Ultrasound Guidance

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In Regional Anesthesia:
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Techniques for Upper-Extremity

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Nerve Blocks
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Provided as an
From the publisher of educational service by

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Disclaimer
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This pocket guide is designed to be a summary of information.

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While it is detailed, it is not an exhaustive review. McMahon Pub-

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lishing, SonoSite, Inc., and the authors neither affirm nor deny
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the accuracy of the information contained herein. No liability will

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be assumed for the use of this review, and the absence of typo-
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graphical errors is not guaranteed. Readers are strongly urged to

consult any relevant primary literature and the complete pre-
scribing information available in the package insert of each drug
and appropriate clinical protocols for each product.
Copyright ©2007, McMahon Publishing, 545 West 45th Street,
New York, NY 10036. Printed in the USA. All rights reserved, includ-
ing the right of reproduction, in whole or in part, in any form.
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Ultrasound Guidance
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In Regional Anesthesia:
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Techniques for Upper-Extremity

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Nerve Blocks
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Brian D. Sites, MD
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Assistant Professor of Anesthesiology and Orthopedic Surgery

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Director of Regional Anesthesia

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Dartmouth-Hitchcock Medical Center

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Lebanon, New Hampshire

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Brian C. Spence, MD
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Assistant Professor of Anesthesiology

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Dartmouth-Hitchcock Medical Center

Lebanon, New Hampshire
Table of Contents
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Philosophy . . . . . . . . . . . . . . . . . . . . 6
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In-Plane Versus Out-of-Plane

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Technique . . . . . . . . . . . . . . . . . . . . 6
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Interscalene Nerve Block . . . . . . . . 12

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Supraclavicular Nerve Block . . . . . . 15

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Infraclavicular Nerve Block . . . . . . . 18

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Axillary Plexus Block . . . . . . . . . . . 22

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Musculocutaneous Nerve
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(MCN) Block . . . . . . . . . . . . . . . . . 25
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Radial Nerve Block . . . . . . . . . . . . . 28

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Median Nerve Block:

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Single Injection . . . . . . . . . . . . . . . 30
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Ulnar Nerve Block . . . . . . . . . . . . . 33

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Philosophy
We believe that vision is the best of the primary human senses.
Ultrasound allows the anesthesiologist to evaluate complex and
varied neural anatomy prior to needle insertion. In addition to
real-time guidance of the needle toward a nerve or plexus,
ultrasound allows the anesthesiologist to witness (and alter) the
spread of local anesthesia after the initiation of an injection.
Ultimately, it is this visual confirmation of the perineural spread
of local anesthesia that generates a rapid and successful block.
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Equipment Specification
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1) Ultrasound system
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2) Ultrasound transducer, 13-6 MHz linear array with variable

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resolution settings
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3) Stimulating needles
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4) Ultrasound gel (sterile and non-sterile)

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5) Sterile transducer cover

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6) Nerve block kit containing sterile drape, skin wheal needles,

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extension tubing, and syringes of choice

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Optional Equipment
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7) Needle guide systems

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B) Transducer-stabilizing device
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In-Plane Versus Out-of-Plane Technique

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Structures of interest (blood vessels, tendons, and nerves) can

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be imaged either on the short axis (cross-section) or the long

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axis.A short-axis view becomes a long-axis view when the probe

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is turned 90 degrees in either direction. Figure 1 demonstrates

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these principles.
There are 2 methods of needle insertion with respect to the
ultrasound beam. State-of-the-art clinical imaging is currently
2-dimensional; the inserted needle can be visualized on either the
long axis or the short axis (Figure 2).When the needle is insert-
ed in the long-axis view, the entire needle can be visualized.This
is known as the in-plane technique.This technique affords visu-
alization of the entire needle and the tip, allowing the operator

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skin surface skin surface

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Figure 1. Demonstration of the differences

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between imaging a structure on the short

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axis versus the long axis.

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For this demonstration, the patient is in the prone position. A. Trans-

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ducer position in order to image the median nerve on the short axis in
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the forearm. B. The corresponding short-axis ultrasound image of the

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median nerve. Note the characteristic circular appearance of the

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nerve. On the short axis, the anesthesiologist has simultaneous anteri-

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or–posterior and lateral–medial perspectives on the nerve. C. If the

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probe position for the short-axis view is turned 90 degrees (clockwise

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or counterclockwise), the long-axis view of the same structure will be

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generated. D. The corresponding long-axis view of the median nerve.

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Note the characteristic tubular appearance. When imaging a nerve on

the long axis, the operator loses the lateral–medial perspective. This
can be disadvantageous when trying to identify needle location and
the circumferential spread of local anesthetic around the nerve.
L, local anesthetic

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Figure 2. The needle in relation to the

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transducer.
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A. The needle is in-plane (long axis) with the ultrasound beam.

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B. The corresponding ultrasound image of the needle in-plane with

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the ultrasound beam. C. The out-of-plane technique with the needle

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imaged on the short axis. This is also referred to as a cross-sectional

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view. D. The corresponding ultrasound image of the needle out-of-

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plane with the ultrasound beam and imaged on the short axis.
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to make very precise real-time adjustments (Figures 2A and 2B).

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When the needle is inserted in the short axis, a cross-sectional

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view of the needle will be obtained (Figures 2C and 2D).This is

known as the out-of-plane technique.The out-of-plane tech-
nique results in the needle being imaged on cross-section.An
18- to 22-gauge needle imaged on cross-section appears as a
small dot, which can be difficult to see in real time. In addition,
the needle will cross the ultrasound beam only once.Therefore,
when the needle is visualized, it may be well above or below the
target nerve, depending on the angle of the insertion.

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 For single-injection nerve blocks, we prefer the in-plane tech-
nique.The out-of-plane technique is preferred for continuous
catheter placement.When using the out-of-plane technique, it is
helpful to inject small amounts of saline, local anesthesia, or 5%
dextrose solution to help define the location of the needle tip as
it advances.The major learning obstacle for the in-plane tech-
nique is the ability to keep the needle in the path of the ultra-
sound beam.When using the out-of-plane technique, consider
the following:
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1. Use an ultrasound system with a high-frequency transducer

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(up to 13 MHz) for superficial blocks that are ≤3 cm deep.This

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allows the best resolution of the neural structures and sur-

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rounding tissue. Deeper blocks will require a lower-frequency

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transducer that provides better penetration of the ultrasound

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beam into the tissue.

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2. The needle is visualized before being advanced when using

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the in-plane technique.The ultrasound beam is very thin,

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which means that subtle movements can bring the needle in

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and out of visualization.

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3. Subtle pressure or angulation of the transducer (probe) can

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dramatically improve or worsen the image.

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4. Practice your needle skills using a turkey breast with an olive

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placed in it. Interventional radiologists use this popular

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model to mimic a cyst in a human breast.

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5. Ask the experts at your institution for clinical pearls and

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insights.We have gained many tricks of the trade by speaking

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with radiologists and ultrasonographers. Specifically, the

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operator should be familiar with depth, color flow indica-

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tors, gain, focus, frequency settings, and image storing.

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6. Keep a database of your cases; you will quickly realize the

improvement in efficiency and efficacy of your regional
anesthesia service.
7. Many ultrasound systems provide optional needle-guide
devices for their transducers.These devices secure the needle
to the transducer and allow the operator to follow a predeter-
mined course to the target of interest.Although on the sur-
face these devices may sound attractive, we have found that

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Figure 3. Setup for the performance of a

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right-sided, single-injection interscalene

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nerve block.
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The dotted line represents the interscalene groove and the solid line
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represents the lateral border of the sternocleidomastoid muscle. Fol-

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lowing the identification of the carotid artery and the internal jugular
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vein, the transducer is moved in a lateral and posterior direction until it

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comes to rest as indicated in this photo.

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they often limit the anesthesiologist’s options.That is, once

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the needle is secured into the needle-guide device, one

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cannot change angles and approaches to the nerve that

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would allow generation of the circumferential spread of local

anesthetic around the nerve.
8. The transducer is held in the operator’s nondominant hand
and the needle in the dominant hand.The ability to use both
hands to drive the needle will give those fortunate individu-
als an ergonomic advantage as they will find it easier to
establish an ergonomically stable situation regardless of
block type and patient position.

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Figure 4. Ultrasound image of the brachial

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plexus.
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Horizontal arrows depict the roots of the brachial plexus at the level
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indicated by Figure 5. The roots of the brachial plexus appear as 2 to 4

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hypoechoic circles with hyperechoic outer rings.

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AS, anterior scalene muscle; IJ, internal jugular vein; MS, middle
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scalene muscle; SCM, sternocleidomastoid muscle

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9. Place the ultrasound machine on the contralateral side of the

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patient and have the operator stand on the ipsilateral side of

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the extremity to be blocked.

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10. All transducers have an orientation marker that should be

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positioned at the upper-left corner of the ultrasound screen,

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allowing the skin surface to be uppermost.When scanning in

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a transverse/cross-sectional plane, the marker on the trans-

ducer should always point toward the operator’s left side,
allowing reproducibility of image orientation.
11. Terminology: hyperechoic, whiter or brighter than surround-
ing tissue; hypoechoic, gray or darker in relation to the sur-
rounding tissue; anechoic, black.

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Figure 5. The posterior approach to perform-

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ing an ultrasound-guided interscalene block.

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The needle is inserted in-plane with the ultrasound beam through the
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middle scalene muscle toward the brachial plexus.

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Interscalene Nerve Block

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Patient Position: Supine with the head rotated toward the

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nonoperative side
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Transducer Location: At level of or below the cricoid cartilage

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Frequency: High
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In-Plane/Out-of-Plane: In-plane
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Nerve Image: 3 to 4 hypoechoic circles located between the

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anterior and middle scalene muscle bellies

Needle Size: 50 mm
Local Volume: 20-30 cc
1. Place transducer over the sternocleidomastoid muscle at the
level of the cricoid cartilage (Figure 3).
2. Image the carotid artery and internal jugular vein in the
short-axis view and then slide the transducer in a lateral
and posterior direction.The roots of the brachial plexus

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Figure 6. The anterior approach to perform-

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ing an ultrasound-guided interscalene block.

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mastoid muscle and the anterior scalene muscle toward the brachial
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plexus. This technique is sometimes easier for right hand-dominant

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individuals performing right-sided interscalene nerve blocks.

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should appear as 2 to 4 hypoechoic circles with hyperechoic

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outer rings (Figure 4).The nerves should be flanked medially

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and laterally by the anterior and middle scalene muscles.

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3. The needle is advanced using the in-plane technique, either

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from the posterior aspect (posterior approach, Figure 5) or

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the anterior aspect (anterior approach, Figure 6) of the trans-

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ducer footprint. For shoulder surgery, the needle should be

advanced under direct guidance between the C5 and C6
nerve roots.
4. Nerve stimulation may be used to confirm entry into the
brachial plexus sheath.
5. Inject local anesthetic.

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Figure 7. Insertion of the needle through the

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middle scalene muscle.

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The needle is indicated by the triangles.

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AS, anterior scalene muscle; C5, the fifth cervical nerve root;
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MS, middle scalene muscle

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Clinical Pearls
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• The best view of the brachial plexus is often found more inferi-
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or in the neck than expected by the conventional description

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(ie, more inferior than at the level of the cricoid cartilage).

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• If you are having difficulty identifying the neural structures,

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obtain a supraclavicular image first (see below) and trace the

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neural structures superiorly up the neck.

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• The tip of the lateral end of the sternocleidomastoid muscle

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should be slightly posterior–lateral to the superior neural

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structures in the interscalene groove.

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• During needle insertion (using the posterior approach), the

great vessels should not be viewed simultaneously with the
brachial plexus in the interscalene groove (Figure 7). If the
great vessels are in the image, you may need to move the
transducer in a more posterior lateral direction.
• We use a mechanical device to hold the transducer.This
device allows 1 person to perform the procedure as well as
eliminating operator fatigue (Figure 8).

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Figure 8. A transducer-stabilizing device.

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This mechanical arm fixes the transducer in place, creating a stable

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image and allowing one person to perform the procedure.

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• Remember that anatomy is variable, especially with the roots

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of the brachial plexus.A well-described variant is when 1 or

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more of the roots do not exist in the interscalene groove, but

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penetrate directly through muscle. In these cases, one will

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see the hypoechoic nerve root(s) in either the anterior or

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medial scalene muscle.

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Supraclavicular Nerve Block

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Patient Position: Supine with the head rotated toward the

nonoperative side
Transducer Location: Parallel to the clavicle resting in the
supraclavicular fossa
Frequency: High
In-Plane/Out-of-Plane: In-plane
Nerve Image: 3 to 6 hypoechoic circles located lateral and
superior to the subclavian artery

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Figure 9. Setup for the performance of a

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right-sided, single-injection supraclavicular

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nerve block.
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The high-frequency linear transducer is placed in the supraclavicular

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fossa. The goal is to first identify the subclavian artery and then
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search for the nerves. You will see 1 of 2 appearances of the brachial
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plexus, depicted in Figures 10 and 11. The needle is inserted from the
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lateral aspect of the transducer. The goal is to situate the needle

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between the first rib and the most inferior nerve trunk or division.
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Needle Size: 50 mm
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Local Volume: 20-30 cc

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1. Place the transducer parallel to the clavicle in the supra-

clavicular groove (Figure 9). Key structures to identify include
the subclavian artery, the first rib, the pleura, and the hypo-
echoic nerves of the brachial plexus.
2. Advance the needle using the in-plane approach from the
lateral aspect of the transducer.
3. The first injection site should be immediately adjacent to the
artery and inferior to the lowest nerve trunk.The needle may

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Figure 10. Divisions of the brachial plexus.

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The divisions appear as 4 or more large hypoechoic circles in a

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superior–lateral perspective with respect to the subclavian artery.

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The divisions of the brachial plexus are indicated by the triangles and
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the chest cavity is indicated by the arrow.

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SC, subclavian artery

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be repositioned around the more superior nerve structures if

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there is an inadequate spread of local anesthetic with the

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initial injection.
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Clinical Pearls
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• This block is nicknamed “the spinal of the arm” because it is

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a total upper-extremity regional anesthetic.This block should

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effectively replace all other blocks of the arm (except inter-

scalene) because it is extremely easy and efficacious to per-
form. Injured extremities do not have to be moved.There
should be optimal tourniquet coverage as well.
• Real-time ultrasound should be used to minimize the risk of
an intra-arterial injection or a pneumothorax. Do not advance
the needle unless the tip is visualized. Lying beneath the first
rib is the pleura of the lung.

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Figure 11. Trunks of the brachial plexus.

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The trunks should appear as 3 hypoechoic circles stacked on one

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another in a linear fashion.

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I, inferior trunk; M, middle trunk; S, superior trunk; SC, subclavian artery

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• For hand surgery, the injection made around the most inferi-
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or aspect of the brachial plexus is critical to the success of

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this block.This injection should be accomplished first in case

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there is any tissue distortion with injection.

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• Two distinct appearances of the brachial plexus appear at

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the supraclavicular level. One can see a grape-like cluster of

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5 to 6 hypoechoic circles, which probably represent the divi-

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sions of the brachial plexus (Figures 10 and 11).When only 3

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hypoechoic structures are visualized, the operator may be

visualizing the trunks of the brachial plexus.

Infraclavicular Nerve Block

Patient Position: Supine with the head rotated toward the
nonoperative side
Transducer Location: Infraclavicular, perpendicular to the
clavicle along the lateral segment and in the infraclavicular fossa

18
 Co
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t
©
A

20
ll

07
ri
gh

M
ts

Figure 12. Setup for performing an

cM
re

ah

ultrasound-guided infraclavicular block.

se
w

on
rv
it

ed
ho

Pu

The transducer is placed in the infraclavicular fossa. The goal of the

.R
ut

bl
is
ep

transducer position is to image the axillary artery on the short axis

pe

hi
ro
rm

approximately 1 to 2 cm medial to the corocoid process. The needle

ng
du
is

can be inserted from either aspect of the transducer and in line with
G
si

ct

ro
on

io

the ultrasound beam. The cords of the brachial plexus often appear as
up wh ed
n
is

in

3 hyperechoic circles located around the axillary artery (see Figure

un le
pr

le

13). Clinical experience suggests that the primary injection site should
oh

ss
o
ib

be between the axillary artery and the posterior cord. Nerve stimula-
ot n p
it

or

he ar

tion is helpful in this block because the cords, being much deeper than
.

rw t
i

the more proximal brachial plexus, are harder to visualize.

is
e
no
te
d.

Frequency: 10-5 MHz, depending on the depth of the plexus

from the surface
In-Plane/Out-of-Plane: In-plane
Nerve Image: 3 hyperechoic exterior nerve structures dis-
tributed around the subclavian artery at 3, 6, and 9 o’clock
positions
Needle Size: 100 mm
Local Volume: 20-30 cc

19
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07
ri
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Figure 13. Anatomy seen during an

ts

cM
re

ah

infraclavicular nerve block.

se
w

on
rv
it

ed
ho

Pu

The axillary artery and vein are seen in the short-axis view.
.R
ut

bl

A, axillary artery; L, lateral cord; M, medial cord; P, posterior cord; PMa,

is
ep
pe

hi
ro
rm

pectoralis major muscle; PMi, pectoralis minor muscle; V, axillary vein

ng
du
is

G
si

ct

ro
on

io

up wh ed
n
is

1. Place the transducer in the infraclavicular fossa, perpendicu-

in

un le
pr

lar to the clavicle along its lateral segment.The infraclavicular

le
oh

ss
o
ib

fossa is a natural depression about 1 cm medial to the coro-

ot n p
it

or

coid process of the scapula.This should allow you to visualize

he ar
.

rw t
i

the axillary artery in the short-axis view (Figure 12). Key

is

structures to identify are the pectoralis major muscle, pec-

e
no

toralis minor muscle, axillary artery, and the axillary vein (Fig-
te
d.

ure 13).
2. Advance the needle from either the inferior or superior side
of the transducer using a 100-mm needle.The goal for the
needle position is between the axillary artery and the poste-
rior cord of the brachial plexus (between 6 and 8 o’clock).
3. Redirect the needle as needed to get circumferential spread
of local anesthesia around the axillary artery.

20
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M
ts

cM
re

ah
se
w

on
rv
it

ed
ho

Pu
.R
ut

bl

Figure 14. Setup for performing an

is
ep
pe

hi

ultrasound-guided, axillary nerve block.

ro
rm

ng
du
is

G
si

ct

ro

The transducer is placed in the axilla. The goal is to first image the
on

io

up wh ed
n

axillary artery on the short-axis view. The needle can be inserted from
is

in

un le
pr

either aspect of the transducer.

le
oh

ss
o
ib

ot n p
it

or

he ar
.

rw t
i

Clinical Pearls
is

• Because the needle must transgress through 2 thick muscle

e
no

beds (pectoralis major and minor), this block can be uncom-

te
d.

fortable for some patients.

• A transducer with a smaller footprint is sometimes better
than the traditional larger linear transducers because the
infraclavicular fossa is small and the larger-footprint probes
can hang over the clavicle.
• The cords of the brachial plexus tend to be more difficult to
visualize compared with the roots, trunks, and divisions.This
difficulty is secondary to the deeper location of the cords.

21
 Deeper structures cannot be imaged with the highest
frequency (highest resolution) transducers.
• We reserve infraclavicular blocks for situations in which
there is a relative contraindication to a supraclavicular block
(eg, subclavian artery pathology, localized infection, and
severe chronic obstructive pulmonary disease [COPD]).
Because one may anesthetize the phrenic nerve with a supra-
clavicular block, this block should be performed judiciously
in a patient who has severe COPD.
Co
py

Axillary Plexus Block

ri
gh

Patient Position: Supine with the head rotated toward the

t
©

nonoperative side.The patient’s arm is abducted and externally

A

20
ll

rotated.
07
ri
gh

Transducer Location: In the axilla at the crease formed by

ts

cM

the pectoralis major and biceps muscles; perpendicular to

re

ah
se
w

the axillary artery

on
rv
it

ed
ho

Frequency: High
Pu
.R
ut

bl

In-Plane/Out-of-Plane: In-plane
is
ep
pe

hi

Nerve Image: The nerves will be located in a variable fashion

ro
rm

ng
du
is

around the axillary artery.The nerves appear as complex,

G
si

ct

ro
on

hyperechoic, and circular or oval structures with the internal

io

up wh ed
n
is

fascicles appearing as multiple hypoechoic smaller circles.

in

un le
pr

Needle Size: 50 mm
le
oh

ss
o
ib

Local Volume: 20-30 cc

ot n p
it

or

Note: The musculocutaneous nerve will be addressed in the

he ar
.

rw t
i

next section.
is

1. Place the transducer in the axilla perpendicular to the course

e
no

of the axillary artery and roughly at the level of the crease

te
d.

formed by the pectoralis major and biceps muscles (Figure 14).

2. Obtain an image of the axillary artery and vein(s) in the
short-axis view.You may use color Doppler to distinguish the
artery from the vein.The artery should be noncompressible
and pulsating, and the vein should be compressible and have
continuous steady flow.The median, ulnar, and radial nerves
most likely will surround the artery in a triangular pattern;
however, their exact location may vary significantly among

22
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Figure 15. Structures in the axillary region.

M
ts

cM
re

ah

The median, ulnar, and radial nerves appear in a variable fashion

se
w

on
rv
it

around the artery. There may be up to 3 large veins associated with

ed
ho

Pu

the plexus. The nerves are usually round or oval and have a hyper-
.R
ut

bl
is
ep
pe

echoic appearance. The median nerve tends to be the most consis-

hi
ro
rm

ng

tent, appearing between the 12 and 2 o’clock positions with respect to

du
is

the artery. The radial nerve is the hardest to image and the ulnar nerve
si

ct

ro
on

io

tends to be the farthest from the artery. The goal is to direct local
up wh ed
n
is

in

anesthetic either circumferentially around the artery or around the indi-

un le
pr

le
oh

vidual nerves.
ss
o
ib

A, axillary artery; M, median nerve; MCN, musculocutaneous nerve;

ot n p
it

or

he ar

R, radial nerve; U, ulnar nerve; V, vein

.

rw t
i

is
e
no

patients.The median nerve tends to appear consistently at

te
d.

the 12 o’clock position with the ulnar nerve between the 2

and 5 o’clock positions.The radial nerve varies, but tends to
appear between 4 and 9 o’clock (Figure 15).
3. Advance the needle from either side of the transducer, using
the in-plane approach. First, we recommend targeting the
nerves that are anticipated to be involved in the surgery. Fol-
lowing an injection, there can be significant distortion of the
anatomy.

23
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ri
gh

Figure 16. Setup for performing an

M
ts

cM
re

ultrasound-guided, musculocutaneous
ah
se
w

on
rv

nerve block.
it

ed
ho

Pu
.R
ut

bl

The transducer is placed at the junction of the biceps and pectoralis

is
ep
pe

hi

major muscles. The in-plane approach is used.

ro
rm

ng
du
is

G
si

ct

ro
on

io

up wh ed
n
is

4. Inject local anesthetic. Depending on the image quality, the

in

un le
pr

goal will be to visualize the local anesthetic surrounding the

le
oh

ss
o
ib

targeted nerves.You may reposition the needle as needed to

ot n p
it

or

obtain appropriate coverage.

he ar
.

rw t
i

is

Clinical Pearls
e
no

• Nerve stimulation may be helpful in identifying nerves several

te
d.

centimeters away from the artery and in a variable orienta-

tion.The nerve stimulator is a great physiologic test of your
anatomic assumptions.
• The ulnar nerve may be located several centimeters from the
artery. In addition, this nerve may be situated next to one of
the axillary veins instead of the axillary artery.
• There may be multiple veins associated with the axillary
brachial plexus.

24
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Figure 17. The MCN in the axilla.

M
ts

cM
re

ah

The short-axis image of the MCN in the axilla at the level described in
se
w

on
rv
it

Figure 16. The nerve appears as a hyperechoic, circular structure lying

ed
ho

Pu

between the 2 muscle beds. The nerve is indicated by the triangles.

.R
ut

bl
is
ep
pe

BM, biceps muscle; CB, corocobrachialis muscle; MCN, musculocuta-

hi
ro
rm

ng

neous nerve
du
is

G
si

ct

ro
on

io

up wh ed
n
is

in

un le
pr

• Arguably less artistic, but easier to do, is to simply use ultra-

le
oh

ss
o
ib

sound guidance to generate local anesthetic spread in a cir-

ot n p
it

or

cumferential pattern around the axillary artery (the doughnut

he ar
.

rw t
i

sign).We reserve this technique for situations in which it is a

is

struggle to image the individual nerves.

e
no

• Because local anesthetics are hypoechoic, the spread of the

te
d.

injection is very easy to visualize. If the local anesthetic is

injected into a blood vessel, the drug will be carried away and
thus not visualized.Therefore, if the local anesthetic is not
visualized spreading around the artery, the practitioner should
assume an intravascular injection and reposition the needle.

25
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Figure 18. Setup for performing an

ts

cM
re

ah

ultrasound-guided, radial nerve block in the

se
w

on
rv
it

antecubital fossa.
ed
ho

Pu
.R
ut

bl
is
ep

The transducer is placed in the lateral aspect of the antecubital fossa.

pe

hi
ro
rm

It is easiest to insert the needle in-plane with the ultrasound beam

ng
du
is

from the lateral aspect of the transducer.

G
si

ct

ro
on

io

up wh ed
n
is

in

un le
pr

Musculocutaneous Nerve (MCN) Block

le
oh

ss
o
ib

Patient Position: Supine with the head rotated toward the

ot n p
it

or

nonoperative side.The patient’s arm is abducted and external-

he ar
.

rw t
i

ly rotated.
is

Transducer Location: In the axilla, perpendicular to the axil-

e
no

lary artery. Start the transducer in the same position as for the
te
d.

axillary block.
Frequency: High
In-Plane/Out-of-Plane: In-plane
Nerve Image: Large, singular hyperechoic structure with
small, internal hypoechoic fascicles, usually located in a fascial
plane between the coracobrachialis and biceps muscles
Needle Size: 50-100 mm
Local Volume: 5-10 cc

26
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Figure 19. Key structures involved in a

ts

cM
re

ah

radial nerve block.

se
w

on
rv
it

ed
ho

Pu

The fascial compartment that houses the radial nerve is indicated by

.R
ut

bl

the arrows.
is
ep
pe

hi
ro
rm

ng

B, brachialis muscle; Br, brachioradialis muscle; JS, joint space

du
is

G
si

ct

ro
on

io

up wh ed
n
is

1. Abduct and externally rotate the patient’s arm to reveal the

in

un le
pr

axilla. Place the transducer in the axilla perpendicular to the

le
oh

ss
o
ib

course of the axillary artery at the junction of the pectoralis

ot n p
it

or

major and biceps muscles (Figures 16 and 17).

he ar
.

rw t
i

2. Move the transducer superiorly toward the biceps muscle.

is

The goal will be to image the MCN on the short-axis view.

e
no

The MCN will appear either in the body of the coraco-

te
d.

brachialis muscle or in the plane between the coraco-

brachialis muscle and the biceps muscle.
3. Advance the needle using the in-plane approach.
4. The goal of the injection is to generate the circumferential
spread of local anesthesia around the nerve.

27
 Co
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A

20
ll

Figure 20. Setup for performing an

07
ri
gh

ultrasound-guided, median nerve block in

ts

cM
re

ah

the forearm.
se
w

on
rv
it

ed
ho

Pu

The in-plane approach is preferred, but the out-of-plane approach may

.R
ut

bl

be used (Figure 21).

is
ep
pe

hi
ro
rm

ng
du
is

G
si

ct

ro
on

Clinical Pearls
io

up wh ed
n
is

• The MCN has an undulating pattern and sometimes can

in

un le
pr

actually be imaged in the long-axis view at 1 site and in the

le
oh

ss
o
ib

short-axis view at another.

ot n p
it

or

• As the transducer is moved more proximally in the arm, the

he ar
.

rw t
i

MCN gets closer to the axillary artery.

is

• Because this nerve is flanked by muscle, it is very easy to

e
no

see.The nerve is hyperechoic, brighter than the surrounding

te
d.

muscle, whereas the muscles are dark (hypoechoic).

Radial Nerve Block

Patient Position: Supine with the head rotated toward the
nonoperative side.The patient’s arm is abducted to 90 degrees
with the hand supinated.
Transducer Location: In the antecubital fossa lateral to the
biceps tendon

28
 Co
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20
ll

Figure 21. Setup for an out-of-plane median

07
ri
gh

nerve block.
ts

cM
re

ah
se
w

on
rv
it

ed
ho

Frequency: High
Pu
.R
ut

bl

In-Plane/Out-of-Plane: In-plane
is
ep
pe

hi

Nerve Image: Hyperechoic oval structure

ro
rm

ng
du

Needle Size: 50 mm
is

G
si

ct

ro
on

Local Volume: 5-10 cc

io

up wh ed
n
is

1. The patient’s arm should be abducted to 90 degrees at the

in

un le
pr

shoulder and then the hand should be supinated (Figure 18).

le
oh

ss
o
ib

2. Place the transducer in the antecubital fossa lateral to the

ot n p
it

or

biceps tendon.
he ar
.

rw t
i

3. The nerve will appear in the short-axis view as a hyper-

is

echoic oval structure. It is located between 2 easily identifi-

e
no

able muscle beds: brachialis and brachioradialis muscles

te
d.

(Figure 19).
4. Insert the needle using the in-plane approach from the lateral
perspective of the transducer. If using nerve stimulation, a
wrist extension should be noted as the needle makes contact
with the hyperechoic oval structure.

29
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07
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M
ts

cM

Figure 22. The median nerve imaged

re

ah
se
w

on the short-axis view in the mid-forearm.

on
rv
it

ed
ho

Pu
.R
ut

The nerve appears as a hyperechoic circle or triangle. The internal

bl
is
ep
pe

hypoechoic fascicles can easily be seen. The nerve is indicated by the

hi
ro
rm

ng

arrows and the tendons are indicated by the triangles. The radial side
du
is

G
si

ct

of the screen is indicated.

ro
on

io

up wh ed
n
is

in

un le
pr

le
oh

ss
o
ib

Clinical Pearls
ot n p
it

or

• The radial nerve is usually accompanied by a small artery at

he ar
.

rw t
i

the level of the antecubital fossa.We recommend screening

is

the nerve region with color Doppler before inserting the

e
no

needle.
te
d.

• Do not confuse the median nerve in the antecubital fossa

with the radial nerve.The median nerve is located in the
medial aspect of the arm next to the brachial artery.

Median Nerve Block: Single Injection

Patient Position: Supine with the head rotated toward the
nonoperative side.The patient’s arm is abducted to 90 degrees
with the hand supinated.

30
 Co
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07
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M
ts

Figure 23. Setup for performing an

cM
re

ah

ultrasound-guided ulnar nerve block in the

se
w

on
rv
it

ed
ho

distal forearm.
Pu
.R
ut

bl
is
ep
pe

The ulnar nerve at the level indicated in this figure lies immediately to
hi
ro
rm

ng

the ulnar side of the ulnar artery (Figure 24).

du
is

G
si

ct

ro
on

io

up wh ed
n
is

Transducer Location: Volar surface of the distal forearm

in

un le
pr

Frequency: High
le
oh

ss
o
ib

In-Plane/Out-of-Plane: In-plane or out-of-plane

ot n p
it

or

Nerve Image: Single hyperechoic structure with small

he ar
.

rw t
i

hypoechoic fascicles
is

Needle Size: 50 mm
e
no

Local Volume: 5-10 cc

te
d.

1. The patient’s arm should be abducted to 90 degrees with the

hand supinated (Figure 20).
2. The transducer should be positioned over the volar surface
of the forearm proximal to the wrist.
3. The median nerve can be located between the palmaris
longus tendon and the flexor carpi radialis tendon and
traced proximal to the desired level for placement of the
block.The goal is to see the nerve on the short-axis view at a

31
 Co
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07
ri
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Figure 24. The ulnar nerve in the distal

ts

cM
re

ah

forearm.
se
w

on
rv
it

ed
ho

Pu

The ulnar nerve is indicated by the triangles. The nerve is hyperechoic

.R
ut

bl

and triangular.
is
ep
pe

hi
ro
rm

A, ulnar artery
ng
du
is

G
si

ct

ro
on

io

up wh ed
n
is

level of the arm that avoids any collateral targets such as

in

un le
pr

blood vessels or tendons.The nerve appears as a large hyper-

le
oh

ss
o
ib

echoic circular or oval structure.The internal hypoechoic

ot n p
it

or

fascicles of the nerve can also be seen.

he ar
.

rw t
i

4. The approach can involve either the in-plane or out-of-plane

is

technique, whichever is ergonomically more comfortable

e
no

(Figure 21).
te
d.

Clinical Pearls
• Small linear transducers with high frequencies tend to work
best.
• The more proximal in the arm the block is performed, the
less painful it is for the patient.
• The more proximal in the arm the block is performed, the
more motor block may result.

32
 Co
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ri
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t
©
A

20
ll

07
ri
gh

Figure 25. Setup for performing an

ts

cM
re

ah

ultrasound-guided ulnar nerve block in the

se
w

on
rv
it

mid-forearm.
ed
ho

Pu
.R
ut

bl
is
ep

The ulnar nerve at this level has been separated from the ulnar artery.
pe

hi
ro
rm

In the mid-forearm, the in-plane approach is preferred, inserting the

ng
du
is

needle from the radial side of the transducer.

G
si

ct

ro
on

io

up wh ed
n
is

in

un le
pr

• Tendons can be easily confused with the median nerve (Figure

le
oh

ss
o
ib

22).The tendons appear flatter than the nerve and become less
ot n p
it

or

distinct as the transducer is moved proximally in the arm.

he ar
.

rw t
i

is

Ulnar Nerve Block

e
no

Patient Position: Supine with the head rotated toward the

te
d.

nonoperative side.The patient’s arm is abducted to 90 degrees

with the hand supinated.
Probe Location: Volar surface of the distal forearm
Frequency: High
In-Plane/Out-of-Plane: In-plane or out-of-plane
Nerve Image: Hyperechoic structure with small internal
hypoechoic fascicles
Needle Size: 50 mm

33
 Co
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ll

07
ri
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M
ts

cM
re

Figure 26. The ulnar nerve in the

ah
se
w

on
rv
it

mid-forearm.
ed
ho

Pu
.R
ut

bl

The ulnar nerve is indicated by the triangles. Note that it has been
is
ep
pe

hi
ro
rm

separated from the ulnar artery.

ng
du
is

A, ulnar artery
si

ct

ro
on

io

up wh ed
n
is

in

un le
pr

Local Volume: 5-10 cc

le
oh

ss
o
ib

1. The patient’s arm should be abducted to 90 degrees with the

ot n p
it

or

hand supinated (Figure 23).

he ar
.

rw t
i

2. The transducer should be positioned over the volar surface

is

of the forearm proximal to the wrist (Figure 23).

e
no

3. The ulnar artery should be identified first, located at the

te
d.

ulnar side of the ulnar artery (Figure 24).The ulnar nerve on

the short-axis view appears as a triangular, hyperechoic
structure with small, internal hypoechoic fascicles. Because
of the ulnar nerve’s intimate association with the ulnar
artery, the in-plane technique is preferred.

34
 Clinical Pearls
• Small linear transducers with high frequencies tend to work
best.
• The more proximal in the arm the block is performed, the
less painful it is for the patient.
• The more proximal in the arm the block is performed, the
more motor block may result.
• We prefer to slide the probe proximally in the arm until the
ulnar nerve separates from the artery in order to help avoid
Co

an arterial puncture.
py

• The nerve can be blocked at the wrist crease; however, we

ri
gh

prefer to follow the nerve proximally until the ulnar nerve

t
©

separates from the artery by about 1 cm.This minimizes the

A

20
ll

risk for an inadvertent arterial puncture (Figures 25 and 26).

07
ri
gh

M
ts

cM
re

ah
se
w

on
rv
it

ed
ho

Pu
.R
ut

bl
is
ep
pe

hi
ro
rm

ng
du
is

G
si

ct

ro
on

io

up wh ed
n
is

in

un le
pr

le
oh

ss
o
ib

ot n p
it

or

he ar
.

rw t
i

is
e
no
te
d.

35
 d.
te
no
e
is
rw t
he ar
ot n p
ss i
le or
un le o .
up wh ed
ro it
G inib
ng io
n oh
hi ct pr
is is
bl du
Pu ro on
ep si
on .R
is
ah rm
ed pe
cM rv
M se ut
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20 ts it
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