Regional anaesthesia · Upper limb
Upper-limb blocks
Blocks for the shoulder, arm, elbow, forearm and hand: how to do them, what they cover and what they cost (the diaphragm, the hand), and which one to choose for the operation in front of you.
Three pages
Choose a region
Each page covers position, equipment, technique, dose, coverage and complications, with a simulated ultrasound scan with the needle and spread, real scans where we have them, the nerves in 3D, and exam questions. The brachial plexus app shows the same blocks on a 3D model and a labelled diagram of the plexus.
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Page 1 · Shoulder
Shoulder
- Interscalene and superior trunk
- Suprascapular and axillary nerve blocks
- Sparing the diaphragm
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Page 2 · Arm
Arm, elbow and hand
- Supraclavicular
- Infraclavicular, costoclavicular and RAPTIR
- Axillary, and the intercostobrachial nerve
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Page 3 · Forearm and hand
Forearm and hand
- Median, ulnar and radial nerve blocks
- The wrist block
- Testing a block and rescuing a gap
Rapid fire
Eight things to know before any upper-limb block
- The higher the block, the closer the phrenic nerve. Interscalene weakens the diaphragm in almost everyone; axillary never does.
- Only blocks above the clavicle reach the shoulder (interscalene, superior trunk, sometimes supraclavicular), or the suprascapular and axillary nerves blocked directly.
- No brachial plexus block covers the cape or the inner upper arm: supraclavicular nerves (cervical plexus) and intercostobrachial (T2).
- Supraclavicular: corner pocket first, or the ulnar side (C8–T1) is missed.
- Axillary: block the musculocutaneous nerve separately, in coracobrachialis.
- Ask where the cuff goes. Upper-arm tourniquet: a plexus block plus intercostobrachial infiltration. No arm tourniquet: a wrist block or local infiltration may be enough.
- Document the nerves before you block after trauma: the radial nerve with humeral shaft fractures, the axillary nerve with shoulder dislocations.
- Count every milligram, rescue blocks and the surgeon’s infiltration included. A common ceiling for ropivacaine is about 3 mg/kg (lean body weight), lower in the frail.
What each block costs
- Interscalene
- Diaphragm (almost always), Horner’s, hoarseness.
- Superior trunk
- Diaphragm less often; not never.
- Supraclavicular
- Diaphragm in up to about a third; pneumothorax risk.
- Infraclavicular, costoclavicular
- Diaphragm usually spared. A deep target, vessels not compressible.
- Axillary
- No diaphragm, no pleura. Many veins: inject slowly.
- Suprascapular, axillary nerve
- No diaphragm (posterior approaches). Shoulder abduction weak.
- Forearm and wrist
- No arm weakness. Fingers still move with a wrist block.
- Every arm block
- A numb, weak arm: sling, protect it from heat and pressure.
Across all three pages
Which block for which operation
Pick an operation to see the area to cover, the recommended block and the alternatives with their doses, what they miss, the tourniquet, and links to each block’s chapter.
Doses are ropivacaine for an adult, as used on the block pages. They are starting points: adjust for weight, age, frailty and every other local anaesthetic the patient receives.
Local anaesthetic systemic toxicity. The neck and the axilla are full of vessels: a small intra-arterial dose near the vertebral artery can cause a seizure at once. Use colour Doppler, inject in small aliquots with aspiration, add up the milligrams (rescue blocks too), and know where the lipid emulsion is.