Minimum Effective Volume of Lidocaine for Ultrasound-Guided Infraclavicular Block
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Abstract:
Background:
The aim of this study was to determine the minimum effective volume of lidocaine 1.5% with epinephrine 5 μg/mL in 90% of patients (MEV90) for single-injection ultrasound-guided infraclavicular block (ICB).Methods:
Using an in-plane technique, a single-injection ultrasound-guided ICB was performed: a 17-gauge, 8-cm Tuohy needle was advanced until the tip was located dorsal to the axillary artery. Volume assignment was carried out using a biased coin design up-and-down sequential method, where the volume of local anesthetic administered to each patient depended on the response of the previous one. In case of failure, the next subject received a higher volume (defined as the previous volume with an increment of 2.5 mL). If the previous patient had a successful block, the next subject was randomized to a lower volume (defined as the previous volume with a decrement of 2.5 mL), with a probability of b = 0.11, or the same volume, with a probability of 1 − b = 0.89. Lidocaine 1.5% with epinephrine 5 μg/mL was used in all subjects. Success was defined, at 30 mins, as a minimal score of 14 of 16 points using a composite scale encompassing sensory and motor block. Patients undergoing surgery of the elbow, forearm, wrist, or hand were prospectively enrolled until 45 successful blocks were obtained.Results:
Fifty-five patients were included in the study. Using isotonic regression and bootstrap confidence interval (CI), the MEV90 for single-injection ultrasound-guided ICB was estimated to be 35 mL (95% CI, 30-37.5 mL). The probability of a successful response at 35 mL was estimated to be 0.91 (95% CI, 0.8-1.0). All patients with a minimal composite score of 14 points at 30 mins achieved surgical anesthesia intraoperatively.Conclusions:
For single-injection ultrasound-guided ICB, the MEV90 of lidocaine 1.5% with epinephrine 5 μg/mL is 35 mL. Further dose-finding studies are required for other concentrations of lidocaine, other local anesthetic agents as well as techniques involving multiple injections, a more medial approach to ICB, or precise location of all 3 cords of the brachial plexus.Keywords:
Neurovascular bundle
To evaluate the effect of different elbow and forearm positions on radiocapitellar alignment.Fifty-one healthy volunteers were recruited and bilateral elbow radiographs were taken to form a radiologic database. Lateral elbow radiographs were taken with the elbow in five different positions: Maximal extension and forearm in neutral, maximal flexion and forearm in neutral, elbow at 90° and forearm in neutral, elbow at 90° and forearm in supination and elbow at 90° and forearm in pronation. A goniometer was used to verify the accuracy of the elbow's position for the radiographs at a 90° angle. The radiocapitellar ratio (RCR) measurements were then taken on the collected radiographs using the SliceOmatic software. An orthopedic resident performed the radiographic measurements on the 102 elbows, for a total of 510 lateral elbow radiographic measures. ANOVA paired t-tests and Pearson coefficients were used to assess the differences and correlations between the RCR in each position.Mean RCR values were -2% ± 7% (maximal extension), -5% ± 9% (maximal flexion), and for elbow at 90° and forearm in neutral -2% ± 5%, supination 1% ± 6% and pronation 1% ± 5%. ANOVA analyses demonstrated significant differences between the RCR in different elbow and forearm positions. Paired t-tests confirmed significant differences between the RCR at maximal flexion and flexion at 90°, and maximal extension and flexion. The Pearson coefficient showed significant correlations between the RCR with the elbow at 90° - maximal flexion; the forearm in neutral-supination; the forearm in neutral-pronation.Overall, 95% of the RCR values are included in the normal range (obtained at 90° of flexion) and a value outside this range, in any position, should raise suspicion for instability.
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Objective To explore the clinical effects of forearm cutaneous neurovascular flaps to be used on repairing remote wound.Methods 17 cases of soft tissue defect of head and facial region and upper extremity were repaired with forearm cutaneous neurovascular flaps.Results The flaps of 16 cases were entirely survived, partial necrosis appeared in 1 case and healed after changing dressing.Following up for 3 to 6 months, the quality and shape of all the flaps and function recovery of all patients were satisfied.Conclusions With adequate blood supply, the survival rate of forearm cutaneous neurovascular flaps is high and the procedure to repair remote wound is easy, and it is one of best ways to repair the soft tissue defect in head and facial region and upper extremity with forearm cutaneous neurovascular flaps.
Key words:
Surgical flaps; Foream/BS/IR/SU ; Musculacutaneous nerve/BS/SU ; Wounds and injuries/SU
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In this experiment, it was found that the maximum recruitment of the elbow flexors, with the exception of Pronator Teres, was greater with the forearm in the supinated position. Increases in the resistance and the speed of movement placed greater demands on all muscles. This was reflected by the increased EMG levels. These findings have clinical implications in the rehabilitation of the elbow flexors following musculo-skeletal or neurological pathology. It is suggested that a program of strengthening of the elbow flexors should include activities in the supinated position. This position places the greatest demand on the major elbow flexors. Additional demands can be made by alteration in the resistance and speed of movement.
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The elbow is a complex joint that is highly involved in most of the activities of daily life. Traumatic, inflammatory and degenerative conditions can affect the elbow and forearm, leaving serious sequelae if misdiagnosed. The elbow is surrounded by vital neurovascular structures that control the hand function. It has common origin muscles controlling wrist and hand functions. This chapter has been designed to address the assessment and evaluation of the forearm and elbow from the perspective of the acute and emergency and the elective scenarios.
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Fractures of the proximal forearm in young children may be unstable with the elbow flexed but stable with it in extension. Fifteen such fractures were managed by immobilisation in long-arm casts with the elbow extended. Only one patient had more than 15 degrees angulation at the time of bony union. All obtained normal elbow movement at two weeks and full forearm rotation at follow-up. No casts fell off. The extended elbow cast is awkward but it provides an alternative to internal fixation for some unstable fractures.
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Purpose The measurement of radial head translation about the capitellum (in percent): the radio-capitellum ratio (RCR) has proven to have excellent inter- and intra-observer reliabilities when measuring the RCR on a lateral radiological view of elbows at 90° of flexion and in the neutral position of the forearm. However, in the clinical setting, radiographs may be taken with the elbow in different positions. However, the purpose was to validate the RCR measurement method on elbows in different positions in flexion-extension and in different positions of the forearm in pronation-supination. Method Fifty-one healthy volunteers were recruited to evaluate the RCR in different elbow positions. Lateral elbow radiographs were taken with the elbow in different magnitude of ROM: maximal extension, maximal flexion, elbow at 90° and forearm in neutral, elbow at 90° and forearm in supination and elbow at 90° and forearm in pronation. The measurements of the RCR were done using the software SliceOmatic. ANOVA and paired T-test were used to assess the difference of the RCR depending on the position of the elbow and of the forearm. Pearson coefficients were calculated to obtain the correlation between the RCR in each different position. Results The mean RCR for each position were the following: elbow in maximal extension: −2%±7%, elbow in maximal flexion: −5%±9%, elbow at 90° and forearm in neutral: −2%±5%, elbow at 90° and forearm in supination: 1%±6% and elbow at 90° and forearm in pronation: 1%±5%. According to the Anova results, a significant difference exists between the RCR in different elbow positions (p=0.01) and in the different forearm positions (p Conclusion The RCR method is dependent on elbow (flexion-extension) and forearm (pronation-supination) positions. At both maximal elbow positions in flexion and extension, the measurements of the RCR have a higher standard deviation. In order to decrease its variability, we recommend as a convention measuring the RCR on lateral radiographs with the elbow at 90° and the forearm in neutral position. However, 95% of the values of RCR (except in maximal flexion which is unusual in trauma) are included in the normal range of RCR from −5% to 13%. Thus a value outside this range in any elbow positions (except maximal flexion) or any forearm positions must raise doubt on elbow alignment. Then, with a capitellum of 25 mm of diameter, the translation of the radial head must be less than 1 mm posterior and less than 3 mm anterior from the center of the capitellum.
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Fracture of the forearm with ipsilateral injury of the elbow joint is a rare traumatic entity in children. Twenty-four such cases were treated in our clinic during the last 4 years (1981-1984). The treatment was surgical in six cases and related to the elbow injuries, while the forearm underwent closed treatment. The results of these cases, regardless of treatment and severity of the injury, did not differ appreciably from the results of common forearm or elbow injuries.
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Biomechanics
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