The Shoulder block: Combined Suprascapular and Axillary Nerve Block

Anatomy
There are five terminal nerves supplying the shoulder joint, 2 all carrying fibres originating
from C5 and C6 nerve roots.
(a) The suprascapular nerve is a branch of the superior trunk. After passing through the
suprascapular notch it lies beneath the supraspinatus, on the lateral supraspinous fossa, in
association with the suprascapular artery. Both structures curve around spinoglenoid
notch. It supplies posterior scapula, acromium, supraspinatus, infraspinatus, teres minor,
and the posterior and superior capsule.
(b) The axillary nerve is a branch of the posterior cord, which then travels via the
quadrilateral space in association with the circumflex artery. Both pass laterally across the
posterior surface of humerus lying beneath the deltoid. It supplies the humeral head and
neck, deltoid, teres minor, inferior capsule and skin over deltoid.
(c) The subscapular nerve is a branch of the posterior cord; it supplies the anterior scapula,
subscapularis and anterior capsule.
(d) The lateral pectoral nerve is a branch of the lateral cord; it supplies lateral portion of
pectoralis major and anterior capsule.
(e) The musculocutaneous nerve is a branch of the lateral cord; it supplies long head of
biceps and anterior capsule.

Innervation of the shoulder joint

Ultrasound Scan Technique
1. Patient position : performed in either the sitting (suprascapular nerve block performance
easier) or lateral position (axillary nerve block performance easier).
2. Landmark and US probe position :
a. Suprascapular nerve: Palpate along the spine of scapula. The ultrasound probe is
placed parallel to the spine, above the supraspinatus (which is immediately anterior to
the spine). Scan the floor of supraspinosus fossa in long axis. The suprascapular nerve
and the artery lie adjacent to each other and beneath the supraspinatus muscle on the
lateral floor of the fossa.
b. Axillary nerve: Locate the axillary crease (where the latissimus dorsi and deltoid
muscle meet). US probe is placed proximal to this, on the posterior deltoid. Scan the
proximal humerus in transverse axis. The nerve and artery travel together, and curve
around the neck of huerus beneath the deltoid muscle; they are thus scanned
longitudinally.

Ultrasound anatomy in long axis of supraspinous fossa. T, indicates trapezius, SN, suprascapular
nerve, SS, supraspinatus, SF, supraspinous fossa, SA, suprascapular artery.
 Ultrasound anatomy in short axis of supraspinous fossa. T, indicates trapezius, S, spine of scapula,
SS, supraspinatus, SN, suprascapular nerve, SA, suprascapular artery, SF, supraspinous fossa.

Performance of suprascapular nerve block in the long axis of the supraspinous fossa

Ultrasound image of suprascapular nerve block performed in the long axis of the supraspinous fossa.
T, indicates trapezius, SS, supraspinatus, N, needle, SN, suprascapular nerve, LA, local anesthetic,
SA, suprascapular artery, SF, supraspinous fossa.
Ultrasound anatomy in short axis of proximal humerus. PD, indicates posterior deltoid, CA,
circumflex artery, AN, axillary nerve, LD, lateral deltoid, H, humerus.

Ultrasound anatomy in long axis of proximal humerus. PD, indicates posterior deltoid, CA,
circumflex artery, AN, axillary nerve, PSH, posterior surface of humerus.
 Performance of axillary nerve block in short axis of the humerus.

Ultrasound image of axillary nerve block in performed in short axis of humerus. LD, indicates lateral
deltoid, N, needle, CA, circumflex artery, AN, axillary nerve, PD, posterior deltoid, H, humerus, LA,
local anesthetic.