Surface Anatomy-Based Clavipectoral Fascia Plane Block for Clavicle Surgery

Introduction: Clavicular fractures are often observed cases. In the majority of clavicle fractures, both in adults and children, the fracture is located in the midshaft. Generally, General Anesthesia techniques are usd in such instances, as regional anesthesia through peripheral nerve block often presents its own challenges. The clavipectoral fascial plane block was first introduced in 2017. Apart from its ease of implementation, the Surface Anatomy-Based Clavipectoral Plane Block can avoid the risks associated with other regional anesthesia techniques such as Plexus Brachialis Block or Interscalene Block. Objective: This report aims to provide an overview of the procedures for carrying out surface anatomy-based clavipectoral fascia plane block for clavicle surgery. Case Report: A 33-year-old man with the primary complaint of pain in the right shoulder following a fall while playing football. The patient was diagnosed with closed re-fracture of the clavicle (D) Allman Group I. Clavicle surgery was conducted with the Surface Anatomy-Based Clavipectoral Fascia Plane Block technique. In this patient, local anesthetic agents were administered as Levobupivacaine 0.375% in a volume of 20 cc. The operation lasts approximately 1.5 hours. The Patient’s hemodynamic condition was stable during the surgery. The patient had no complaints and post-operative pain was effectively managed. Conclusion: The surface Anatomy-based Clavipectoral fascia plane block can be considered for clavicular surgery, especially in Allman Group type 1. Besides being easy to implement, this technique also poses fewer risks compared to other regional anesthesia techniques.

INTRODUCTION

Clavicular fractures are cases that we often encounter. A clavicle fracture can result from various causes, such as a traffic accident or a fall during activities. In the majority of clavicle fractures, both in adults and children, the fracture is located in the midshaft (¹). Generally, the general anesthesia (GA) technique is preferred in such instances, as regional anesthesia through peripheral nerve block often presents its own challenges. Several published case reports and series have been reported the efficacy of a brachial plexus block (interscalene approach) or a combination block (interscalene with cervical superficialis) (²,³). However, performing two different blocks plus using ultrasonography as guidance can be something time-consuming.

The clavipectoral fascial plane block was first introduced in 2017 by Dr. Luis Valdes at the European Society of Regional Anesthesia and Pain Therapy Congress (⁴-⁷). Apart from its ease of implementation, the Surface Anatomy-Based Clavipectoral Plane Block can avoid the risks associated with interscalene blocks, including ipsilateral nerve palsy, vocal cord paralysis, and pneumothorax (³). Blocks can deliver effective postoperative analgesia when utilizing long-acting agents, less opioid use, and disminished postoperative nausea and vomiting in comparison to general anesthesia (⁸).

CASE REPORT

A 33-year-old man presented with complaints of pain in the right shoulder following a fall during playing soccer. The patient reported that he fell with his right shoulder hitting the field first. There was no history of fainting, vomiting, or seizures. Subsequent to the incident, the patient reported exacerbated pain in the right shoulder with movement. Previous history of asthma, allergies, hypertension, diabetes mellitus, seizures, breathing difficulties, and familial diseases are denied. The patient experienced a previous anesthesia procedure in 2007 for Clavicle Surgery and again in 2010 for the Removal of an Implant from the clavicle.

The physical examination found a height of 174 cm, a weight of 97 kg with a BMI of 32 kg/m 2 categorizing him as obese class I. The vital signs examination found a Blood Pressure of 110/70 mmHg, Heart Rate of 84 beats per minutes, Respiratory Rate of 20 breaths per minutes, temperature of 36.5°C, and oxygen saturation (SpO2) of 98% with nasal cannula of 3 lpm oxygen in a supine position. Airway is clear, respiration is sufficient, circulation is normal. The examination of heart and lung found no abnormalities.

Local examination of the right claviclular region found cicatricial changes, accompanied by swelling in the middle 1/3, unclear deformity. Tenderness present, crepitus observed in the middle 1/3 of the clavicle, neurovascular disturbance disruption absent, SpO2 digits 1-5: 97%-99%. The movement examination found limited shoulder range of motion (ROM), positive discomfort, but the elbow and wrist exhibited complete range of motion.

The results of PA Thoracic X-ray indicate lung contusion, mild bilateral pleural effusion with differential diagnosis of Hematothorax, a comminuted fracture in the middle 1/3 of the right clavicle accompanied by soft tissue swelling, and complete fractures of the right posterior ribs 3, 4, and 5. Assessment of invalid cast conducted (Figure 1).

Figure 1.Posteroanterior Thoracic X-ray Before Surgery

Preoperative anesthetic assessment indicated a 33-year-old male with close re-fracture of the clavicle (D) Allman Group I, segmental type, scheduled for open reduction and internal fixation (ORIF) of the clavicle using an S-plate, with a physical status classified as ASA II, and a plan for Clavipectoral Block. The patients presented with lung contusions, mild bilateral pleural effusion, and Hematothorax, without severe respiratory distress. The patient’s untritional state is indicated by a BMI of 32 kg/m2 (categorized as Obese Class I).

The patient was scheduled for clavicle surgery utilizing an S-plate, clasified as ASA II, with clavipectoral block anesthesia planned. The patient’s operative preparation and management will be explained in detail before to, during, and after the operation. In this case, ORIF of the clavicle was performed utilizing the clavipectoral block anesthesia technique. In this patient, Levobupivacaine 0.375% was administered as 20 cc with injection in three sides of the clavicle. The injection was administered in the medial end, the location of the fracture, and the lateral end.

Figure 2.Injection Site of the Local Anesthetic Agent

The operation lasts approximately 1.5 hours. The hemodynamic stability of operation is maintained as, a systolic blood pressure of 110-140 mmHg and diastolic blood pressure of 70-79 mmHg, respiratory rate of 18-20 breaths per minute, heart beart of 75-90 beats per minute, lifting strength, regular SpO2 of98% with nasal cannula at 3 lpm oxygen.

Table 1.Intraoperative Hemodynamic Monitoring

Hemodynamic	Value
Time (WIB)	13.00	13.15	13.30	13.45	14.00	14.15	14.30
Systole (mmHg)	140	136	110	115	110	140	132
Diastole (mmHg)	79	74	70	72	74	76	74
HR (bpm)	90	88	70	72	76	83	88
SpO2 (%)	100	100	100	98	99	100	100

The administered surgical medications include Ondansetron 4mg intravenously, Injection of Paracetamol 1 gr intravenously, and Midazolam 3 mg. Throughout the duration, 3 lpm of O₂is administered via a nasal cannula.

Hemodynamics during surgery are presented inFigure 1. The postoperative condition was recorded with vital signs of blood pressure at 138/77 mmHg, heart rate at 82 beats per minute, respiratory rate at 20 breaths per minute, and oxygen saturation (SpO2) at 98% while receiving oxygen through nasal cannula at 3 liters per minute. Following the completion of the operation, the patient was transferred back to the ward. The patient

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