Brachial Overview

Question 1

Brachial Plexus is formed by what nerves?

Answer 1

C5-T1

Question 2

5 divisions of the brachial plexus

Answer 2

Roots
Trunks
Divisions
Cords
Branches or Terminal Nerves

Question 3

Lance’s mnemonic for the brachial plexus

Answer 3

Randy Travis Drinks Cold Beer

Proximal to distal

Question 4

Dermatomes for anterior arm

Answer 4

C5-T1 covers everything except upper medial aspect. “think inside the bicep”

T2 covers the rest

Question 5

Dermatomes for shoulder and lateral arm

Answer 5

C5-C7

Axillary nerve covers the deltoid portion of the shoulder

Question 6

Dermatomes for medial arm and hand

Ulnar nerve

Answer 6

C8-T1

Question 7

Arm innervation

Answer 7

Question 8

Medial Arm Innervation

Answer 8

Question 9

Hand Innervation

Answer 9

Question 10

4 brachial plexus blocks

Answer 10

1. Interscalene
2. Supraclavicular
3. Infraclavicular
4. Axillary

Question 11

Which brachial plexus block covers the entire arm?

Answer 11

None

Question 12

Interscalene

Blocks “Roots” or Randy

Answer 12

Blocks C5-C7
Does NOT block C8-T1

This is an ulnar nerve sparring block (medial elbow and forearm)

Question 13

What surgeries are the interscalene good and bad for?

Answer 13

Good:
Shoulder and upper arm
Bad:
forearm, elbow, and hand

Question 14

Disadvantages to interscalene block?

3

Answer 14

1. ipsilateral hemidiaphragmatic paresis
2. hoarseness
3. Horner’s Syndrome

Question 15

What is Horner’s Syndrome?

Answer 15

Miosis: pupil constriction
Ptosis: upper eyelid droop
Anhidrosis: makes little to no sweat

Question 16

The Supraclavicular and Infraclavicular block does the same thing, what are the differences?

Answer 16

• Supra block is at the Trunks and Divisons level
• Infra block is at the Cords level
• Infra not indicated for shoulder surgery because of the more distal needle insertion site

Question 17

Supra/infraclacivular blocks what nerves?

Answer 17

C5-T1

Does not cover T2

Question 18

Is the supraclacivular block indicated for shoulder surgery?

Answer 18

Not really, it works but not as well as the interscalene

less effective spread to the suprascapular and axillary nerves than the interscalene block

Question 19

Why do we still use the supraclavicular block for shoulder surgery then?

Answer 19

Avoids interscalene complications like paralyzing half of the diaphram

Question 20

Axillary nerve block

Answer 20

Blocks the hand but not the upper arm
Can only block the entire forearm/elbow with a supplemental musculocutaneous block

Question 21

Axillary block, which nerves?

Answer 21

At the Branches level:
Median
Radial
Ulnar

Musculocutaneous sparring

Question 22

Where does the musculocutaneous nerve innervate?

Answer 22

lateral forearm only

Question 23

Do we need to a supplemental musculocutanseous block for hand surgery?

Answer 23

No, it only innervates the lateral forearm so an axillary block would be suffcient

Question 24

Do we need to a suplemental musculotanseous block for forearm surgery?

Answer 24

Yes, it innervates the lateral forearm so an axillary block would not be suffcient

Question 25

Anatomically what does the musculocutaneous nerve do in the axilla?

Answer 25

It diverges away from the Median, Radial, and Ulnar neurovascular bundle ## Footnote This is why it is missed when preforming the axillary block

Question 26

What is strange about the axillary block and the axillary nerve

Answer 26

It is not blocked by the axillary nerve block because the axillary nerve is on the cords level and the axillary block is on the branches level ## Footnote Since the axillary nerve innervates the upper arm/shoulder this is not a good block for shoulder surgery

Question 27

During hand surgery that uses a tourniquet what block/s need to be done?

Answer 27

Axillary and Musculocutaneous

Question 28

What is the supplemental T2 block called?

Answer 28

Intercostobrachial Block

Question 29

What does the T2 Intercostobrachial block cover?

Answer 29

Upper medial arm (what the brachial plexus does not innervate)

Question 30

What is the T2 block indicated for?

Answer 30

Axillary surgery and medial elbow surgery

Question 31

Does the T2 block help with tourniquet pain?

Answer 31

Nope

Question 32

Where is the T2 Intercostobrachial block performed?

Answer 32

Axillary region (think medial) Upper boarder of the bicep lower border of the tricpes

Question 33

What does the Medial Cutaneous block cover?

Answer 33

C8-T1 ## Footnote AKA Ulnar nerve block

Question 34

What block is the medial cutaneous added to?

Answer 34

Interscalene

Question 35

What blocks are indicated for forearm surgery?

Answer 35

Axillary + Musculocutaneous or Supra/Infraclavicular

Question 36

What block is indicated for shoulder surgery?

Answer 36

Interscalene ## Footnote Maybe Supraclavivular is some parts of the country

Question 37

What block is indicated in hand surgery?

Answer 37

1. Axillary (lower risk for complications) 2. Supra/Infraclavicular

Question 38

Possible Complications: Interscalene ## Footnote HIRE-VUU

Answer 38

Horner's Syndrome Ipsilateral phrenic nerve palsy RLN palsy and hoarseness Epidural/subarachnoid injection Vertebral Artery puncture Ulnar sparring Upper arm T/Q pain (T1&T2)

Question 39

Possible Complications: Supraclavicular ## Footnote SIR-HUP

Answer 39

Subclavian artery puncture Ipsilateral phrenic nerve palsy (less common) RLN palsy and hoarsness (less common) Horner's Syndrome (less common) Upper arm T/Q pain (T2) Pneumothorax (highest risk)

Question 40

Possible Complications: Infraclavicular ## Footnote PAU

Answer 40

Pneumothorax Axillary artery puncture Upper arm T/Q pain (T2)

Question 41

Possible Complications: Axillary ## Footnote SAU

Answer 41

Spares musculocutaneous Axillary artery puncture Upper arm T/Q pain (T2)

Question 42

Contraindications: Interscalene

Answer 42

Respiratory Dx/COPD Contralateral phrenic nerve dysfunction

Question 43

Contraindications: Supraclavicular

Answer 43

Respiratory Dx/COPD Contralateral phrenic nerve dysfunction

Question 44

Contraindications: Infraclavicular

Answer 44

Ipsilateral cental line or pacemaker ## Footnote **Best for COPD patients**