Single Shot vs Catheter Infraclavicular Brachial Plexus Block After Distal Radius Fracture Repair

If the patient is willing to participate and signs the consent, he/she will be randomized to
one of the two treatment groups:

1. Single shot block

2. Continuous catheter

In the institution investigators usually advocate for regional anesthesia and intravenous
sedation for the repair of open fracture of the distal radius.

Patients will be monitored during block performance with standard ASA monitors. All patients
will receive 2 L of oxygen via a nasal cannula. Sedatives will be titrated to effect.
Midazolam 1-2 mg, and fentanyl 50-100 mcg will be used for sedation.

Block time out will be preformed according to standard operating procedure. All blocks will
be done under ultrasound guidance. Sonosite S nerve machine will be used with a low frequency
curvilinear (C5) US probe with 2-5 MHZ frequency. Both single shot and continuous ICB will be
performed according to the SOP in the department. Ultrasound survey of the deltopectoral
groove below the clavicle will take place. The axillary artery and the three cords
(posterior, medial and lateral) of the brachial plexus will be identified in short axis view
deeper to the pectoralis minor muscle.

For single shot blocks: A 4 inch 21 gauge single shot (B-Braun) needle will be introduced
in-plane towards the posterior cord of the brachial plexus and 1-2 mL of dextrose 5% (D5%)
bolus will be used to verify correct placement of the needle in the vicinity of the posterior
cord and adequate spread pattern to both lateral and medical cord. 20 ml of of Ropivicaine
0.5% will be injected through the needle with intermittent aspiration after each 5 ml bolus
injection.

For the continuous block: A 4 gauge 18 inch tuohy needle ( B -Braun) will be introduced
towards the posterior cord as above. When the needle tip and the pattern of spread is
confirmed using D5% solution, a 21 gauge catheter will be introduced 2 cm beyond the needle
tip under ultrasound visualization. The needle will be withdrawn over the catheter. Injection
of a total of 20 ml of ropivacaine 0.5% ( in divided 5 ml boluses with intermittent
aspiration) will take place through the catheter while observing the spread of local
anesthetic under ultrasound. The catheter hub will be affixed to the upper lateral chest with
sterile occlusive dressings and an anchoring device.

Block success will be defined as a change in cutaneous sensation to touch with an alcohol pad
in the posterior, medial and lateral cord distribution over the forearm and the hand within
30min after injection. Subjects with successful catheter placement per protocol and nerve
block onset will be retained in the study. Subjects with a failed catheter insertion or
misplaced catheter indicated by a lack of sensory changes will have their catheter replaced
or will be single shot blocked and withdrawn from the study.

Intraoperative sedation will consist of intermittent boluses of midazolam (1-2 mg), fentanyl
(50-100 mcg) and propofol infusion, titrates to sedation and patient comfort (25-50
mcg/kg/min).

All patients will receive prophylaxis for postoperative nausea and vomiting (PONV) during
surgery. The protocol for prophylaxis against PONV includes administration of 4 mg of
dexamethasone after induction of anesthesia and 4 mg of ondansetron 20 minutes before
recovery from anesthesia. Dexamethasone is withheld if the patient has poorly controlled
diabetes mellitus (DM). Uncontrolled DM will be defined as random blood glucose above 250
mg/dl.

Inclusion Criteria:

- Patients scheduled for open reduction and internal fixation of a distal radius
fracture

- American Society of Anesthesiologists (ASA) physical status I -III

- Mentally competent and able to give consent for enrollment in the study

Exclusion Criteria:

- Patient younger than 18 years old

- Allergy to local anesthetics, systemic opioids (fentanyl, morphine, hydromorphone and
any of the drugs included in the standard of care

- Patients opting to go under general anesthesia and those refusing the block

- Chronic pain syndromes; Patients will be defined to have chronic pain if they are
using regular daily doses of systemic narcotics for the past 6 months prior to the
surgery

- BMI of 40 or more