Combined Interscalene Brachial Plexus and
Superficial Cervical Plexus Nerve Block for
Midshaft Clavicle Surgery: A Case Series
Caroline G. Fugelli, MD
Erling Tjelta Westlye, MD
Hege Ersdal, MD, PhD
Kristian Strand, MD, PhD
Conrad Bjørshol, MD, PhD
Clavicle fractures are common, and there has been a
recent increase in surgical fixation of displaced frac-
tures. General anesthesia is traditionally preferred
for these operations because regional anesthesia can
be challenging. This is partly due to a complex nerve
innervation in this region, which makes the correct
choice of nerve block difficult. The objective of this
study was to evaluate the efficacy of a combined inter-
scalene brachial plexus block and superficial cervical
plexus peripheral nerve block as anesthesia for clavicle
surgical procedures. Ten midshaft clavicle fractures
were surgically repaired using a combination of an
C
lavicle fractures are very common injuries.
They account for 2.6% of all fractures and
44% of injuries to the shoulder girdle.1 It
has been suggested that the high frequency
of fractures could be explained by the bone’s
superficial location and thin shaft. Most fractures occur
on the middle third (midshaft) of the bone. Furthermore,
shaft fractures are more likely to be displaced compared
with fractures of other parts of the clavicle.1
Lately there has been an increase in operative fixation
for clavicle fractures.2 Our hospital treats approximately
270 clavicle fractures per year, and according to operative
case logs the incidence of surgical repair increased from
13% to 18% in the 2014 to 2017 period.
Anesthesia for clavicle surgery has traditionally con-
sisted of general anesthesia. However, regional anesthesia
for upper limb surgery represents several advantages
over general anesthesia, including better postoperative
analgesia, less nausea and vomiting, more hemodynamic
stability, fewer side effects, and a favorable complica-
tions profile.3 Peripheral nerve blocks can result in less
postoperative opioid consumption, which might lead to
a shorter hospital stay and improved patient satisfaction.3
One reason for not using regional anesthesia for clavicle
surgery may be the unclear description of peripheral
nerve innervation of the clavicular area, in particular, the
midshaft region of the clavicle.4
374 AANA Journal  October 2019  Vol. 87, No. 5 www.aana.com/aanajournalonline
ultrasound-guided interscalene brachial plexus block
and a superficial cervical plexus block as the primary
anesthetic. All patients underwent surgery successfully
using regional anesthesia with light sedation, without
the need for rescue opioids or rescue local anesthesia.
No adverse events were recorded. This case series
describes a successful peripheral nerve block combi-
nation that can be used for clavicle surgery.
Keywords: Brachial plexus block, cervical plexus block,
clavicle, general anesthesia, local anesthesia.
There are suggestions that the clavicle is innervated
by nerves deriving from either the interscalene brachial
plexus (ISBP) or the superficial cervical plexus (SCP), or
from a combination of nerves from both plexuses.4 This
complex innervation represents a challenge for the an-
esthesia provider when it comes to selecting the correct
nerve block, leaving general anesthesia as the most con-
servative alternative.
In this study, we present a case series in which 10 mid-
shaft clavicle fracture operations were performed suc-
cessfully using a combination of an upper ISBP and SCP
nerve block as anesthesia in lightly sedated patients. This
study adheres to the CAse REport (CARE) guidelines.5
Case Summary
The study was approved by the hospital’s institutional review
board before the study started. Written informed consent
was obtained from all the included patients. The study
period was between September 2016 and January 2018.
All patients above the age of 18 years with a mid-
shaft clavicle fracture who were admitted when the first
author (C.G.F) was on duty were recruited if they did
not present with any of the exclusion criteria. Exclusion
criteria included risks of pulmonary decompensation
due to phrenic nerve palsy or worsening of an existing
neurologic condition with the use of a nerve block. After
receiving information concerning the choice between
regional or general anesthesia before the operation, all (n
= 10) gave consent to regional anesthesia.
The surgical technique consisted of internal fixation
of the fracture with a plate.

Methods of Block
The first and second authors (C.G.F. and E.W.), both ex-
perienced in ultrasound-guided peripheral nerve blocks,
performed all the included procedures. The patient’s
neck was scanned using a 7.5-MHz linear, 5-cm ultra-
sound probe (SonoSite Edge, Fujifilm SonoSite Inc). The
transducer was moved until both the upper ISBP and the
SCP were obtained in a short-axis position in the same
view (Figure 1a). A 50-mm, echogenic, nonstimulating
needle was used (Ultraplex, B Braun; Figure 1b). The
upper ISBP was defined as the upper/middle trunk of
the brachial plexus (Figure 1c). The SCP was localized
under the posterolateral belly of the sternocleidomas-
toid muscle (Figure 1d). With the patient in a supine
position, the needle was inserted in a lateral-to-medial
direction, in-plane technique, with the injection target
lateral to the upper ISBP (Figure 1c). Following initial
injection, the tip of the needle was withdrawn and redi-
rected toward the SCP, where an additional injection was
performed (Figure 1d). The nerve block consisted of only
one needle pass. The local anesthetic (LA) administered
was ropivacaine, 7.5 mg/mL (Table). Sensory block was
confirmed with a cold temperature test (Figure 2).
Patients were sedated intraoperatively with a propofol
infusion to an Observer’s Assessment of Alertness and
Sedation (OAA/S) Scale score of 3 or 4, aiming for a
cooperative, spontaneously breathing patient. Propofol
sedation was discontinued in time for the patient to be Figure 1. Performance of Superficial Cervical Plexus
fully awake at the end of surgery. (SCP) and Upper Interscalene Brachial Plexus (ISBP)
If patients were awake and pain free after surgery, they Nerve Block
were moved directly to the ward. Intraoperative respira- (a) Transducer is positioned at the patient’s neck. (b) Needle is
inserted in-plane from lateral to medial. (c) Ultrasonogram of
tory assistance, postoperative respiratory decompensation,
upper ISBP block, with the needle tip and spread of LA lateral to
and Horner syndrome or hoarseness, were registered in the the upper/middle trunk of the brachial plexus. (d) Ultrasonogram
anesthesia, postoperative care, or ward medical records. of SCP block, with the needle and spread of LA under the
posterolateral belly of the SCM. Red dashed line indicates borders
Results of the different muscles. Yellow dashed line indicates trunks of
the ISBP. Blue dots indicate injected LA.
All patients underwent surgery successfully using periph-
Abbreviations: AS, anterior scalene muscle; LA, local anesthetic;
eral regional anesthesia, without additional intraopera- MS, medial scalene muscle; n, needle; SCM, sternocleidomastoid
tive opioids or rescue LA. muscle.
The Table presents patient characteristics, the volume
of LA used for the nerve block, and the time interval tion of an upper ISBP and SCP nerve block for anesthesia
from the performed nerve block until the end of surgery. in open fixation of midshaft clavicle fractures. To our
No complications were recorded. Nine patients were knowledge, this study is the largest case series to date
transferred directly to the ward after the operation. One using a uniform combination of ultrasound-guided upper
patient was observed for 35 minutes in the postoperative ISBP and SCP block. Our results imply that this approach
care unit but did not receive any opioid or oxygen supply could be a good alternative for patients who have consid-
during this observation period. erable risk associated with general anesthesia or simply
do not want general anesthesia. Because 9 patients were
Discussion transferred directly to the ward without observation
In this report, we present a case series using a combina- in the postoperative care unit, it seems likely that the

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 Variable Mean (SD)
Age, mean (SD), y 47.2 (23-65)
ASA classification, mean (SD) 1.2 (1-2)
Weight, mean (SD), kg 76.5 (59-120)
Volume of ropivacaine, 7.5 mg/mL, for nerve block, mean (SD), mL 30.8 (25-35)
Time from performed nerve block to end of surgery, mean (SD), min 137 (79-190)

Table. Patient Demographic and Perioperative Characteristics of Nerve Block and Patient Flowa
aContinuous variables (ie, age, ASA classification, weight, volume of local anesthesia, time from performed nerve block to end of
surgery) are presented as mean (SD).

trunk and SCP,9 and selective C5 through C6 nerve root

Figure 2. Fracture, Nerve Block, and Surgical
Characteristics of 10th Patient in Case Series (a)
Preoperative radiograph of the clavicle fracture. (b) Postoperative
radiograph after fixation of the fracture with a plate. (c) After
ISBP and SCP block is performed, the drawn stippled line shows
sensory block. Solid line represents the planned surgical area.
(d) Intraoperatively, the surgeon presents the components of
the fracture, with no reported discomfort from the patient. (e)
Intraoperatively, the open surgical field after the fracture has been
fixated with a plate.
Abbreviations: ISBP, interscalene brachial plexus; SCP, superficial
cervical plexus.
block also can provide excellent postoperative analgesia.
Furthermore, our study findings suggest that this combi-
nation is sufficient for operative fixation of the clavicle,
also in the proximal part of this bone.
Limited data exist on regional anesthesia for surgery
on the clavicle. The data that do exist are provided mostly
as letters or correspondence, and a few case reports, with
no consistent peripheral nerve block description. Nerve
block combinations suggested are as follows: ISBP and
SCP,6 low ISBP and SCP,7 supraclavicular brachial plexus
and supraclavicular nerve,8 ISBP between upper/middle
block combined with SCP.10
It is believed that the SCP is responsible for the
sensation of the fascia and skin over the clavicle, but it
has been suggested that the supraclavicular nerve (C3
through C4) arising from the SCP might mediate sensa-
tion from bony parts of the proximal clavicle. Several
authors support the view that an SCP can be sufficient
for analgesia, but not to anesthetize the entire clavicle
and perform surgery.4,11
Whether the clavicle is innervated by the cervical
plexus or the brachial plexus is still unclear. Description
of the innervation of the deeper structures varies in the
literature, and some data link it to nerve roots or nerves
that are part of the ISBP. It has been reported to derive
from the C5 root through the suprascapular nerve.12,13
Others suggest that it is necessary to block several nerves
from the C5/6 and C7 roots to be sufficient for surgery.
Nerves such as the axillary, the subclavian, and the long
thoracic nerve could contribute to both sensory and
deeper innervation of the distal half of the clavicle.4,10,14
As discussed earlier, a uniform description of where
the ISBP should be blocked has not been established.
Injection of LA adjacent to the ISBP is associated
with a risk of unintentional spinal or epidural block.14
Ultrasound guidance may reduce this risk. Salvadores de
Arzuaga et al10 reported that they targeted the roots when
performing the ISBP block. However, dural sleeves can
extend into the cervical nerve roots, and some authors
argue that LA should not be placed at a level where the
tubercles can be identified because of the risk of uninten-
tional spinal or epidural blockade.14 It has been shown
that 5 mL of LA injected at the C5 nerve root using ul-
trasound guidance in human cadavers could spread intra-
thecally and to the phrenic nerve.15 Therefore, we believe
it is safer to perform a block more distant to the C5 root
(upper ISBP block), with less risk of proximal spread
to the intrathecal area, because this has been shown to
provide comparable anesthesia.15
Tran et al4 pointed out that the effect of an SCP block
is somewhat variable. Carried out at the C6 level (at the
level of the cricoid cartilage), LA may diffuse to the un-
derlying interscalene groove and surreptitiously block the
brachial plexus. Flores et al16 recommended to perform

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the block at the C4 level (upper pole of thyroid cartilage)
and with 5 mL or less of LA to avoid concomitant brachial
plexus block by penetration of the prevertebral fascia. A
direct communication between subcutaneous fat, connec-
tive tissue in the neck, and the prevertebral layer beneath
the deep cervical fascia has been suggested.16 From an an-
atomical point of view, this area has not been completely
elucidated. Current data support the concept of deeper
neck compartments potentially communicating directly
with the subcutaneous tissue. This anatomical pathway
can explain why a SCP block has been reported to lead to
blockade in the deeper compartments of the neck, such
as stellate ganglion block (Horner syndrome) or recur-
rent laryngeal nerve block.16 In addition, if large amounts
of LA are used or the needle is put to medially, phrenic
nerve palsy can occur. The phrenic nerve originates pre-
dominantly from the C4 nerve root and rests underneath
the prevertebral layer above the anterior scalene muscle.
To reduce the incidence of all these complications, we
suggest minimizing the volume of LA, the needle place-
ment at the C4 level, and needle-tip placement main-
tained just underneath the SCM belly.
In the present study, the volume of LA for both
nerve blocks was based on recommendations from
previous publications.7,9,10,17 We injected 8 to 15 mL
of LA for the SCP block. Acquainted by mentioned
precautions, a smaller volume is probably sufficient;
however, no adverse events were recorded for our pa-
tients. Furthermore, we did not adhere strictly to the
C4 level, because we wanted to target the SCP and
upper ISBP in the same view to minimize needle passes.
Importantly, we performed the nerve blocks at the most
cranial level, where we could get a sufficient view of both
plexuses. The anatomy in the neck region is variable, and
the use of ultrasound is of great advantage by identifying
anatomical structures and the spread of LA, thus prevent-
ing excessive spread of the anesthetic and reducing the
incidence of adverse effects.
In conclusion, our case series supports the efficacy of
a uniform combination of an upper ISBP and SCP nerve
block as anesthesia for surgical fixation of midshaft
clavicle fractures. We believe that regional anesthesia
is a safe and important alternative for this group of pa-
tients. It suffices as sole anesthesia as well as provides
excellent immediate postoperative analgesia. Moreover,
because 9 of 10 patients bypassed the postoperative care
unit, our results indicate a benefit concerning operation
logistics. Further investigations with larger sample sizes
are needed to evaluate the minimum LA volume and in-
cidence of adverse effects.
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AUTHORS
Caroline G. Fugelli, MD, is a senior consultant and chief of the Ortho-
pedic/Neurosurgical Department of Anesthesiology, Stavanger University
Hospital, Stavanger, Norway. Email: Fuca@sus.no.
Erling Tjelta Westlye, MD, is a resident in the Department of Anesthe-
siology, Stavanger University Hospital.
Hege Ersdal, MD, PhD, is a senior consultant in the Department of
Anesthesiology, Stavanger University Hospital.
Kristian Strand, MD, PhD, is a senior consultant and chief of the
Intensive Care Unit, Department of Intensive Care Medicine, Stavanger
University Hospital.
Conrad Bjørshol, MD, PhD, is a senior consultant in the Department
of Anesthesiology and project manager at The Regional Centre for Emer-
gency Medical Research and Development (RAKOS), Prehospital Medicine
 October 2019  Vol. 87, No. 5 377
Clinic, Stavanger University Hospital. Dr Bjørshol also is an associate DISCLOSURES
professor in the Department of Clinical Medicine, University of Bergen, The authors have declared no financial relationships with any commercial
Bergen, Norway. entity related to the content of this article. The authors did not discuss off
label use within the article.

378 AANA Journal  October 2019  Vol. 87, No. 5 www.aana.com/aanajournalonline