ESRA19-0299\u2005Bilateral infraclavicular and anterior suprascapular nerve blocks for operative fixation of bilateral proximal humerus fractures

Abstract

Background and aims Interscalene block is considered to be the gold standard regional anaesthetic technique for shoulder surgery, but is associated with diaphragmatic paralysis; therefore bilateral blocks are not used as they may lead to complete diaphragmatic paralysis. We present a unique case report of a patient who had fixation of bilateral proximal humerus fractures under bilateral infraclavicular brachial plexus blocks combined with suprascapular nerve blocks followed by general anaesthesia. Methods A 39 year old obese hypertensive male with Barrett’s oesophagus was posted for fixation of bilateral proximal humerus fractures. the patient was sedated with a target controlled infusion of propofol and remifentanil; bilateral ultrasound-guided infraclavicular blocks were performed with 30 ml per side of 0.375% ropivicaine followed by 10 ml of 0.375% ropivacaine injection to block the suprascapular nerve in the sub-omohyoid plane. He was then given general anaesthesia. Results Surgery lasted 9 hours; the patient required no rescue analgesics in recovery. Regular paracetamol, gabapentin and modified release oxycodone were prescribed for post-operative analgesia. the patient required 10 mg of immediate release oxycodone 16 hours post-surgery. Conclusions Bilateral supraclavicular blocks have been reported for bilateral shoulder trauma. This technique still carries a high risk of phrenic nerve palsy. Suprascapular nerve blockade is essential for shoulder surgery but is missed in infraclavicular blocks which are performed to avoid diaphragmatic paralysis. the anterior approach for suprascapular nerve blockade is advantageous in patients in whom positioning is difficult due to fractures. Hence, infraclavicular blocks combined with anterior suprascapular nerve blocks may prove to be a safer alternative for bilateral shoulder surgeries.