Review began 12/13/2021 Review ended 12/15/2021 Published 12/20/2021 © Copyright 2021 Sonawane et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC- BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Awake Single-Stage Bilateral Clavicle Surgeries Under Bilateral Clavipectoral Fascial Plane Blocks: A Case Report and Review of Literature Kartik Sonawane , Saisrivas Dharmapuri , Shlok Saxena , Tuhin Mistry , J. Balavenkatasubramanian 1. Anesthesiology, Ganga Medical Centre and Hospitals Private Limited, Coimbatore, IND Corresponding author: Kartik Sonawane,
[email protected] Abstract The clavicle is a frequently fractured bone with an infrequent bilateral occurrence. Regional anesthesia (RA) for clavicle surgeries is always challenging due to its complex innervation arising from the two plexuses (cervical and brachial). Various RA techniques described for clavicle surgeries include plexus blocks, fascial plane blocks, and truncal blocks. Plexus blocks are associated with undesirable effects, such as phrenic nerve blockade and paralysis of the entire upper limb, limiting their application for bilateral regional clavicle surgeries. The clavipectoral fascial plane block (CPB) is a novel, procedure-specific, phrenic-sparing, and motor-sparing RA technique that can provide anesthesia or analgesia for clavicle surgeries. The decision to use the CPB and/or other RA techniques may depend on the site of clavicle injury or variations in clavicular innervation. We report a case of single-stage bilateral clavicle surgery successfully managed with a bilateral CPB alone using ultrasound guidance and landmark guidance separately. The patient was kept awake and comfortable throughout the surgery. In conclusion, CPB can be an effective alternate RA technique in avoiding undesired side effects of more proximal techniques such as phrenic nerve involvement and motor blockade of upper limbs. Landmark- guided CPB can be an alternative with equianalgesic efficacy as of ultrasound-guided CPB in resource-poor or emergency settings. Categories: Anesthesiology, Pain Management, Orthopedics Keywords: clavicle surgery, modified clavipectoral fascial plane block, awake clavicle surgery, clavipectoral fascial plane block, fascial plane block, bilateral clavicle fracture Introduction Clavicle fractures (CFs) are frequently encountered in emergency and operating room settings, accounting for 2.6% of all fractures [1]. The most common site for CF is in its middle third, with an incidence of 5-10% in young patients [2-4]. However, bilateral CFs are extremely rare [5-8], with an incidence of only 0.011-0.017% [9], comprising <0.5% of all CF. Most CFs heal with good functional results after early surgical intervention. Therefore, the surgical fixation of bilateral CF in a single-stage depends entirely on the surgeon’s approach, taking into account the type/site of fractures, associated injuries, and expected functional outcomes of the patient. Such surgery would require general anesthesia (GA) with or without regional anesthesia (RA) due to limitations in administering bilateral plexus blocks. Regional anesthesia for clavicle surgeries is quite challenging because of the complex innervations contributed by cervical and brachial plexuses [10]. RA options for the clavicle comprise plexus blocks, truncal blocks, or fascial plane blocks [10]. Plexus blocks involve the cervical plexus (superficial cervical plexus block or selective supraclavicular nerve block) with or without brachial plexus (interscalene or selective superior trunk) blocks. While the plexus blocks are associated with motor weakness of the upper extremity, the efficacy of the truncal blocks like erector spinae plane block [11] or the pectoral nerve blocks [12-13] (PEC1 and PEC2) is yet to be determined. The clavipectoral fascial plane block (CPB) can provide anesthesia or analgesia for CF, eliminating the disadvantages of plexus blocks [14]. Although CPB is administered under ultrasound guidance, it can be given using landmark guidance with equianalgesic efficacy. Since this case report, a handful of additional case reports demonstrated and supported the effectiveness of CPB for clavicle surgery [15-18]. This case report is the first of its kind to document a single-stage awake bilateral clavicle surgery performed under bilateral CPB alone, using ultrasound and landmark guidance separately, with equivocal results. We also discussed modifications required when performing CPB in a comminuted type of CF and limitations of CPB in certain scenarios due to insufficient drug spread leading to inadequate analgesic coverage. The 1 1 1 1 1 Open Access Case Report DOI: 10.7759/cureus.20537 How to cite this article Sonawane K, Dharmapuri S, Saxena S, et al. (December 20, 2021) Awake Single-Stage Bilateral Clavicle Surgeries Under Bilateral Clavipectoral Fascial Plane Blocks: A Case Report and Review of Literature. Cureus 13(12): e20537. DOI 10.7759/cureus.20537
patient provided written informed consent for undergoing the procedure, sharing case-related images (with hidden identity), and publishing this case report. Case Presentation A 31-year-old, healthy male driver was admitted to the emergency room with a bilateral Allman type I clavicle fracture (Figure 1, panels A1-1A2) due to direct trauma from a bicycle handlebar following a self- skid. He had no associated brachial plexus or chest injury. He was scheduled for a single-stage open reduction and internal fixation of both clavicles with screws and locking plates under bilateral CPB. 2021 Sonawane et al. Cureus 13(12): e20537. DOI 10.7759/cureus.20537 2 of 11
FIGURE 1: Radiographic and clinical images of the bilateral clavipectoral fascial plane block and bilateral clavicle fracture surgery A1, A2: Radiographic images of right and left clavicle fracture; B1, B2: Performance of ultrasound-guided clavipectoral fascial plane block; B3: Performance of landmark-guided clavipectoral fascial plane block; C1, C2: Surgical fields of bilateral clavicle surgery with implants in situ; D1, D2, D3: Patient positioning during surgery and intraoperative radiographic pictures; E: Smiling patient able to lift both upper extremities immediately after surgery Preoperatively, the patient was premedicated with intravenous pantoprazole 40 mg, ramosetron 0.3 mg, and midazolam 2 mg. A local anesthetic (LA) mixture was prepared using 20 ml of 2% lignocaine with epinephrine, 20 ml of 0.5% bupivacaine, 20 ml of normal saline, and 8 mg of dexamethasone. The CPB was performed using ultrasound on the right side and landmark guidance (Figure 1, Table 1) on the left side. 2021 Sonawane et al. Cureus 13(12): e20537. DOI 10.7759/cureus.20537 3 of 11
Ultrasound-guided CPB (US-CPB) Landmark-guided CPB (LM-CPB) Local anesthetic (LA): 20 ml of 2% lignocaine with epinephrine + 20 ml 0.5% of bupivacaine + 20 ml of normal saline + 8 mg dexamethasone LA volume: 10 ml for medial and lateral injections 10 ml around the fracture site (in modified approach) 10 ml for the skin infiltration around the incision site (if required) Patient position: Supine with head turned to the opposite side Probe/Landmarks: High-frequency linear probe kept, Sagittally over the medial and lateral ends of the clavicle, OR Transversely along the length of the clavicle Palpating medial and lateral ends of the clavicle using fingers Needle: 1.5 inch 23G hypodermic needle Needle direction and LA deposition: With the probe in the sagittal plane:The needle is inserted in-plane from caudal-to-cranial direction depositing LA between clavipectoral fascia and periosteal collar. OR With the probe kept transversely along the clavicle: First moving probe medially towards the medial end, the needle is inserted in-plane from medial-to-lateral direction depositing LA above periosteal collar from medial end to the midpoint of the clavicle. Then, moving probe laterally towards the lateral end, the needle is inserted in-plane from lateral-to-medial direction depositing LA from lateral to the midpoint of clavicle above the periosteal collar. Third injection is required in a modified approach where the probe is kept over the fracture site, and LA is deposited around it under vision. First injection: Medial end of the clavicle is palpated using a finger. LA is deposited over the medial end from the medial-to-lateral direction after hitting the bone. Second injection: Lateral end of the clavicle is palpated using a finger. LA is deposited over the lateral end from the lateral-to-medial direction after hitting the bone. Third injection: LA is deposited around the fracture site after hitting the bone on either side of the fracture site Analgesic coverage: Osteotomal innervations of the whole clavicle due to LA distribution over periosteum and dermatomal innervation may get involved due to the diffusion of the LA. Rescue technique: Separate skin infiltration is required if supraclavicular nerves are not covered Advantages: Completely motor-sparing technique; simple to learn, administer, or teach Less painful due to hypodermic needle Completely motor-sparing technique; simple to learn, administer, or teach; economical as no requirement of special equipment like ultrasound or special skills; suitable for remote, poor resource, or emergency setting; less painful due to hypodermic needle Disadvantage: Limited extent of field block; may be ineffective in revision surgery, implant removal surgery, comminuted fractures, or nonunion/malunion surgery; not economical due to requirement of equipment like ultrasound and special skills in regional anesthesia Limited extent of field block; may be ineffective in revision surgery, implant removal surgery, comminuted fractures, or nonunion/malunion surgery TABLE 1: Descriptive comparison between ultrasound-guided and landmark-guided clavipectoral fascial plane block CPB: Clavipectoral fascial plane block, LA: Local anesthetic Ultrasound-guided right CPB With the patient in the supine position and head turned to the left side, a high-frequency linear ultrasound probe (Sonosite HFL38x/13-6 MHz; Fujifilm SonoSite, Bothell, WA) was positioned transversely over the right clavicle (Figure 1, panel B1). After identifying hyperechoic clavicular shadow under ultrasound (Figure 1, panel B2), a 1.5-inch hypodermic (23G) needle was inserted in-plane from the medial and lateral ends of the probe to deposit LA solution over the periosteal collar. Landmark-guided left CPB With the patient in the same position and head turned to the right side, the fingers were kept over the medial and lateral ends of the clavicle (Figure 1, panel B3). A 1.5-inch hypodermic (23G) needle was inserted adjacent to the palpating fingers to deposit LA solution after making contact with the periosteum of the left clavicle. 2021 Sonawane et al. Cureus 13(12): e20537. DOI 10.7759/cureus.20537 4 of 11
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