Ultrasound-Guided Axillary Brachial Plexus Block

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Indications: elbow, forearm, and hand surgery

Transducer position: short axis to arm, just distal to the pectoralis major insertion
Goal: local anesthetic spread around axillary artery
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Local anesthetic: 15–20 mL

GENERAL CONSIDERATIONS
The axillary brachial plexus block is relatively simple to perform and may be associated
with a lower risk of complications compared with interscalene (eg, spinal cord or vertebral
artery puncture) and supraclavicular brachial plexus blocks (eg, pneumothorax). In clinical
scenarios in which access to the upper parts of the brachial plexus is difficult or
impossible (eg, local infection, burns, indwelling venous catheters), the ability to
anesthetize the plexus at a more distal level may be important. Although individual
nerves can usually be identified this is not absolutely necessary because the deposition of
local anesthetic around the axillary artery is sufficient for an effective block.

ULTRASOUND ANATOMY Courses

Nov 19 - Nov 21
The structures of interest are superficial (1–3 cm below the skin), and the axillary artery is 6th International
readily identified within a centimeter of the skin surface on the medial aspect of the Symposium On Regional
Anesthesia, Pain and
proximal arm (Figure 1-A). The artery is accompanied by one or more axillary veins, often
Perioperative Medicine
located medially to the artery. Importantly, excessive pressure with the transducer during Crowne Plaza, Dubai, UAE

imaging may compress the veins, rendering veins invisible and prone to puncture with Jun 27 - Jul 4

the needle. Surrounding the axillary artery, three of the four principal branches of the Cutting Edge Medical
Education: Leadership &
brachial plexus can be seen: the median (superficial and lateral to the artery), the ulnar
Research Seminar
(superficial and medial to the artery), and the radial (posterior and lateral or medial to the SCI Caparello, Beach Cala
Rossa, Corsica, France
artery) nerves. The nerves appear as round hyperechoic structures (Figure 1-B). Several
May 10 - May 17
authors have reported the anatomical variations of the nerves relative to the axillary
Cutting Edge Medical
artery; Figure 2 illustrates the most common patterns.
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SCI Caparello, Beach Cala
Rossa, Corsica, France
Three muscles surround the neurovascular bundle: the biceps (anterior and superficial), Advanced Ultrasound-
Guided Techniques
the wedge-shaped coracobrachialis (anterior and deep), and the conjoined tendon of the San Diego, CA
teres major and latissimus dorsi (medial and posterior). The musculocutaneous nerve is
Building Blocks of
located in the fascial layers between the biceps and coracobrachialis muscles, though its Ultrasound-Guided
location is variable and can be seen within either muscle. It is usually seen as a Regional Anesthesia
San Diego, CA, USA
hypoechoic flattened oval structure with a bright hyperechoic rim. Moving the transducer
proximally and distally along the long axis of the arm, the musculocutaneous nerve
appears to move toward or away from the neurovascular bundle in the fascial plane
between the two muscles. Variations are determined by the position of the
musculocutaneous nerve relative to the median nerve and by the position of the ulnar
nerve relative to the axillary vein. For additional information see Functional Regional
Anesthesia Anatomy.

FIGURE 1. (A) Cross-sectional anatomy of the axillary fossa and ultrasound image (B) of the terminal nerves of
brachial plexus. The BP is seen scattered around the axillary artery and enclosed within the adipose tissue compartment
containing the axillary artery (AA), and axillary veins (AV). MCN, musculocutaneous nerve. MN, median nerve; RN, radial
nerve; UN, ulnar nerve; MACN, medial antebrachial cutaneous nerve; CBM, coracobrachialis muscle.

FIGURE 2. Most common patterns of nerve location around the axillary artery in ultrasound-guided axillary brachial
plexus block.

DISTRIBUTION OF ANESTHESIA
The axillary brachial plexus block (including the musculocutaneous nerve) results in
anesthesia of the upper limb from the mid-arm down to and including the hand.
Importantly, the block lends its name from the approach and not from the axillary nerve,
which itself is not blocked because it departs from the posterior cord more proximally in
the axilla. Therefore, the skin over the deltoid muscle is not anesthetized (Figure 3). With
nerve stimulator and landmark-based techniques, the blockade of the
musculocutaneous nerve is often unreliable. However, the musculocutaneous nerve is
readily visualized and reliably anesthetized by a separate injection using ultrasound
guidance. When required, the medial skin of the upper arm (intercostobrachial nerve, T2)
can be blocked by an additional subcutaneous injection just distal to the axilla.
 FIGURE 3. Sensory distribution after axillary brachial plexus
block.

EQUIPMENT
Ultrasound machine with linear transducer (8–14 MHz), sterile sleeve, and gel
Standard nerve block tray
Syringes with local anesthetic (20 mL)
5-cm, 22-gauge, short-bevel, insulated stimulating needle
Peripheral nerve stimulator
Opening injection pressure monitoring system
Sterile gloves

Learn more about Equipment for Peripheral Nerve Blocks

LANDMARKS AND PATIENT POSITIONING

An abduction of the arm to 90 degrees is necessary to allow for transducer placement
and needle advancement, (Figure 4). Care should be taken not to over-abduct the arm, as
this may cause patient discomfort as well as traction on the brachial plexus, making it
theoretically more vulnerable to injury by needle or injection. The pectoralis major muscle
is palpated as it inserts onto the humerus, and the transducer is placed on the skin
immediately distal to that point, perpendicular to the axis of the arm. The starting point
should have the transducer overlying both the biceps and triceps muscles (ie, on the
medial aspect of the arm). Sliding the transducer proximally will bring the axillary artery,
the conjoint tendon and the terminal branches of the brachial plexus into view, if not
readily apparent.

FIGURE 4. Patient position and needle insertion for ultrasound-guided (in-plane) axillary brachial plexus block. All
needle redirections are done through the same needle insertion site.

GOAL
The goal is to deposit local anesthetic around the axillary artery. Typically, two or three
injections are required. In addition, an aliquot of local anesthetic should be injected
around the musculocutaneous nerve.

TECHNIQUE
The skin is disinfected and the transducer is positioned in the short axis orientation to
identify the axillary artery about 1–3 cm from the skin surface. Once the artery is
identified, an attempt is made to identify the hyperechoic median, ulnar, and radial
nerves (Figure 5). However, these may not always be well visualized with ultrasound.
Frequently present, an acoustic enhancement artifact deep to the artery is often
misinterpreted as the radial nerve. Prescanning should also reveal the position of the
musculocutaneous nerve, in the plane between the coracobrachialis and biceps muscles
or within either of the muscles (a slight proximal-distal movement of the transducer is
often required to bring this nerve into view) (Figure 6).
FIGURE 5. The median (MN), ulnar (UN), and radial (RN) nerves are seen scattered around the axillary artery (AA).
The musculocutaneous nerve (MCN) is seen between the biceps and coracobrachialis muscle (CBM), away from the rest
of the brachial plexus. AV, axillary vein.

FIGURE 6. The musculocutaneous nerve (MCN) is located few cms away from the axillary artery (AA) between the
biceps and the coracobrachialis muscle. The course of the MCN along the upper arm display frequent anatomic
variations. Systematic scanning to identify the nerve and a separate injection of local anesthetic are usually required for
a successful axillary brachial plexus block.

The needle is inserted in-plane from the anterior aspect and directed toward the
posterior aspect of the axillary artery (Figure 7). Because nerves and vessels are positioned
closely together in the neurovascular bundle by adjacent musculature, advancement of
the needle may require careful hydrodissection with a small amount of local anesthetic or
other injectates. This technique involves the injection of 0.5–2 mL, indicating the plane in
which the needle tip is located. The needle is then carefully advanced stepwise few
millimeters at a time. The use of nerve stimulation is recommended to decrease the risk
of needle-nerve injury during needle advancement. Local anesthetic should be deposited
posterior to the artery first, to avoid displacing the structures of interest deeper and
obscuring the nerves, which may occur if injections for the median or ulnar nerves are
carried out first.

FIGURE 7. Needle insertions for axillary brachial plexus block. Axillary block can be accomplished by two to four
separate injections, depending on the disposition of the nerves around the axillary artery (AA) and the quality of the
image. MCN, musculocutaneous nerve; MN, median nerve; RN, radial nerve; UN, ulnar nerve. AA, axilary vein, AV,
axillary vein.

The posteriorly located radial nerve is often visualized more clearly once surrounded by
local anesthetic. Once 5–7 mL has been administered, the needle is withdrawn almost to
the level of the skin, redirected toward the median and ulnar nerves, and a further 7–10
mL is injected in these areas to complete the spread around the nerves. The described
sequence of injection is demonstrated in Figure 8.

FIGURE 8. This image demonstrates the ideal distribution pattern of local anesthetic. In this particular disposition of
nerves, a single needle pass superficially to the artery allows for two injections: one for the median (MN) and a second
one between the ulnar (UN) and radial (RN). The musculocutaneous (MCN) requires a separate injection.

An alternative, perivascular approach is to simply inject local anesthetic deep to the

artery, at the 6 o’clock position, instead of targeting the three nerves individually. This
technique may shorten the duration of the block procedure, but also delay onset time,
resulting in no difference in total time from skin puncture to the onset of the surgical
block. The last step in the procedure, the needle is withdrawn and redirected toward the
musculocutaneous nerve. Once adjacent to the nerve (stimulation will result in elbow
flexion), 5–7 mL of local anesthetic is deposited. Occasionally, the musculocutaneous
nerve will lie in close proximity to the median nerve, rendering a separate injection
unnecessary. In an adult patient, 20 mL of local anesthetic is usually adequate for
successful blockade, although successful blocks have been described with smaller
volumes. Adequate spread within the axillary brachial plexus sheath is necessary for
success but infrequently seen with a single injection. This is accomplished with two to
three redirections and injections of 5-7 mL are usually necessary for a reliable blockade, as
well as a separate injection to block the musculocutaneous nerve.

TIPS
Frequent aspiration and slow administration of local anesthetic are critical for
decreasing the risk of intravascular injection. Cases of systemic toxicity have been
reported after apparently straightforward ultrasound-guided axillary brachial plexus
blocks.
If no spread is seen on the ultrasound image despite local anesthetic injection, the
tip of the needle may be located in a vein. If this occurs, injection should be halted
immediately and the needle is withdrawn slightly. Pressure on the transducer
should be eased before reassessing the ultrasound image for the presence of
vascular structures.
Anatomic variations in the position of the musculocutaneous nerve have been
described. In 16% of cases, the musculocutaneous nerve splits off of the median
nerve distally to the axilla. In this case, a separate injection is not needed to block
the musculocutaneous nerve as it will be blocked by the local anesthetic injected
around the median nerve.

CONTINUOUS ULTRASOUND-GUIDED
AXILLARY BLOCK
The indwelling axillary catheter is a useful technique for analgesia and sympathetic block.
The goal of the continuous axillary block is to place the catheter within the vicinity of the
branches of the brachial plexus (ie, within the “sheath” of the brachial plexus). The
procedure is similar to that previously described in Ultrasound-Guided Interscalene
Brachial Plexus. The needle is typically inserted in-plane from the anterior to posterior
direction, just as in the single-injection technique). After an initial injection of local
anesthetic to confirm proper needle tip position posterior to the axillary artery, the
catheter is inserted 3–5 cm beyond the needle tip. Injection is then repeated through the
catheter to document adequate spread of local anesthetic, wrapping the axillary artery.
Alternatively, the axillary artery can be visualized in the longitudinal view with the
catheter being inserted in the longitudinal plane alongside the axillary artery. The
longitudinal approach requires a significantly greater degree of ultrasonographic skill; no
data suggesting that one approach is more effective than the other currently exist.

Continue reading: Axillary Brachial Plexus Block – Landmarks and Nerve Stimulator
Technique

Supplementary video related to this block can be found at Ultrasound-Guided Axillary

Brachial Plexus Block Video
 Learn ultrasound anatomy of Axillary Brachial Plexus Block on NYSORA SIMULATORS™.

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Axillary Brachial Plexus Block

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