Nerve Block: Ulnar Nerve: Difference between revisions
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==Background== | ==Background== | ||
* | [[File:Nerves of the left upper extremity.gif|thumb|Nerves of the left upper extremity.]] | ||
[[File:Gray421.png|thumb|Transverse section across distal ends of radius and ulna.]] | |||
*Ulnar nerve block is a quick, safe, and effective means of pain reduction for hand injuries, including reduction of [[Boxer's Fracture]]<ref>Ünlüer, EE. Ultrasound-guided Ulnar Nerve Block For Boxers Fractures. Am.J.Emerg.Med. 2016;34(8):1726.</ref> | |||
==Indications== | ==Indications== | ||
* [[Boxer's Fracture]] | *[[Boxer's Fracture]] | ||
* [[Burns|Hand Burns]] | *[[Burns|Hand Burns]] | ||
* [[Hand and finger tendon injuries|Complex Hand Injury]] | *[[Hand and finger tendon injuries|Complex Hand Injury]] | ||
*Need for pain control or to perform painful procedure in distribution of ulnar nerve | |||
==Contraindications== | ==Contraindications== | ||
* | *Infection overlying injection site | ||
==Equipment Needed== | ==Equipment Needed== | ||
* 10 cc Syringe with a 27 Gauge Needle | *10 cc Syringe with a 27 Gauge Needle | ||
* | *Blunt fill needle (to draw up anesthetic) | ||
* Local Anesthetic (e.g. [[Lidocaine]] | *Local Anesthetic (e.g. [[Lidocaine]] or [[Bupivacaine]]) | ||
* Antiseptic (e.g. Chlorhexidine, Betadine | *Antiseptic (e.g. Chlorhexidine, Betadine) | ||
* Sterile Gloves | *Sterile Gloves | ||
* Sterile Drape | *Sterile Drape and sterile ultrasound probe cover | ||
* Linear Ultrasound Probe | *Linear Ultrasound Probe | ||
==Procedure== | ==Wrist Block Procedure== | ||
[[File:Blind_Ulnar_Nerve_Block.jpg|thumb|Ulnar Nerve Block at the Wrist]] | |||
* | [[File:Ultrasound_Ulnar_Nerve.png|thumb|Ulnar Nerve at the Distal Wrist]] | ||
* Place the patient's extremity in the supinated position | [[File:Ulnar_Nerve_US_Probe.png|thumb|Following the Ulnar Nerve Distally]] | ||
* Cleanse the skin with chosen antiseptic | |||
* Create a sterile field using | *Obtain informed consent | ||
* In a sterile fashion, apply a small wheel of local anesthetic to the area immediately | **Patient should be made aware that they will lose both sensory and motor function of the ulnar distribution until the anesthetic wears off | ||
* The ulnar nerve should be immediately deep to the Flexor Carpi Ulnaris Tendon | *Place the patient's extremity in the supinated position | ||
*Cleanse the skin with chosen antiseptic | |||
*Create a sterile field using sterile drape | |||
*In a sterile fashion, apply a small wheel of local anesthetic to the area immediately medial to tendon of the Flexor Carpi Ulnaris and approximately 2 cm proximal to the wrist crease. | |||
*The ulnar nerve should be immediately deep to the Flexor Carpi Ulnaris Tendon | |||
===Non-Ultrasound Guided Technique=== | ===Non-Ultrasound Guided Technique=== | ||
*Direct the Needle radially, deep to the Flexor Carpi Ulnaris | |||
* Direct the Needle radially, deep to the Flexor Carpi Ulnaris | *The ulnar nerve is ulnar in relation to the ulnar artery; even still, it is important to aspirate prior to injecting anesthetic to rule out intra-arterial placement | ||
* The ulnar nerve is ulnar in relation to the ulnar artery; even still, it is important to aspirate prior to injecting anesthetic to rule out intra-arterial placement | *Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection | ||
* Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection | *Inject approximately 5 mL of local anesthetic | ||
* Inject approximately 5 mL of local anesthetic | |||
===Ultrasound Guided Technique=== | ===Ultrasound Guided Technique=== | ||
*Have a partner help place the Linear Ultrasound Probe into the Sterile Probe Cover | |||
*Starting mid forearm of the volar aspect in a transverse plane, locate the Ulnar Nerve | |||
* Have a partner help place the Linear Ultrasound Probe into the Sterile Probe Cover | *Sliding Distally, the Ulnar Nerve and Artery should separate from each other | ||
* Starting mid forearm of the volar aspect in a transverse plane, locate the Ulnar Nerve | *Injection site is generally approximately 2 cm proximal to the wrist crease. | ||
* Sliding Distally, the Ulnar Nerve and Artery should separate from each other | *In plane, visualize the needle on the Ultrasound monitor as you advance towards the Ulnar Nerve. | ||
* Injection site is generally approximately 2 cm proximal to the wrist crease. | *Make sure to aspirate prior to injecting to rule out vascular penetration (low risk given ultrasound guidance) | ||
* In plane, visualize the needle on the Ultrasound monitor as you advance towards the Ulnar Nerve. | *Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection | ||
* Make sure to aspirate prior to injecting to rule out vascular penetration (low risk given ultrasound guidance) | *Inject approximately 5 mL of local anesthetic in the area immediately surrounding the Ulnar Nerve | ||
* Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection | ==Elbow Block Procedure== | ||
* Inject approximately 5 mL of local anesthetic in the area immediately surrounding the Ulnar Nerve | [[File:Ulnar_Elbow.jpg|thumb|Ulnar Nerve Path at Elbow]] | ||
*Obtain informed consent | |||
**Patient should be made aware that they will lose both sensory and motor function of the ulnar distribution until the anesthetic wears off | |||
*Place the patient's extremity in the supinated position with elbow flexed between 45 & 90 degrees | |||
*Cleanse the skin with chosen antiseptic | |||
*Create a sterile field using sterile drape | |||
*In a sterile fashion, apply a superficial small wheel of local anesthetic to the area proximal to the medial humeral epicondyle | |||
===Non-Ultrasound Guided Technique=== | |||
*Injection site should be chosen approximately 2-3 cm proximal to the sulcus ulnaris groove | |||
**This is done as the ulnar nerve is relatively fixed in the tight groove and it is important to minimize risk of direct nerve trauma and neurapraxia due to pressure build up | |||
*Direct the needle cephalad at 45 degrees<ref>McCahon, RA et al. Peripheral nerve block at the elbow and wrist. Contin Educ Anaesth Crit Care Pain (2007) 7 (2): 42-44.</ref> | |||
*Aspirate prior to injection to rule out intravascular placement | |||
*Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection | |||
*Inject approximately 3-5 mL of local anesthetic | |||
==Complications== | ==Complications== | ||
* Inadvertent intravascular injection | *Inadvertent intravascular injection | ||
* Infection | *Infection | ||
* Bleeding/hematoma | *Bleeding/hematoma | ||
* Neurapraxia | *Neurapraxia | ||
==See Also== | ==See Also== | ||
*[[Nerve blocks (main)]] | *[[Nerve blocks (main)]] | ||
*[[Local anesthetic systemic toxicity]] | *[[Local anesthetic systemic toxicity]] | ||
==External Links== | |||
*[http://www.sonoguide.com/ulnar_plexus_block.html SonoGuide] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Procedures]] | |||
[[Category:Ultrasound]] | |||
Latest revision as of 21:45, 12 June 2021
Background
- Ulnar nerve block is a quick, safe, and effective means of pain reduction for hand injuries, including reduction of Boxer's Fracture[1]
Indications
- Boxer's Fracture
- Hand Burns
- Complex Hand Injury
- Need for pain control or to perform painful procedure in distribution of ulnar nerve
Contraindications
- Infection overlying injection site
Equipment Needed
- 10 cc Syringe with a 27 Gauge Needle
- Blunt fill needle (to draw up anesthetic)
- Local Anesthetic (e.g. Lidocaine or Bupivacaine)
- Antiseptic (e.g. Chlorhexidine, Betadine)
- Sterile Gloves
- Sterile Drape and sterile ultrasound probe cover
- Linear Ultrasound Probe
Wrist Block Procedure
- Obtain informed consent
- Patient should be made aware that they will lose both sensory and motor function of the ulnar distribution until the anesthetic wears off
- Place the patient's extremity in the supinated position
- Cleanse the skin with chosen antiseptic
- Create a sterile field using sterile drape
- In a sterile fashion, apply a small wheel of local anesthetic to the area immediately medial to tendon of the Flexor Carpi Ulnaris and approximately 2 cm proximal to the wrist crease.
- The ulnar nerve should be immediately deep to the Flexor Carpi Ulnaris Tendon
Non-Ultrasound Guided Technique
- Direct the Needle radially, deep to the Flexor Carpi Ulnaris
- The ulnar nerve is ulnar in relation to the ulnar artery; even still, it is important to aspirate prior to injecting anesthetic to rule out intra-arterial placement
- Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection
- Inject approximately 5 mL of local anesthetic
Ultrasound Guided Technique
- Have a partner help place the Linear Ultrasound Probe into the Sterile Probe Cover
- Starting mid forearm of the volar aspect in a transverse plane, locate the Ulnar Nerve
- Sliding Distally, the Ulnar Nerve and Artery should separate from each other
- Injection site is generally approximately 2 cm proximal to the wrist crease.
- In plane, visualize the needle on the Ultrasound monitor as you advance towards the Ulnar Nerve.
- Make sure to aspirate prior to injecting to rule out vascular penetration (low risk given ultrasound guidance)
- Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection
- Inject approximately 5 mL of local anesthetic in the area immediately surrounding the Ulnar Nerve
Elbow Block Procedure
- Obtain informed consent
- Patient should be made aware that they will lose both sensory and motor function of the ulnar distribution until the anesthetic wears off
- Place the patient's extremity in the supinated position with elbow flexed between 45 & 90 degrees
- Cleanse the skin with chosen antiseptic
- Create a sterile field using sterile drape
- In a sterile fashion, apply a superficial small wheel of local anesthetic to the area proximal to the medial humeral epicondyle
Non-Ultrasound Guided Technique
- Injection site should be chosen approximately 2-3 cm proximal to the sulcus ulnaris groove
- This is done as the ulnar nerve is relatively fixed in the tight groove and it is important to minimize risk of direct nerve trauma and neurapraxia due to pressure build up
- Direct the needle cephalad at 45 degrees[2]
- Aspirate prior to injection to rule out intravascular placement
- Discontinue and reposition should the patient report shooting "electrical" pains or numbness prior to injection
- Inject approximately 3-5 mL of local anesthetic
Complications
- Inadvertent intravascular injection
- Infection
- Bleeding/hematoma
- Neurapraxia