key: cord-0027012-wxmctuqk
authors: Azizi, Khalid; Benhamza, Sabah; Motiaa, Youssef
title: Novel use of ultrasound guidance in wide-awake local anesthesia technique for clavicle surgery
date: 2021-06-30
journal: Korean J Anesthesiol
DOI: 10.4097/kja.21282
sha: 13cf49d5d496917b361505380decfd06e46e4638
doc_id: 27012
cord_uid: wxmctuqk

nan

sence of spread of local anesthetic solution to the brachial plexus. The 70 min procedure was performed successfully without sedation, and a clavicle plate was fixed using screws. Stability of the fixation was evaluated using active shoulder movements. No surgical drain was required. Intravenous acetaminophen (1 g) and ketoprofen (100 mg) were administered. No supplemental analgesics were used, and the patient was discharged after 24 h.

The second case involved a 45-year-old man, who had undergone surgery for an acromioclavicular dislocation treated with tension band wiring and a medial malleolus fracture fixed using Kirschner wires (K-wires). The patient was scheduled for hardware removal. After anesthetic skin infiltration, we performed ultrasound-guided WALANT at the lateral portion of the clavicle and the acromioclavicular junction using the previously described technique (Fig. 1C ). We administered a total of 50 ml of local anesthetic solution prepared as described above, including 10 ml injected into the medial malleolus. The same ultrasonographic image was observed after subperiosteal injection, with visualization of the spread of local anesthetic around the entry points of the K-wires (Fig. 1D ). The surgery lasted 25 min with no additional analgesic requirement. No adverse effects were observed. The patient reported no pain in the immediate postoperative period, required no rescue analgesia and was discharged on the same day with oral medication.

Although the benefits of ultrasound guidance in WALANT have been reported for hand surgery [4] , our report is the first to examine its clinical utility for clavicle procedures. Ahmad et al. [3] expanded the use of WALANT to clavicle surgery and reported 16 patients who successfully underwent clavicle fixation. However, two patients with displaced segmental fractures experienced mild pain during fixation. Anesthesia was then completed by intraoperatively injecting a supplemental WALANT solution. No complications were observed in this first case series, suggesting that this approach may be an effective alternative. However, special precautions must be taken when injecting blindly near the lung, brachial plexus, and subclavian vessels. This encouraged us to perform this technique under ultrasound guidance. Advantages of this method include the ability to visualize the correct spread of local anesthetic around the clavicle, and to avoid inadvertent puncture of adjacent structures. Remarkably, subperiosteal diffusion results in a typical thickening and echotexture modification of the cortical line. Ultrasound guidance also allows the deposition of local anesthetic around the fixation devices and into the fracture site, thus avoiding supplementary intraoperative injections.

In addition to its technical simplicity, WALANT might reduce the risk of nerve damage and phrenic nerve palsy associated with regional techniques commonly used for awake clavicle repair [2] . Although WALANT is performed anatomically distant from the phrenic nerve, theoretically precluding its involvement, we did not assess diaphragmatic function by ultrasound to validate this. Moreover, WALANT avoids motor blockade of the upper limb, allowing the patient to dress independently right after surgery, and making it suitable for outpatient surgery. Active patient movements also assist the surgeon in assessing fixation stability. However, there are some concerns including delayed onset of blockade and patient discomfort due to prolonged surgery [3] .

We have presented two cases describing the advantages of ultrasound guidance in WALANT for clavicle surgery, with a novel ultrasonographic image of subperiosteal injection. Effective postoperative analgesia and the absence of upper limb motor blockade facilitate early recovery. This alternative could constitute a diaphragm sparing option in patients with respiratory impairment, but also in more common cases. Further investigation is required to establish the efficiency and safety of this novel technique.

None.

No potential conflict of interest relevant to this article was reported. 

Ultrasound-guided interscalene block combined with intermediate or superficial cervical plexus block for clavicle surgery: a randomised double blind study

Diaphragm-sparing brachial plexus blocks: a focused review of current evidence and their role during the COVID-19 pandemic

Plating of clavicle fracture using the wide-awake technique

Anesthesia for hand surgery

Supplemental Video 1. Ultrasonographic video of the subperiosteal spread of local anesthetic after out-of-plane WALANT injection. Note the thickening and echotexture modifications of the clavicular cortical line.

Khalid Azizi, https://orcid.org/0000-0002-4864-306X Sabah Benhamza, https://orcid.org/0000-0001-8899-8618 Youssef Motiaa, https://orcid.org/0000-0002-3957-0700