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Bloqueo del plano de la fascia clavipectoral para analgesia tras cirugía de

clavícula

Article · November 2019

DOI: 10.1016/j.redar.2019.06.006

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Revista Española de Anestesiología y Reanimación (English

Edition)
Available online 1 December 2019
In Press, Corrected Proof

Letter to the Director

Clavipectoral fascia plane block for analgesia after clavicle

surgery
Bloqueo del plano de la fascia clavipectoral para analgesia tras
cirugía de clavícula ☆
Y.O. Atalay , E. Mursel, B. Ciftci, G. Iptec

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https://doi.org/10.1016/j.redare.2019.06.007 Get rights and content

Refers to Y.O. Atalay, E. Mursel, B. Ciftci, G. Iptec

Bloqueo del plano de la fascia clavipectoral para analgesia tras cirugía de clavícula
Revista Española de Anestesiología y Reanimación, Volume 66, Issue 10, December 2019, Pages 562-
563

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To the Editor,
Clavicular fracture is the most common injury of the shoulder girdle, and has an incidence of
35%. It mainly occurs in young men, usually as a result of sports activities or traffic accidents,
and the most common fracture occurs in the middle third or diaphysis of the clavicle.
Although most such diaphyseal fractures can be treated non-surgically, there is growing
evidence that better functional outcomes are achieved with surgical treatment.1 Pain
management, therefore, after clavicular fracture or surgery is very important. Since initial
post-fracture pain may not respond to opioids, peripheral nerve blocks may be a useful
complement to oral medication. A thorough understanding of the sensory innervation of the
peripheral nerve is essential to achieve good analgesia following clavicular fracture or surgery.
This innervation is complex, and the supraclavicular, subclavian, long thoracic/suprascapular
nerves, alone or together, may be responsible for pain transmission after clavicular fracture
and surgery. Superficial cervical plexus block, interscalene block, and combined superficial

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02.12.2019 Clavipectoral fascia plane block for analgesia after clavicle surgery - ScienceDirect

cervical plexus-interscalene block can be used to anaesthetise the clavicle.2 The superficial
cervical block can also be combined with the clavipectoral fascia plane block. The clavipectoral
fascia is a thick fascia located on the clavicular portion of the pectoralis major muscle that
extends superior, medial and superolateral from the clavicle, the costochondral joints, and the
coracoid process, respectively. It suspends the floor of the axilla and protects the
neurovascular structure, occupying the space between the clavicle and the pectoralis minor
muscle. The clavipectoral fascia completely surrounds the clavicle, and the nerve endings of
the clavicle penetrate this fascia.3

The clavipectoral fascia plane block was first described by Valdés in 2017.4 Following this,
Roqués et al. presented the combined superficial cervical plexus-clavipectoral fascia plane
block for clavicular surgery at the 44th Annual Regional Anesthesiology and Acute Pain
Medicine Meeting in 2019.5 In their presentation, they describe injecting 10–50 ml of long-
acting local anaesthetic into the fascia of the medial and lateral thirds, towards the clavicle
fracture. They reported that this technique provided good quality anaesthesia, and also gave
prolonged analgesia for fractures of the medial third of the clavicle.

We present a case of successful postoperative pain management using superficial cervical

plexus-clavipectoral fascia plane block in a 47-year-old woman, ASA II (hypothyroidism),
weight 63 kg, height 165 cm, who underwent right clavicle fracture surgery under general
anaesthesia. The patient read the manuscript and gave her consent for publication. After
obtaining the patient's consent for postoperative nerve block, we performed an ultrasound-
guided superficial cervical plexus–clavipectoral fascia plane block of the clavipectoral fascia at
the end of surgery. The procedure was performed under aseptic conditions using a GE Vivid
Q® ultrasound device (GE Healthcare, USA) with a 12 MHz linear transducer. The patient was
placed supine, with her head turned slightly to the left. After blocking the superficial cervical
plexus, the ultrasound probe was placed on the anterior superior border of the medial third of
the clavicle, and a 22 gauge needle was inserted in a caudal-cranial direction. After visualizing
the clavicle and clavipectoral fascia, and performing aspiration to rule out intravascular
puncture, 2 ml of saline was injected to confirm correct positioning, and then 20 ml of 0.25%
bupivacaine was deposited between the periosteum and the clavipectoral fascia (Fig. 1). IV
ibuprofen 800 mg was administered 30 min before the end of surgery for multimodal
postoperative analgesia. The patient was extubated and transferred to the post-anaesthesia
care unit (PACU), where her pain was evaluated on a visual analogue scale (VAS). Pain was rated
at 0, so no analgesia was administered. After obtaining a modified Aldrete score of ≥9, she was
discharged from the PACU, and received ibuprofen 400 mg every 8 h. The maximum VAS
score reported by the patient was 2 at rest, due to headache. She did not experience pain at the
surgical site until 24 h after surgery, when she reported a pain score of VAS 3, which we treated
with multimodal analgesia (NSAIDs and tramadol). Roqués et al. used this combined block
(superficial cervical plexus-clavipectoral fascia plane block) for anaesthesia in clavicular
fracture, injecting local anaesthetic into the medial and lateral thirds of the affected clavicle.
When the patient is in the beach-chair position, we usually prefer general anaesthesia; for this
reason we performed the block for postoperative analgesia, and since the surgery
encompassed the entire clavicle we did not perform 2 punctures for the nerve block. We, like
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02.12.2019 Clavipectoral fascia plane block for analgesia after clavicle surgery - ScienceDirect

Roqués et al., observed that superficial cervical plexus-clavipectoral fascia plane block is a
simple, safe procedure that provides prolonged analgesia (24 h) for fractures of the medial
third of the clavicle. We believe that this nerve block is suitable not only for anaesthesia and
postoperative pain management, but also for emergency pain management in patients with
acute clavicular fracture, and for biopsies or curettage of clavicle bone tumours. Further
randomised trials are needed to compare the effectiveness of the clavipectoral fascia plane
block with other currently used nerve blocks.

Download : Download high-res image (410KB) Download : Download full-size image

Figure 1. Ultrasound view of the clavipectoral fascia plane block. Observe the spread of local
anaesthetic between the clavicle and the clavipectoral fascia plane.

Funding
None declared.

Conflicts of interest
The authors declare that they have no conflicts of interest.

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References
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Fractures of the clavicle in the adult. Epidemiology and classification
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View publication stats

02.12.2019 Clavipectoral fascia plane block for analgesia after clavicle surgery - ScienceDirect

2 D.Q.H. Tran, W. Tiyaprasertkul, A. Gonzalez

Analgesia for clavicular fracture and surgery: a call for evidence
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3 R. Drake, A.W. Vogl, A. Mitchell

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As part of the lecture: analgesia for clavicular surgery/fractures
36th annual ESRA congress, Lugano, Switzerland (2017)
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5 V. Roqués, L. Valdés, A. Pradere, et al.

How I do it: PoCUS and fascial plane blocks
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block for clavicle surgery. 44th annual regional anesthesiology and acute pain medicine
meeting, Las Vegas, NV, USA, April 11–13 (2019)
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☆
Please cite this article as: Atalay YO, Mursel E, Ciftci B, Iptec G. Bloqueo del plano de la fascia clavipectoral para
analgesia tras cirugía de clavícula. Rev Esp Anestesiol Reanim. 2019. https://doi.org/10.1016/j.redar.2019.06.006

View Abstract

© 2019 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España, S.L.U.
All rights reserved.

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