Upper Extremity Brachial Plexus Ultrasound-Guided

Supraclavicular Block

Brachial plexus block at trunk/division level — dense, reliable anaesthesia for elbow, forearm and hand surgery. Often called the "spinal of the arm."

ESRA PROSPECT ↗ NYSORA ↗

💡

Key point The supraclavicular approach blocks the brachial plexus at its most compact point — the trunks/divisions — providing dense, reliable anaesthesia for elbow, forearm, and hand surgery with a single injection.

15–25

min onset

8–16h

duration

25–35

mL volume

Anatomy

The brachial plexus is formed by the anterior rami of C5–T1. At the supraclavicular level, it has reorganised into three trunks (superior C5–6, middle C7, inferior C8–T1) dividing into anterior and posterior divisions. This is the most compact arrangement — ideal for complete block with a single injection.

Key relationships

The plexus lies lateral and posterior to the subclavian artery in the supraclavicular fossa
Sandwiched between anterior and middle scalene muscles
The first rib lies inferiorly — important depth landmark and safety floor
The pleural dome is immediately posteromedial — pneumothorax is the classic complication
The phrenic nerve (C3–5) runs on the anterior scalene and is frequently blocked (~50–80%)

Gray's Anatomy — brachial plexus dissection showing anatomical relationships — **Fig. 2.** Anatomical dissection of the right brachial plexus (Gray's Anatomy, 1918, public domain). Note the relationship between the plexus trunks, subclavian artery, scalene muscles and clavicle. The supraclavicular fossa approach targets the plexus at trunk level, immediately above the first rib. Image: Wikimedia Commons, public domain.

Indications

Provides anaesthesia/analgesia for the elbow, forearm, wrist, and hand. For complete shoulder coverage, an interscalene block is preferred.

Surgical Site	Block Role	Notes
Elbow surgery (distal humerus, olecranon, radial head)	First-line	Excellent coverage of all approaches
Forearm fractures, ORIF radius/ulna	First-line	Dense sensorimotor block
Wrist and hand surgery	First-line	May supplement with distal blocks for ulnar border
Carpal tunnel release	Alternative	Wrist blocks often preferred for simple CTS
Shoulder surgery	Partial	Prefer interscalene for complete shoulder coverage
AV fistula creation	First-line	Sympathectomy may improve vessel calibre

Contraindications

Absolute

Patient refusal
Infection at injection site
Allergy to local anaesthetics

Relative

Contralateral pneumothorax or pneumonectomy
Severe respiratory disease (FEV₁ <50%) — phrenic palsy risk
Pre-existing coagulopathy
Pre-existing neuropathy (document carefully)

Technique — Ultrasound-Guided

⚡

Real-time ultrasound guidance is strongly recommended to reduce the risk of pneumothorax and vascular injection. Nerve stimulation alone is no longer standard of care.

Equipment

Probe: High-frequency linear (10–15 MHz), placed parallel to clavicle in supraclavicular fossa
Needle: 50 mm short-bevel insulated 22G, in-plane approach from lateral
Position: Supine, head turned 45° away, ipsilateral arm alongside body

Step-by-step

Initial scan — identify subclavian artery
Place probe in the supraclavicular fossa in coronal-oblique orientation. Identify the subclavian artery — pulsatile, compressible, anechoic circle. Confirm with colour Doppler if needed. Note depth of pleura.
Identify brachial plexus
The plexus appears lateral and slightly posterior/superior to the artery as a cluster of hypoechoic oval structures ("bunch of grapes"). The first rib is the bright hyperechoic band with posterior acoustic shadow beneath the artery.
Needle insertion — lateral to medial, in-plane
Insert the needle at the lateral end of the probe. Advance under real-time visualisation targeting the "corner pocket" — the space between the inferior trunk and the first rib, postero-inferior to the artery. This position uses gravity to distribute LA around all trunks.
Aspiration and incremental injection
Aspirate before each aliquot. Inject 5 mL increments with intermittent aspiration. Observe circumferential spread. Total volume 25–35 mL. Reposition needle if spread appears unilateral.

Sonoanatomy

On the US image the brachial plexus appears as a cluster of hypoechoic (dark) oval/round structures lateral to the subclavian artery. The first rib produces a bright white hyperechoic band with posterior acoustic shadow. The pleura appears as a thin, bright, sliding line posteromedial to the artery.

Fig. 4 (schematic). US anatomy: brachial plexus (green) lateral to subclavian artery (red), above first rib. Needle target: "corner pocket" postero-inferior to plexus cluster.

Ultrasound image — supraclavicular view showing brachial plexus trunks (UT, MT, LT), subclavian artery (SA), first rib, and pleura. NYSORA. — **Fig. 5.** Ultrasound image — supraclavicular view (coronal-oblique, linear probe). The brachial plexus trunks are circled in yellow: UT = upper trunk (C5–6), MT = middle trunk (C7), LT = lower trunk (C8–T1). SA = subclavian artery (anteromedial, red label); **MSM** = middle scalene muscle; **OHM** = omohyoid muscle. The 1st rib produces a bright hyperechoic band with posterior acoustic shadow. Pleura is visible anteriorly and posteriorly at depth.
*Image courtesy of NYSORA (nysora.com). Source: Tips for a Supraclavicular Brachial Plexus Block — NYSORA. Used for educational purposes.*

👁️

Sonoanatomy tip: Start by locating the subclavian artery — pulsatile dark circle. Then look laterally and slightly posteriorly for the plexus cluster. The first rib produces a bright white line with complete posterior shadowing. The "corner pocket" injection point is the angle between the inferior plexus and the first rib, posteromedial to the artery.

Local Anaesthetics & Dosing

⚠️

Maximum dose limits must always be respected. Calculate mg/kg dose before injection. Consider dose reduction in elderly, low weight, or hepatic insufficiency. Verify against local formulary and current SmPC before clinical use.

Agent	Concentration	Volume	Dose	Onset	Duration (plain)	+Adrenaline
Ropivacaine	`0.5%`	25–35 mL	125–175 mg	15–25 min	8–12 h	—
Ropivacaine	`0.75%`	20–30 mL	150–225 mg	10–20 min	10–16 h	—
Bupivacaine	`0.5%`	20–30 mL	100–150 mg	15–25 min	10–16 h	14–20 h
Levobupivacaine	`0.5%`	20–30 mL	100–150 mg	15–25 min	10–14 h	12–18 h
Lidocaine	`1.5–2%`	20–30 mL	300–400 mg	5–10 min	2–4 h	3–6 h
Mepivacaine	`1.5%`	25–35 mL	375–525 mg	8–15 min	4–6 h	6–8 h

⭐ Recommended — Surgical Anaesthesia (ambulatory)

Ropivacaine 0.5% — 30 mL (150 mg total)

+ Dexamethasone 8 mg IV as adjuvant. Provides 12–16 h analgesia in most patients.

⚡ Fast-onset — Day-case Hand Surgery

Mepivacaine 1.5% 20 mL + Ropivacaine 0.5% 15 mL (mixture)

Fast onset ~10 min, extended duration ~8 h. Useful when rapid surgical onset is required.

Adjuvants

Adjuvant	Dose	Route	Effect	Evidence
Dexamethasone	4–8 mg	IV or perineural	Extends duration by 6–8 h, ↓ opioid use	Strong
Dexmedetomidine	0.5–1 mcg/kg	Perineural or IV	Extends duration by 4–6 h	Moderate
Adrenaline	2.5–5 mcg/mL	With LA	Extends duration (lidocaine/mepivacaine); intravascular marker	Strong
Clonidine	150 mcg	Perineural	Modest extension; sedation possible	Limited

Complications

Complication	Incidence	Risk	Mitigation
Phrenic nerve palsy	50–80%	High	Reduced volume (15–20 mL); counsel patients with respiratory compromise
Pneumothorax	0.1–0.7% (US-guided)	Moderate	Identify pleura before injection; real-time US; in-plane technique
Vascular puncture	1–3%	Moderate	Colour Doppler; in-plane visualisation; avoid medial trajectory
LAST	<0.1%	Low	Incremental injection; aspirate; Intralipid 20% immediately available
Horner syndrome	1–5%	Low	Self-limiting; warn patients preoperatively
Persistent neuropathy	<0.05%	Low	Avoid intraneural injection; low injection pressure; document pre-existing deficits

🚨

Intralipid 20% (500 mL) must be immediately available whenever performing any peripheral nerve block. Ensure full LAST resuscitation kit is present. Follow AAGBI LAST guidelines.

Video Resources

Educational videos embedded from YouTube. All content is from educational/institutional channels.

Supraclavicular Block — Anatomy & Technique

Anatomy, indications, and ultrasound-guided technique walkthrough.

Scanning Technique & Sonoanatomy

Detailed review of US scanning technique and sonographic landmarks.

Finding the Brachial Plexus — US Landmarks

Step-by-step probe placement and landmark identification for beginners and intermediates.

Live Procedure Demonstration

Real-time US-guided supraclavicular block demonstration with commentary.

Clinical Disclaimer Information on this page is for educational reference only and does not constitute medical advice. Drug doses and techniques described are general reference values and must be verified against local formulary, SmPC, and BNF before clinical use. All clinical decisions must be made by a qualified practitioner based on individual patient assessment. The site owner accepts no liability for any clinical outcome.

References

Tran DQH et al. Supraclavicular nerve blocks: systematic review and meta-analysis. Reg Anesth Pain Med. 2017;42(5):556–566.
Neal JM et al. ASRA Practice Advisory on Local Anesthetic Systemic Toxicity. Reg Anesth Pain Med. 2018;43(2):113–123.
NYSORA. Ultrasound-Guided Supraclavicular Brachial Plexus Block. nysora.com ↗
ESRA PROSPECT Working Group. Procedure-specific postoperative pain management recommendations. esraeurope.org/prospect ↗
NYSORA. Tips for a Supraclavicular Brachial Plexus Block. nysora.com ↗ [Ultrasound image, used for educational purposes]
Abdallah FW, Brull R. Perineural dexmedetomidine: systematic review. Br J Anaesth. 2013;110(6):915–925.
Desmet M et al. Intravenous dexamethasone and nerve block duration. Br J Anaesth. 2017;117(6):799–807.
King of the Curve. Understanding Brachial Plexus Injury: Nerve Anatomy and Clinical Relevance. kingofthecurve.org ↗ [Anatomical diagram, used for educational purposes]