Landmark Guided Lower Interscalene Block as a Rescue Approach in a Case of Elusive Supraclavicular Block for Elbow Surgery

Vol 3 | Issue 2 | July-December 2022 | Page 105-106 | Pratibha Jain, A. Sashank, Divyanand Mishra

DOI: 10.13107/ijra.2022.v03i02.064

Authors: Pratibha Jain [1], A. Sashank [1], Divyanand Mishra [1]

[1] Department of Anaesthesia and Pain Management, Pandit Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh, India.

Address of Correspondence
Dr. Divyanand Mishra,
Department of Anaesthesia and Pain Management, Pandit Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh, India.

Letter to Editor

Dear Editor,
Our case was an 18 yrs/m, weighing 54 kg without co morbidities presented with pain in right elbow and was posted for screw fixation of fracture capitulum. His routine blood work and airway examination were normal to undergo the surgery under supraclavicular block (SCB). On arrival, patient’s PR was 84/min, BP- 118/72 mm Hg, SpO2- 98% on room air.
For right sided SCB, patient was placed supine, head turned to left side with shoulder depressed and needle was inserted lateral to subclavian artery pulsation just above the clavicle, posterolaterally. There was inadvertent puncture of subclavian artery each time, despite using standard techniques. Hence we decided to abandon standard SCB and proceed with lower interscalene block (LISB).Using modified Winnie’s approach interscalene groove was palpated and needle was inserted 2-3 cm below the classical interscalene block (ISB) site. Paresthesia was attained over whole upper limb and then Inj. Lignocaine + Adrenaline (2%) 10 ml along with inj. Bupivacaine 0.5% 10 ml was injected after repeated negative aspirations. A satisfactory sensory and motor blockade was obtained after 15 minutes of injection. Throughout the procedure, patient was continuously monitored and surgery was completed within 1.5h without any adverse event. The patient was shifted to ward. The block weaned off in 6 hrs and his vitals were stable throughout his course of stay in the hospital.
Traditionally, the subclavian artery is an important relation of the brachial plexus for landmark guided SCB. However, anatomical variation may be present in as much as 50% of the population. [1] T1 nerve root supplies skin both above and below the elbow. Some authors have suggested a combined ISB + axillary block to get profound anaesthesia for elbow surgery. [2,3] Axillary nerve block was not contemplated in our case as optimal arm positioning was precluded due to severe pain at elbow. The advantages of LISB over SCB and ISB or ISB + axillary block are that it significantly reduces the risk of pneumothorax , inadvertent arterial puncture, ulnar sparing (as lower trunks of brachial plexus are more superficial in LISB) and avoids multiple injections. LISB also provides adequate anaesthesia and analgesia to whole upper limb which could be due to the relative proximity of the inferior trunks to the other components of brachial plexus as they become tightly bundled between the clavicle and first rib at this level.[2] Performing an LISB is easier due to its accessibility and shallow location of the brachial plexus, which may be favourable to those who disfavour or may not be comfortable with the supraclavicular approach. [4]
Our case exemplifies that in those centres where ultrasound machine is unavailable and access to the brachial plexus for SCB by landmark technique remains elusive despite troubleshooting, lower interscalene block can be safely used to provide similar quality and extent of surgical anaesthesia.


1. Uysal I, Sekar M, Karabulut AK, Buyukmumcu M, Ziylan T. Brachial plexus variations in human foetuses. Neurosurgery 2003;53(3):676-684.
2. Gadsden JC, Tsai T, Iwata T, Somsundarum L, Robards C, Hadzic A. Low interscalene block provides reliable anesthesia for surgery at or about the elbow. Journal of Clinical Anesth 2009;21:98-102.
3. Faryniarz D, Morelli C, Coleman S, et al. Interscalene block anesthesia at an ambulatory surgery center performing predominantly regional anesthesia: a prospective study of one hundred thirty-three patients undergoing shoulder surgery. J Shoulder Elbow Surg 2006;15:686-90.
4. Brown AR, Parker GC. The use of a reverse axis (axillary interscalene) block in a patient presenting with fractures of the left shoulder and elbow. Anesth Analg 2001;93:1618-20.

How to Cite this Article: Jain P, Sashank A, Mishra D | Landmark Guided Lower Interscalene Block as a Rescue Approach in a Case of Elusive Supraclavicular Block for Elbow Surgery | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 105-106.

(Abstract Text HTML)    (Download PDF)

91 replies
  1. Eaton Park Quận 2
    Eaton Park Quận 2 says:

    Thanks a lot for the helpful write-up. It is also my opinion that mesothelioma cancer has an extremely long latency period of time, which means that indication of the disease may well not emerge until eventually 30 to 50 years after the preliminary exposure to asbestos fiber. Pleural mesothelioma, that’s the most common type and impacts the area within the lungs, could potentially cause shortness of breath, upper body pains, and a persistent coughing, which may result in coughing up body.

  2. 模特空降
    模特空降 says:

    Today, considering the fast way of living that everyone is having, credit cards get this amazing demand in the economy. Persons coming from every arena are using the credit card and people who are not using the credit cards have prepared to apply for one. Thanks for expressing your ideas about credit cards.

  3. winmacsofts
    winmacsofts says:

    One thing I want to touch upon is that fat reduction plan fast may be possible by the right diet and exercise. An individual’s size not just affects the look, but also the general quality of life. Self-esteem, despression symptoms, health risks, plus physical capabilities are damaged in fat gain. It is possible to make everything right whilst still having a gain. In such a circumstance, a problem may be the perpetrator. While too much food instead of enough physical exercise are usually to blame, common health concerns and popular prescriptions could greatly amplify size. Thanks alot : ) for your post right here.

  4. vape-manufactory
    vape-manufactory says:

    This is really interesting, You are a very skilled blogger. I’ve joined your feed and look forward to seeking more of your fantastic post. Also, I’ve shared your web site in my social networks!

  5. how to sell merchant services
    how to sell merchant services says:

    Coming from my observation, shopping for technology online may be easily expensive, nonetheless there are some tips and tricks that you can use to help you get the best bargains. There are generally ways to come across discount bargains that could make one to possess the best gadgets products at the smallest prices. Great blog post.

  6. how to become an iso
    how to become an iso says:

    Simply desire to say your article is as amazing. The clearness in your post is just nice and i could assume you’re an expert on this subject. Fine with your permission allow me to grab your RSS feed to keep up to date with forthcoming post. Thanks a million and please continue the rewarding work.

  7. clitoris spreader
    clitoris spreader says:

    Hello There. I found your blog using msn. This is an extremely well written article. I?ll be sure to bookmark it and come back to read more of your useful info. Thanks for the post. I will definitely comeback.

  8. how to be a payment processor
    how to be a payment processor says:

    One thing I’ve noticed is that there are plenty of beliefs regarding the banking companies intentions if talking about home foreclosure. One myth in particular is the bank wants your house. The lending company wants your hard earned money, not the house. They want the cash they lent you with interest. Keeping away from the bank will still only draw a foreclosed conclusion. Thanks for your post.

  9. situs porno
    situs porno says:

    There are some attention-grabbing points in time on this article but I don?t know if I see all of them center to heart. There is some validity but I’ll take hold opinion till I look into it further. Good article , thanks and we would like more! Added to FeedBurner as nicely

  10. merchant services agent programs
    merchant services agent programs says:

    Youre so cool! I dont suppose Ive read something like this before. So good to find any person with some authentic thoughts on this subject. realy thanks for starting this up. this web site is something that’s needed on the net, somebody with a bit originality. helpful job for bringing one thing new to the internet!

  11. comprar cogumelos mágicos
    comprar cogumelos mágicos says:

    I’ve observed that in the world nowadays, video games are definitely the latest craze with kids of all ages. Often times it may be not possible to drag young kids away from the video games. If you want the best of both worlds, there are several educational games for kids. Great post.

  12. designer books decor
    designer books decor says: is a Global Trusted Online Fake Books Decor Store. We sell high quality budget price fake books decoration, Faux Books Decor. We offer FREE shipping across US, UK, AUS, NZ, Russia, Europe, Asia and deliver 100+ countries. Our delivery takes around 12 to 20 Days. We started our online business journey in Sydney, Australia and have been selling all sorts of home decor and art styles since 2008.

  13. zaragoza integrale
    zaragoza integrale says:

    That is the proper weblog for anyone who wants to seek out out about this topic. You understand so much its nearly arduous to argue with you (not that I actually would need?HaHa). You undoubtedly put a brand new spin on a subject thats been written about for years. Great stuff, just great!

  14. link bokep
    link bokep says:

    Hey very cool blog!! Man .. Excellent .. Amazing .. I will bookmark your site and take the feeds also?I’m happy to find so many useful info here in the post, we need develop more strategies in this regard, thanks for sharing. . . . . .

  15. 유로247
    유로247 says:

    I like the helpful information you provide to your articles. I will bookmark your weblog and check once more here regularly. I am fairly sure I?ll be informed plenty of new stuff proper right here! Good luck for the following!

  16. macanwin
    macanwin says:

    Thanks for your article. I would also like to say that the first thing you will need to carry out is find out if you really need credit score improvement. To do that you will have to get your hands on a duplicate of your credit report. That should not be difficult, because government makes it necessary that you are allowed to receive one cost-free copy of your credit report per year. You just have to check with the right folks. You can either look at website with the Federal Trade Commission or contact one of the main credit agencies right away.

  17. how to sell merchant services over the phone
    how to sell merchant services over the phone says:

    Thanks for your publication. What I want to say is that when looking for a good internet electronics store, look for a website with entire information on critical indicators such as the level of privacy statement, protection details, payment methods, as well as other terms as well as policies. Always take time to investigate the help along with FAQ pieces to get a better idea of how the shop works, what they are able to do for you, and just how you can make the most of the features.

  18. berita bola
    berita bola says:

    Fantastic blog! Do you have any suggestions for aspiring writers? I’m hoping to start my own blog soon but I’m a little lost on everything. Would you propose starting with a free platform like WordPress or go for a paid option? There are so many options out there that I’m completely confused .. Any tips? Cheers!

  19. bokep indo
    bokep indo says:

    Admiring the dedication you put into your website and detailed information you present. It’s great to come across a blog every once in a while that isn’t the same outdated rehashed information. Wonderful read! I’ve saved your site and I’m adding your RSS feeds to my Google account.

  20. situs bokep
    situs bokep says:

    hi!,I love your writing so much! proportion we keep up a correspondence extra about your article on AOL? I need an expert in this space to resolve my problem. Maybe that’s you! Having a look ahead to peer you.

  21. film prono
    film prono says:

    Hmm it seems like your site ate my first comment (it was extremely long) so I guess I’ll just sum it up what I had written and say, I’m thoroughly enjoying your blog. I as well am an aspiring blog writer but I’m still new to the whole thing. Do you have any points for inexperienced blog writers? I’d really appreciate it.

  22. hawk play
    hawk play says:

    Hello, Neat post. There’s a problem along with your site in internet explorer, might test this? IE nonetheless is the marketplace leader and a large component to other folks will leave out your fantastic writing because of this problem.

  23. ریحانه
    ریحانه says:

    You really make it seem so easy with your presentation but I find this topic to be really something that I think I would never understand. It seems too complicated and extremely broad for me. I am looking forward for your next post, I’ll try to get the hang of it!

  24. merchant sales representative
    merchant sales representative says:

    After study just a few of the blog posts on your web site now, and I actually like your means of blogging. I bookmarked it to my bookmark web site record and will likely be checking back soon. Pls try my web page as effectively and let me know what you think.

  25. link bokep
    link bokep says:

    Generally I don’t read article on blogs, but I wish to say that this write-up very forced me to try and do so! Your writing style has been amazed me. Thanks, very nice article.

  26. USA News
    USA News says: is a trusted latest USA News and global news provider. website provides latest insights to new trends and worldwide events. So keep visiting our website for USA News, World News, Financial News, Business News, Entertainment News, Celebrity News, Sport News, NBA News, NFL News, Health News, Nature News, Technology News, Travel News.

  27. situs bokep
    situs bokep says:

    I believe that avoiding refined foods will be the first step in order to lose weight. They might taste excellent, but processed foods have got very little nutritional value, making you take more just to have enough vigor to get throughout the day. If you’re constantly consuming these foods, converting to cereals and other complex carbohydrates will help you to have more strength while having less. Good blog post.

  28. Fashion
    Fashion says:

    When I initially commented I clicked the “Notify me when new comments are added” checkbox and now each time a comment is added I get three emails with the same comment. Is there any way you can remove people from that service? Many thanks!

  29. Mosaic| Marble Onyx Suppliers| black edging stones| pure white granite| stone basin countertop}
    Mosaic| Marble Onyx Suppliers| black edging stones| pure white granite| stone basin countertop} says:

    Thanks for your posting on the traveling industry. I will also like to add that if you are one senior thinking about traveling, it really is absolutely imperative that you buy travel insurance for retirees. When traveling, older persons are at high risk of having a health care emergency. Having the right insurance package on your age group can protect your health and provide peace of mind.


Leave a Reply

Want to join the discussion?
Feel free to contribute!

Leave a Reply

Your email address will not be published. Required fields are marked *