US-Guided Axillary Brachial

Plexus Block

OK 1
IG/AT/LV
ULTRASOUND ANATOMY
● The structures of interest are superficial (1–3 cm below the skin), and the axillary
artery is readily identified within a centimeter of the skin surface on the medial
aspect of the proximal arm.
● The artery is accompanied by one or more axillary veins, often located medially to
the artery.
● Surrounding the axillary artery, three of the four principal branches of the 
brachial plexus can be seen: the median (superficial and lateral to the artery), the
ulnar (superficial and medial to the artery), and the radial (posterior and lateral or
medial to the artery) nerves.
Anatomy of the brachial plexus at axilla and at the
midhumeral level.
Indications and Contraindications
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

• Local anesthetic: 15–20 mL

 Landmarks
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, median antebrachial cutaneous
nerve; CBM, corachobrachialis muscle.
Equipments
● 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
Injection techniques
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.
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.
The musculocutaneous nerve
(MCN) is located few cm 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.
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.
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.
Thank you