Infraclavicular coracoid approach brachial plexus block for radial club hand repair

Radial club hand is a congenital deformity in which the radius is absent, the metacarpophylangeal and interphalayngeal joints are fused and muscles arising from the radius are absent. This can alter the motor response to peripheral nerve stimulation. The classical motor response to median nerve stimulation (contractions of the fingers) cannot be elicited, hence fine twitches in the hand, at the wrist or in the surgical area or pronation-supination at a current of 0.5 mA were taken as endpoints. The aim of this study was to assess the feasibility of achieving successful infraclavicular coracoid approach block in the intra- and postoperative periods when ideal responses to electrical nerve stimulation are absent because of congenital anomalies.

Thirty-five patients aged 8 months to 2 years, weighing 7-12 kg were selected and the blocks were performed under light general anesthesia. Fentanyl 2 microg.kg(-1) was used as rescue analgesic in case of block failure. Postoperatively CHEOPS pain score was recorded at h1, h4 h6, h8, and h10 postoperatively. Tramadol 2 mg.kg(-1) was given in case of inadequate pain relief (CHEOPS>4).

In no patient could we elicit the finger flexion response which is typical of median nerve stimulation. Intraoperatively, one out of 35 children (3.3%) showed reaction to pain. In the postoperative period two out of 35 (6%) children had high pain scores and were given tramadol. Analgesia lasted for 6.5+/-1.50 h.

Despite the limitation of absence of an ideal response to nerve stimulation in radial club hand, endpoints such as fine twitches in the hand, at the wrist or in the surgical area or pronation-supination were sufficient to achieve a successful block. This block gives satisfactory intra- and postoperative analgesia.