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LETTERS TO EDITOR
Year : 2023  |  Volume : 17  |  Issue : 1  |  Page : 136-137

Common flexor plane block: A novel approach to median and ulnar nerve block at elbow


1 Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India

Correspondence Address:
Amarjeet Kumar
Room No 505, B-Block, OT Complex, All India Institute of Medical Sciences, Patna - 801 507, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.sja_507_22

Rights and Permissions
Date of Submission08-Jul-2022
Date of Decision09-Jul-2022
Date of Acceptance10-Jul-2022
Date of Web Publication02-Jan-2023
 


How to cite this article:
Kumar A, Sinha C, Kumar A. Common flexor plane block: A novel approach to median and ulnar nerve block at elbow. Saudi J Anaesth 2023;17:136-7

How to cite this URL:
Kumar A, Sinha C, Kumar A. Common flexor plane block: A novel approach to median and ulnar nerve block at elbow. Saudi J Anaesth [serial online] 2023 [cited 2023 Feb 1];17:136-7. Available from: https://www.saudija.org/text.asp?2023/17/1/136/364864



The superficial flexor muscles of forearm (pronator teres [PT], flexor carpi radialis, palmaris longus, flexor carpi ulnaris [FCU], and flexor digitorum superficialis [FDS]) have a common origin from the front of the medial epicondyle of the humerus.[1],[2],[3] Both PT and FCU have two different origin. The humeral head of these two muscles originated from the common flexor. The ulnar head of PT is originated from coronoid process and of FCU is originated from the olecranon process of ulna. The median nerve enters the forearm by passing between the two head of PT, and ulnar nerve enters the forearm by passing between the two head of FCU.[1],[2],[3] In this report, both nerves (median and ulnar) were blocked by single injection below the common flexor group of muscles. Written and informed consent for publication was taken from the patient. A 22 years female patient having post burn contracture of right hand involving index, middle, and ring fingers was scheduled for contracture release and skin grafting. Ultrasound (US) guided common flexor plane block was performed after the administration of general anesthesia. A linear US probe was placed on right cubital fossa 1 cm distal to elbow crease. The probe was slide medially to identify superficial common flexor muscles, deep flexor muscles, median nerve, ulnar nerve, and ulnar artery [[Figure 1], Panel A]. A sonoplex needle was inserted in-plane to the US probe from medial to lateral direction and needle tip was positioned in center of a fascial plane between superficial common flexor muscles and deep flexor muscles [[Figure 1], Panel B]. Drug (8 ml, 0.25% bupivacaine) was injected in interfascial plane [[Figure 1], Panel C]. Sensory assessment shows complete sensory blockade in the median nerve and the ulnar nerve territory of hand and no blockade in radial nerve territory.
Figure 1: (a) Ultrasound image identifying superficial common flexor muscles, deep flexor muscles, median nerve, ulnar nerve, and ulnar artery (b) in-plane approach to common flexor fascial plane (white arrow: Needle trajectory), and (c) injected drug spread in a fascial plane between superficial and deep flexor muscles and around the median nerve

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Earlier method for median and ulnar nerve block involves individual paraneural injections.[4] Jolly et al.[5] described a single injection technique for US-guided median and ulnar nerve block. They have injected the methylene blue in a fascial plane between FDS and FDP at mid forearm (6 cm distal to the crease at elbow) level and avoiding the ulnar artery localization. On dissecting the forearm, they have detected staining of both median and ulnar nerve in all cases. However, according to many documented studies, the ulnar nerve descends on the medial aspect of the forearm, over the FDP muscle and deep to the FCU.[1],[2],[3] This situation may require a separate injection of drug in a fascial plane between FCU and FDP for the ulnar nerve block. In our case, the injected drug spread was detected laterally up to median nerve (between two head of PT) and medially up to ulnar nerve (between two head of FCU). The primary advantages of this approach are the single injection site, lower risk of nerve injury given the distance from the nerves, and avoiding the ulnar artery. Complete hand anesthesia could be accomplished with this block when given in conjugation with radial nerve block.

Declaration of patient consent

Taken from patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Drake RL, Vogl AW, Mitchell AW. Gray's Anatomy for Students. 2nded. Philadelphia, PA: Churchill Livingstone/Elsevier; 2010.  Back to cited text no. 1
    
2.
Sinnatamby CS. Last's Anatomy Regional and Applied. 12thed. Edinburgh: Churchill Livingstone Elsevier, 2011.  Back to cited text no. 2
    
3.
Knipe H, Hacking C. Ulnar nerve. Reference article, Radiopaedia.org. [Last accessed on 2022 Jun 19]. https://doi.org/10.53347/rID-24690  Back to cited text no. 3
    
4.
Hadzic A. Ultrasound-guided forearm blocks. In: Hadzic's Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia. 2nd ed. Ch. 33. New York: McGraw Hill; 2012.  Back to cited text no. 4
    
5.
Jolly MD, Nanda M, Armbruster J, Anumudu C, Maquoit G, Rojas A, et al. Flexor digitorum plane block: A novel approach to median and ulnar nerve blockade. J Clin Anesth2022;80:110879.  Back to cited text no. 5
    


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