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Atlas of Peripheral Nerve Blocks and Anatomy for Orthopaedic Anesthesia PDF

212 Pages·2007·76.06 MB·English
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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 FM-X3941.indd iii 8/17/07 4:18:16 PM 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 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 Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: [email protected]. You may also complete your request on-line via the Elsevier website at http://www.elsevier.com/permissions. 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 FM-X3941.indd iv 8/17/07 4:18:17 PM 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. FM-X3941.indd v 8/17/07 4:18:17 PM 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 FM-X3941.indd ix 8/17/07 4:18:18 PM 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 FM-X3941.indd xi 8/17/07 4:18:18 PM 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) Ch01-X3941.indd 1 8/8/07 11:58:17 AM 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. Ch01-X3941.indd 3 8/8/07 11:58:18 AM 4 REGIONAL BLOCKS AND ANATOMY FOR ORTHOPEDIC ANESTHESIA C6 C7 C8 T1 C5 FIGURE 1-2 Dermatomes of the upper limb. Ch01-X3941.indd 4 8/8/07 11:58:18 AM CHAPTER 1: Proximal Brachial Plexus: Applied Anatomy 5 C6 C5 C7 C8 FIGURE 1-3 Osteotomes of the upper limb. Ch01-X3941.indd 5 8/8/07 11:58:20 AM 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. Ch01-X3941.indd 6 8/8/07 11:58:21 AM

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Master all of the blocks required for orthopaedic anesthesia, including both single-injection and continuous nerve blocks! This text and its companion DVD thoroughly review the anatomy points you need to know to effectively execute these techniques, and demonstrate all 16 essential nerve blocks as p
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