Nerve Blocks of the Upper Extremities

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  • A nerve block is indicated when it will provide advantages over other techniques.
  • Specific indications include deep abrasions and “road burn,” hydrofluoric acid burns, severely swollen and contused hands, deep lacerations of the palm, and burns of the hand.
  • Allergies to local anesthetics
  • Peripheral vascular, heart, and liver disease may increase the risk of severe complications.
  • For the majority of blocks, a 25-gauge needle is ideal.
  • 10-mL syringe for local anesthetic injection
  • Gauze sponges
  • Towels
  • 18-gauge needle for withdrawing anesthetic from the vial
  • Anesthetic
    • For most of the blocks described in this chapter, 0.25% bupivacaine is suggested as the anesthetic of choice, but equal volumes of 1% lidocaine with epinephrine can be substituted.
    • Higher concentrations of lidocaine (up to 2%) or bupivacaine (0.5%) are commonly used for large nerves.
  • Median nerve.
    • The nerve lies in the midline and deep to the fascia, just below the palmaris longus tendon or slightly radial to it, between the palmaris longus and the flexor carpi radialis tendons.
    • The palmaris longus may be absent in up to 20% of patients, in which case the nerve is found about 1 cm in the ulnar direction from the flexor carpi radialis tendon.
    • The nerve supplies the radial side of the palm of the hand and the tips of the thumb and first two fingers.
  • Ulnar nerve.
    • The ulnar nerve follows the ulnar artery into the wrist, where they both lie deep to the flexor carpi ulnaris tendon.
    • At the level of the proximal palmar crease, the artery and the nerve lie just off the radial border of the flexor carpi ulnaris tendon.
    • The nerve supplies the dorsal and palmar aspects of the ulnar side of the hand.
  • Radial nerve.
    • The distal branch of the nerve lies on the radial side of the wrist and has a branch that wraps around dorsally.
    • The radial nerve follows the radial artery into the wrist.
    • These branches wrap around the wrist and fan out to supply the dorsal radial aspect of the hand from the thumb to the fourth finger.

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  • Links to medical evidence and related procedures

  • Specific follow-up for the anesthetic procedure is not needed unless there is a complication.
  • With major nerve blocks, do not release the patient to go home until sensation and function have returned.
  • With minor blocks, the patient may be sent home, but properly caution the patient about the risks.

Nerve Injury

  • Neuritis, an inflammation of the nerve, is the most common nerve injury.
  • Minimize direct nerve damage by choosing proper needle type, positioning, and manipulation.
  • Avoid intraneural injection, because it may rarely cause nerve ischemia and injury.

Intravascular Injection

  • Intravascular injection may rarely result in both systemic and limb toxicity. 
  • Epinephrine can cause a prolonged vasospasm and ischemia if it is injected into an artery.
    • Severe epinephrine-induced tissue vasospasm or blanching may be reversed with local or intravascular injection of phentolamine.


  • Hematoma formation may result from arterial puncture.
  • Apply direct pressure for 5 to 10 minutes.


  • Minimize the risk by following aseptic technique and using a low concentration of epinephrine.

Systemic Toxicity

  • Allergic reactions account for only 1% of untoward reactions

Limb Injury

  • Patients may inadvertently injure the anesthetized limb, so patients with major blocks should not be released until sensation and function have returned.
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