Anatomische Landmarken für periphere Nervenblöcke an Unterarm und Handgelenk: Eine Untersuchung an Leichenpräparaten

Zusammenfassung

Hintergrund Es gibt keine Daten, die eine standardisierte, auf Orientierungspunkten basierende Technik zur Blockierung sensibler Nerven des Unterarms gewährleisten.

Ziel Ziel dieser Untersuchung war es, Stellen an Unterarm und Ellenbogen zu definieren, an denen unter Orientierung an gut tastbaren knöchernen Landmarken Nervenblockaden relativ sicher erfolgreich möglich sind.

Methoden An fünf Leichenarmen wurden der Ramus superficialis des N. radialis (RSNR), der dorsale Ast des N. ulnaris (RDNU), der laterale, mediale und dorsale N. cutaneus antebrachii (NCAL, NCAM, NCAD) sowie der Ramus palmaris des N. medianus (RPNM) präpariert. In Bezug auf den Processus styloideus radii und ulnaris, das Listerʼsche Tuberkulum sowie den Epikondylus medialis und lateralis sowie Verbindungslinien zwischen diesen gut tastbaren Knochenvorsprüngen wurden Stellen lokalisiert, an denen die vorgenannten Nerven aufzufinden und zu blockieren sind.

Ergebnisse Die Nerven können an folgenden Stellen sicher blockiert werden: der RSNR 85 mm proximal des Listerʼschen Tuberkels auf einer Linie zwischen letzterem und dem Epicondylus humeri medialis; der NCAL 38 mm und der NCAD 32 mm ulnar vom Epicondylus humeri lateralis; der NCAM 14 mm radial zum medialen Epicondylus; der RDNU 27 mm proximal zum Ulnastyloid in Richtung des lateralen Epicondylus; der RPNM auf einer nach ulnar zielenden Senkrechten zur Verbindungslinie zwischen dem Processus styloideus radii (PSR) und dem medialen Epikondylus 45 mm proximal des PSR und 21 mm nach ulnar.

Schlussfolgerung Unter Verwendung gut tastbarer Knochenvorsprünge am distalen Unterarm und Ellenbogen und Verbindungslinien zwischen ihnen lassen sich der RSNR, RDNU, RPNM sowie die NNCAL/M und D sicher lokalisieren.

Evidenzgrad IV

Abstract

Background There are no data ensuring a standardized landmark-based-technique for blocking sensitive nerves of the forearm.

Purpose To identify locations were with use of good palpable bony landmarks and lines between them sensitive nerve blocks on the forearm can be done with great success.

Material and Methods Dissection of the superficial branch of the radial nerve (SBRN), the dorsal branch of the ulnar nerve (DBUN), the lateral, medial and dorsal antebrachial cutaneous nerve (LACN, MACN, and DACN) as well as the palmar branch of the median nerve (PBMN) was performed on five upper limbs of five different Caucasian cadavers. With respect to radius and ulnar styloid, Lister’s tubercle, and the medial and lateral epicondyle of the humerus as well as connecting lines between these bony landmarks locations were defined, where the mentioned nerves can be found and blocked.

Results The six nerves can be safely blocked at the following sites: the SBRN 85 mm proximal to Lister’s tubercle on a line drawn between the latter and the medial humeral epicondyle; the LACN 38 mm and the dorsal one 32 mm ulnar from the lateral epicondyle; the MACN 14 mm radial to the medial epicondyle; the DBUN 27 mm proximal to the ulnar styloid in direction to the lateral epicondyle; the PBMN 45 mm proximal to the radial styloid following a line between the latter and the medial epicondyle and 21 mm ulnarwards perpendicular to this line.

Conclusion Using superficial good palpable landmarks at the wrist and elbow as well as connecting lines between them the SBRN, DBUN, PBMN, LACN, MACN, and DACN can easily be located.

Schlüsselwörter

Periphere Nervenblockaden - Ramus superficialis Nervus radialis - Ramus dorsalis Nervus ulnaris - Ramus palmaris Nervus medianus - Nervus cutaneous antebrachii lateralis - medialis - dorsalis

Key words

Peripheral nerve blocks - superficial branch of the radial nerve - dorsal branch of the ulnar nerve - palmar branche of the median nerve - lateral - medial and dorsal antebrachial cutaneous nerve

Publikationsverlauf

Eingereicht: 30. Juni 2020

Angenommen: 07. Januar 2021

Artikel online veröffentlicht:
15. Februar 2021

• Literatur

• 1 Vlassakov KV, Narang S, Kissin I. Local anesthetic blockade of peripheral nerves for treatment of neuralgias: systematic analysis. Anesth Analg 2011; 112: 1487-93 DOI: 10.1213/ANE.0b013e31820d9787.
• 2 Foldes P, Rosenquist RW. Opinion/editoral review of recent literature: Where ultrasound has yet to make a difference in regional anesthesia. Int Anesth Clin 2011; 49: 22-33 DOI: 10.1097/AIA.0b013e31821b7c10.
• 3 Netter FH. Atlas of human anatomy. 1. Aufl.. New Jersey: Summit, Ciba- Geigy Corporation; 1989
• 4 Thiel W. Die Konservierung ganzer Leichen in natürlichen Farben. Anatomischer Anzeiger 1992; 174: 185-195
• 5 Bonica JJ. Diagnostic and therapeutic blocks, a reappraisal based on 15 years’ experience. Anesth Analg 1958; 37: 58-68
• 6 Waldman SD. Diagnostic and Prognostic Nerve Blocks. In: Kopf A, Patel NB, eds: IASP Guide to Pain Management in Low-Resource-Settings. 2010: 293-298 https://s3.amazonaws.com/rdcms-iasp/files/production/public/Content/ContentFolders/Publications2/FreeBooks/Guide_to_Pain_Management_in_Low-Resource_Settings.pdf Stand: 26.12.2020
• 7 Stokvis A, van der Avoort DJ, van Neck JW. et al. Surgical management of neuroma pain: a prospective follow-up study. Pain 2010; 151: 862-869 doi:281 DOI: 10.1016/j.pain.2010.09.032.
• 8 Malessy MJA, de Boer R, Muñoz I Romero. et al. Predictive value of a diagnostic block in focal nerve injury with neuropathic pain when surgery is considered. PLoSOne 2018; 13: e0203345 DOI: 10.1371/journal.pone.0203345.
• 9 Moritz T, Prosch H, Pivec CH. et al. High-resolution ultrasound visualization of the subcutaneous nerves of the forearm: a feasibility study in anatomic specimen. Muscle Nerve 2014; 49: 676-679 DOI: 10.1002/mus.24064.
• 10 Barrington MJ, Watts SA, Gledhill SR. et al. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications. Reg Anesth Pain Med 2009; 534-541 DOI: 10.1097/aap.0b013e3181ae72e8.
• 11 Antonakakis JG, Ting PH, Sites B. Ultrasound-guided regional anesthesia for peripheral nerve blocks: an evidence based outcome review. Anesth Clin 2011; 29: 294 179-191 DOI: 10.1016/j.anclin.2011.04.008.
• 12 Kwofie K, Shastri U, Vandepitte C. Standard approaches for upper extremity nerve blocks with an emphasis on outpatient surgery. Curr Opin Anesthesiol 2013; 26: 501-508 DOI: 10.1097/ACO.0b013e328362d08a.
• 13 Kiliç A, Kale A, Usta A. et al. Anatomic course of the superficial branch of the radial nerve in the wrist and its location in relation to wrist arthroscopy portals: a cadaveric study. Arthroscopy 2009; 25: 1261-1264 DOI: 10.1016/j.arthro.2009.05.015.
• 14 Vialle R, Pietin-Vialle C, Cronier P. et al. Anatomic relations between the cephalic vein and the sensory branches of the radial nerve: How can nerve lesions during vein puncture be prevented?. Anesth Analg 2001; 93: 1058-1061 DOI: 10.1097/00000539–200110000–00052.
• 15 Auerbach DM, Collins ED, Kunkle KL. et al. The radial sensory nerve. An anatomic study. Clin Orthop Relat Res 1994; 308: 241-249
• 16 Abrams RA, Brown RA, Botte MJ. The superficial branch of the radial nerve: an anatomic study with surgical implications. J Hand Surg Am 1992; 17: 1037-41 DOI: 10.1016/s0363–5023(09)91056–5.
• 17 Robson AJ, See MS, Ellis H. Applied anatomy of the superficial branch of the radial nerve. Clin Anat 2008; 21: 38-45 DOI: 10.1002/ca.20576.
• 18 Humphrey CD, Kriet JD. Nerve repair and cable grafting for facial paralysis. Facial Plast Surg 2008; 24: 170-176 DOI: 10.1055/s-2008–1075832.
• 19 Higgins JP, Fisher S, Serletti JM. et al. Assessment of nerve graft donor sites used for reconstruction of traumatic digital nerve defects. J Hand Surg Am 2002; 27: 286-292 DOI: 10.1053/jhsu.2002.31154.
• 20 Viscomi CM, Reese J, Rathmell JP. Medial and lateral antebrachial cutaneous nerve blocks: an easily learned regional anesthetic for forearm arteriovenous fistula surgery. Reg Anesth 1996; 21: 2-5
• 21 Rosen JE, Rokito AS, Khabie V. et al. Examination of the lateral antebrachial cutaneous nerve: an anatomic study in human cadavers. Am J Orthop 1998; 27: 690-692
• 22 Wongkerdsook W, Agthong S, Amarase C. et al. Anatomy of the lateral antebrachial cutaneous nerve in relation to the lateral epicondyle and cephalic vein. Clin Anat 2011; 24: 56-61 DOI: 10.1002/ca.21067.
• 23 Beldner S, Zlotolow DA, Melone Jr CP. et al. Anatomy of the lateral antebrachial cutaneous and superficial radial nerves in the forearm: a cadaveric and clinical study. J Hand Surg Am 2005; 30: 1226-1230 DOI: 10.1016/j.jhsa.2005.07.004.
• 24 Mok D, Nikolis A, Harris PG. The cutaneous innervation of the dorsal hand: detailed anatomy with clinical implications. J Hand Surg Am 2006; 31: 565-574 DOI: 10.1016/j.jhsa.2005.12.021.
• 25 McAdams TR, Hentz VR. Injury to the dorsal sensory branch of the ulnar nerve in the arthroscopic repair of ulnar-sided triangular fibrocartilage tears using an inside-out technique: a cadaver study. J Hand Surg Am 2002; 27: 840-844 DOI: 10.1053/jhsu.2002.34370.
• 26 Rodeo SA, Forster RA, Weiland AJ. Neurological complications due to arthroscopy. J Bone Joint Surg Am 1993; 75: 917-926 DOI: 10.2106/00004623–199306000–00015.
• 27 Botte MJ, Cohen MS, Lavernia CJ. et al. The dorsal branch of the ulnar nerve: an anatomic study. J Hand Surg Am 1990; 15: 603-607 DOI: 10.1016/s0363–5023(09)90022–3.
• 28 Botte MJ, Cooney WP, Linscheid RL. Arthroscopy of the wrist: anatomy and technique. J Hand Surg Am 1989; 14: 313-316 DOI: 10.1016/0363–5023(89)90029–4.
• 29 Casoli V, Vérolino P, Pélissier P. et al. The retrograde neurocutaneous island flap of the dorsal branch of the ulnar nerve: anatomical basis and clinical application. Surg Radiol Anat 2004; 26: 8-13 DOI: 10.1007/s00276–003–0174–2.
• 30 Bertelli JA, Pagliei A. The neurocutaneous flap based on the dorsal branches of the ulnar artery and nerve: a new flap for extensive reconstruction of the hand. Plast Reconstr Surg 1998; 101: 1537-1543 DOI: 10.1097/00006534–199805000–00017.
• 31 Puna R, Poon P. The anatomy of the dorsal cutaneous branch of the ulnar nerve. J Hand Surg Eur Vol 2010; 35: 583-585 DOI: 10.1177/1753193410373186.
• 32 Hoppenfeld S, DeBoer P. Surgical exposures in orthopedics: the anatomic approach. 2. Aufl.. Philadelphia: Lippincott Williams and Wilkins; 1994: 103-107
• 33 Tubiana R, McCullough CJ, Masquelet AC. An atlas of surgical exposures of the upper extremity. 1. Aufl.. Philadelphia: J. B. Lippincott Company; 1990: 196-197
• 34 Clemente CD. Anatomy: a regional atlas of the human body. 3. Aufl.. Philadelphia: Lea and Febiger; 1997: 42-47
• 35 MacAvoy MC, Rust SS, Green DP. Anatomy of the posterior antebrachial cutaneous nerve: practical information for the surgeon operating on the lateral aspect of the elbow. J Hand Surg Am 2006; 3: 908-911 DOI: 10.1016/j.jhsa.2006.03.013.
• 36 Giovanni AJ. A technique for selective blockade of the medial antebrachial cutaneous nerve. Anesthesiology 1969; 30: 242-243 DOI: 10.1097/00000542–196902000–00022.
• 37 Thallaj A, Marhofer P, Kettner SC. et al. High-resolution ultrasound accurately identifies the medial antebrachial cutaneous nerve at the midarm level: a clinical anatomic study. Reg Anesth Pain Med 2011; 36: 499-501 DOI: 10.1097/AAP.0b013e318228a359.
• 38 Chaynes P, Bécue J, Vaysse P. et al. Relationships of the palmar cutaneous branch of the median nerve: a morphometric study. Surg Radiol Anat 2004; 26: 275-280 DOI: 10.1007/s00276–004–0226–2.
• 39 Matloub HS, Yan JG, Mink Van Der Molen AB. et al. The detailed anatomy of the palmar cutaneous nerves and its clinical implications. J Hand Surg Br 1998; 23: 373-379 DOI: 10.1016/s0266–7681(98)80061–2.
• 40 DaSilva MF, Moore DC, Weiss AP. et al. Anatomy of the palmar cutaneous branch of the median nerve: clinical significance. J Hand Surg Am 1996; 21: 639-643 DOI: 10.1016/S0363–5023(96)80018–9.
• 41 Dowdy PA, Richards RS, McFarlane RM. The palmar cutaneous branch of the median nerve and the palmaris longus tendon: a cadaveric study. J Hand Surg Am 1994; 19: 199-202 DOI: 10.1016/0363–5023(94)90005–1.
• 42 Bezerra AJ, Carvalho VC, Nucci A. An anatomical study of the palmar cutaneous branch of the median nerve. Surg Radiol Anat 1986; 8: 183-188 DOI: 10.1007/BF02427847.
• 43 Carroll RE, Green DP. The significance of the palmar cutaneous nerve at the wrist. Clin Orthop Relat Res 1972; 83: 24-28 DOI: 10.1097/00003086–197203000–00006.
• 44 Hobbs RA, Magnussen PA, Tonkin MA. Palmar cutaneous branch of the median nerve. J Hand Surg Am 199; 15: 38-43 DOI: 10.1016/s0363–5023(09)91103–0.