely thank Mary K. Bryson, MAMS,
I sincerely thank them and other colleagues for CMI, for the beautiful and clear artwork and
their encouragement, suggestions, and support. Susan McClellen for the excellent photographs.
I am incredibly grateful for the support and I am indebted to Kathy Fear, MSN, CRNA;
friendship of my colleagues in the Departments Steve Borene, M.D.; Chris Theron, Ph.D.; and Kyle
of Orthopaedic Surgery and Anesthesia at the Stahle for their valuable help. Finally, I would like
University of Iowa who have greatly enriched to extend a word of thanks to the editorial and
my career. A special word of thanks to my good production teams at Elsevier for their guidance
friend and colleague Dr. Rick Rosenquist for and professional support.
his continued support and encouragement and
xi
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1
C h a p t e r
Proximal Brachial Plexus:
Applied Anatomy
■ Phrenic Nerve ■ Dorsal Scapular Nerve
■ Superior Trunk of the Brachial ■ Nerve to Levator Scapulae
Plexus
■ Accessory Nerve
■ Suprascapular Nerve
■ Transectional Anatomy (C6)
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CHAPTER 1: Proximal Brachial Plexus: Applied Anatomy 3
PHRENIC NERVE Phrenic Nerve Surface Anatomy
The phrenic nerve ([1] on Fig. 1-1) originates Superficially, the phrenic nerve lies just behind
mainly from C4 and receives a small branch from the posterior border of the sternocleidomastoid
the C5 root of the brachial plexus. It runs caudad muscle, at the level of C6 or the cricoid cartilage
on the belly of the anterior scalene muscle (Figs. (Fig. 1-7, arrow). Electrical stimulation of the
1-4 and 1-6). phrenic nerve causes contractions of the dia-
The external jugular vein (Fig. 1-5, top arrow) phragm, resulting in clear abdominal twitches. If
is superficial to the brachial plexus. The sterno- this is encountered during interscalene block,
cleidomastoid muscle (bottom arrow) partially the needle must be redirected approximately
or completely overlies the phrenic nerve. 1 cm posteriorly.
If the sternocleidomastoid muscle is removed, (See phrenic nerve transcutaneous stimula-
as in the dissection shown in Figure 1-6, the tion movie on DVD).
phrenic nerve (arrow) can clearly be seen on Text continued on page 8
the belly of the anterior scalene muscle.
1 Phrenic nerve
2 Nerve to Levator Scapulae
3 Spinal accessory nerve
4 Dorsal scapular nerve
5 Suprascapular nerve
6 Superior trunk
7 Middle trunk
8 Inferior trunk
9 Long thoracic nerve
10 Nerves to longus colli
and scalene muscles
11 Nerve to subclavius muscle
12 Lateral cord
13 Posterior cord
14 Medial cord
15 Lateral pectoral nerve
16 Medial pectoral nerve
17 Upper subscapular nerve
18 Lower subscapular nerve
19 Medial cutaneous nerve
of arm
20 Medial cutaneous nerve
of upper arm
21 Axillary nerve
22 Musculocutaneous nerve
23 Radial nerve
24 Median nerve
25 Ulnar nerve
FIGURE 1-1 Schematic representation of the roots, trunks, divisions, cords, and terminal branches of the brachial plexus.
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4 REGIONAL BLOCKS AND ANATOMY FOR ORTHOPEDIC ANESTHESIA
C6
C7
C8
T1
C5
FIGURE 1-2 Dermatomes of the upper limb.
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CHAPTER 1: Proximal Brachial Plexus: Applied Anatomy 5
C6
C5
C7
C8
FIGURE 1-3 Osteotomes of the upper limb.
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6 REGIONAL BLOCKS AND ANATOMY FOR ORTHOPEDIC ANESTHESIA
FIGURE 1-4 Transection of the neck at the C6 level. The needle is on the brachial plexus, and the arrow indicates the
phrenic nerve.
FIGURE 1-5 Lateral view of the posterior triangle of the neck. The top arrow indicates the external jugular vein, the middle
arrow the clavicular head, and the bottom arrow the sternal head of the sternocleidomastoid muscle. Note the superficial
cervical plexus behind the midpoint of the posterior border of the clavicular head of the sternocleidomastoid muscle.
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