Shoulder and elbow surgery
Anaesthesia
Different types of anesthesia can be used, depending on the type and duration of the planned operation. The type of anesthesia to be used will be discussed with the anesthetist during the preoperative consultation.
Intravenous anesthesia
It is advisable to eat a light, tolerated meal 2 hours before the operation. Before the operation, a nurse sets up a venous line. The area to be operated on is partially drained of blood with an elastic bandage, then two tourniquets are placed on the arm and inflated to prevent blood flowing back into the forearm. The anaesthetist or surgeon may administer a dilute solution of anaesthetic via the vein, the amount of which is proportional to the patient’s weight. The anesthetic usually takes about ten minutes to take effect. The two tourniquets are deflated in turn as tolerated. With this type of anesthesia, the procedure can last around 40 minutes.
The risks are low. If the tourniquet is opened too quickly, this can cause dizziness and sometimes short-term syncope, which may be accompanied by convulsions. The venous line placed on the other limb enables all necessary medication to be administered.
General anesthesia
General anaesthesia is performed by experienced anaesthetists and adapted to the patient’s general condition and type of surgery. It requires a more thorough pre-operative consultation and assessment. However, thanks to improvements in this technique over the years, risks are considerably reduced. The anaesthetist will provide all the necessary information on the procedure and any associated risks.
Locoregional anesthesia
Fasting is recommended, as if the anesthetic is not sufficient, it may be necessary to switch to general anesthesia (narcosis).
Axillary block
The anaesthetist disinfects the armpit and injects the anaesthetic solution around the nerves of the arm under ultrasound control. This maneuver is not very painful. Anesthesia develops in about 30 minutes. If anesthesia is not complete, the surgeon can supplement it by infiltrating the tissue directly at the surgical site. The tourniquet can be used for up to two hours. Circulation should then be restored for 20 minutes to allow the tissues to reoxygenate. The duration of anesthesia varies from 4 to 12 hours, depending on the product injected. Sensory and muscular paralysis is complete during this period.
Risks: very low. Hematomas and nerve irritation, with residual pain lasting several weeks, have been described in the literature. Complications associated with the administration of anesthetic substances are monitored by the anesthetist or his assistants. Premedication is routinely administered in hospitals and for long-term operations. If desired, oxygen and sedatives can also be administered.
Inter-stage block
Interscalene block is indicated for surgery on the shoulder and proximal humerus, as well as on the lateral two-thirds of the clavicle. Interscalene block can also be used for surgery on the arm or forearm; however, the higher incidence of incomplete lower trunk block with this technique may provide inadequate analgesia in the ulnar distribution. Patient positioning and comfort, surgeon preference and procedure duration may necessitate the concomitant administration of general anesthesia. An interscalene catheter can be inserted for prolonged postoperative analgesia.
For shoulder and clavicle surgery, the interscalene block consists in injecting anesthetic around the roots/trunks of the brachial plexus as they pass between the anterior and middle scalene muscles, at the level of the cricoid cartilage. The patient is positioned supine, with the head contralateral to the side to be blocked. Reference points are the sternocleidomastoid muscle, the anterior and middle scalene muscles, the external jugular vein and the cricoid cartilage. If electrostimulation is used, a clear motor response is sought distal to the shoulder with a current intensity of 1.5 mA. For correct localization, it is necessary to demonstrate clonus of the deltoid muscle (axillary nerve stimulation) if surgery is planned on the shoulder, or of the biceps muscle if surgery is planned on the proximal third of the humerus.
Supraclavicular block
Supraclavicular block is an extensive block used for surgery on the humerus, elbow, forearm and hand. It involves injecting anesthetic around the divisions of the brachial plexus in the sheath compartment, posterolateral to the subclavian artery. The landmarks are the clavicle, the clavicular part of the sternocleidomastoid muscle and the anterior scalene muscle. The patient is positioned supine, with the head contralateral to the side to be blocked.
Block infraclaveale
The infraclavicular block is often used as an alternative to the supraclavicular block, due to its greater safety and simplicity. It consists of an injection of anesthetic posterior to the subclavian artery, from where it travels around the cords of the brachial plexus. The patient is positioned supine, with the head contralateral to the side to be blocked.
