Infraclavicular brachial plexus block using a multiple injection technique and an approach in the cranial direction in a patient with anticipated difficulties in tracheal intubation

A man with a pathologic diaphysial fracture of the middle third of the left humerus underwent emergency surgery for osteosynthesis of the fracture. Preoperative examination revealed that intubation would be difficult due to a history of radical surgery for epidermoid carcinoma of the oropharynx, and local-regional anesthesia was therefore considered. An interscalene approach was contraindicated because of the presence of an ulcerated metastatic cutaneous lesion in the area of puncture; and axillary block was also ruled out given that the fracture made movement painful. However, a satisfactory block and optimal conditions for surgery were achieved through an infraclavicular block using a cephalad multiple injection technique. Among the various levels of brachial plexus blockade, the infraclavicular option is little known and the least utilized, considering that one of its advantages is that the upper limb does not need to be moved for referencing (giving it an advantage over the axillary block) and that it has a lower incidence of pneumothorax (in comparison with a supraclavicular approach). Combined with a multiple injection technique and puncture in a cephalad direction, this solution allowed proximal surgery to be performed on the arm of a patient in whom intubation would have been difficult.