A 3-year-old boy, weighing 18 kg, ASA physical status I, required surgery for a fracture of the lower third of the left humerus. After a thorough discussion of the risks and benefits with his parents, who then provided written informed consent, a USG supraclavicular brachial plexus block was undertaken. After inducing general anesthesia with 1 mg/kg of ketamine, a laryngeal mask airway (LMA) was inserted and ventilation was spontaneous.

A portable system with a linear array 5-10 MHz transducer (SonoSite® 180plus, Bothell, USA) was used for the USG supraclavicular brachial plexus block. The probe was placed in the coronal-oblique plane in the supraclavicular fossa and the puncture was in-plane (IP) from the lateral to medial (Fig. 1). The brachial plexus was identified as hypoechoic nodules surrounded by a hyperreflective fascial sheath, superior and lateral to the subclavian artery (Fig. 2). After infiltrating the adjacent skin and subcutaneous tissue, a 25-gauge 50-mm insulated block needle (UniPlex NanoLine, Pajunk®, Germany) was advanced along the long axis of the probe in plane with US beam guidance. When the brachial plexus bundle (Fig. 3) was reached, the nerve stimulator (Stimuplex® HNS 12, B/Braun, Germany) was turned on, starting from 1.0 mA and decreasing by 0.5 mA to elicit a muscle twitch. After injecting 1ml of 0.5% ropivacaine, the muscle twitch disappeared and local anesthetic spread at the time of injection was observed in real time. Nine ml of 0.5% ropivacaine was injected after a negative aspiration test.

The patient underwent a closed reduction and percutaneous pinning of the distal humerus. Maintenance of anesthesia was carried out with sevoflurane 1.5 vol% in 50% oxygen/air until the end of the surgery. His vital signs did not change and no opioid supplementation was administered during surgery. The child did not require rescue analgesia in the postoperative period and no adverse effects were noted.

An 11-year-old boy weighing 46 kg, ASA physical status I, required surgery for a fracture of the upper end of the left humerus. After a thorough discussion of the risks and benefits with the patient and parents, who then provided written, informed consent, a USG supraclavicular brachial plexus block was performed.

Immediately before placing the block, midazolam 2 mg and sufentanil 2.5 µg were administered intravenously for patient comfort. A portable system with a linear array 6-13 MHz transducer (SonoSite® M-turbo, Bothell, USA) was used for the USG supraclavicular brachial plexus block. The probe was placed in the coronal-oblique plane in the supraclavicular fossa and the puncture was IP from the lateral to medial. Neurostimulation was not used to confirm the correct position. The brachial plexus was identified as hypoechoic nodules surrounded by a hyper-reflective fascial sheath, superior and lateral to the subclavian artery (Fig. 4). After infiltrating the adjacent skin and subcutaneous tissue, a 22-gauge epidural needle (Tuohy Epidural Needle®, B/Braun, Germany) was advanced along the long axis of the probe in plane with the US beam. Upon reaching the brachial plexus bundle (Fig. 5), 1 ml of 0.5% ropivacaine was injected and the local anesthetic spread at the time of injection was observed in real time. Twenty four ml of 0.5% ropivacaine was injected after a negative aspiration test. Successful motor and sensory block of the upper limb occurred within 30 min of the injection.

The patient underwent a closed reduction and percutaneous pinning of the proximal humerus. Surgery proceeded uneventfully with no adverse effects noted.

A 12-year-old boy weighing 45 kg, ASA physical status I, was scheduled to undergo an open reduction and internal fixation of the radius and ulna fracture of the right forearm. After a thorough discussion of the risks and benefits with the patient and parents, who then provided written, informed consent, a USG supraclavicular brachial plexus block with perineural infusion was undertaken.

Immediately before placing the block, intravenous midazolam 2 mg and sufentanil 2.5 µg were administered. After sterile skin preparation and local anesthetic skin infiltration with 2% lidocaine, a 18 gauge Touhy-tip needle (Perican®, B/Braun, Germany) was guided IP using a linear array 5-10 MHz transducer (SonoSite® 180plus, Bothell, USA) to deposit 25 ml of 0.5% ropivacaine around the brachial plexus, which was cephalad and lateral to the subclavian artery (Fig. 6). Neurostimulation was not used to confirm the correct position. After injecting the local anesthetics, a flexible 20 gauge perineural catheter (Contiplex A®, B/Braun, Germany) was then inserted 2 cm past the tip of the needle lateral to the subclavian artery. The injection port was attached to the end of the catheter, and the catheter tip position was confirmed by injecting 1 ml of saline via the catheter under US visualization. The successful motor and sensory block of the upper limb occurred within 30 min of the injection.

The patient underwent an open reduction and internal fixation with a dynamic compression plate of the proximal ulna. The operation and recovery room stay were uneventful and without complications. The patient was pain free and comfortable. A 0.1% ropivacaine perineural infusion was initiated with a basal rate of 3 ml/h, a patient-controlled bolus dose of 2 ml, and a lockout interval of 20 min via a small, light, portable electronic infusion pump (Accumate® 1000, Wooyoung Medical, Korea).

The patient reported excellent postoperative analgesia without analgesic requirements during the infusion and no adverse events were encountered. The catheter was removed on the second postoperative day.

A 12-year-old girl weighing 47 kg, ASA physical status I, was scheduled to undergo an open reduction and internal fixation with a plate for a Monteggia fracture of the right forearm. After a thorough discussion of the risks and benefits with the patient and parents, who then provided written, informed consent, a USG supraclavicular brachial plexus block with perineural infusion was performed.

Immediately before block placement, midazolam 2 mg and sufentanil 2.5 µg were administered intravenously. After sterile skin preparation and local anesthetic skin infiltration with 2% lidocaine, a 18 gauge Touhy-tip needle (Perican®, B/Braun, Germany) was guided IP using a linear array 5-10 MHz transducer (SonoSite® 180plus, Bothell, USA) to deposit 25 ml of 0.5% ropivacaine around the brachial plexus, which was cephalad and lateral to the subclavian artery. Neurostimulation was not used to confirm the correct position. After injecting local anesthetics, a flexible 20 gauge perineural catheter (Contiplex A®, B/Braun, Germany) was then inserted 2 cm past the tip of the needle lateral to the subclavian artery. The injection port was attached to the end of the catheter, and the catheter tip position was confirmed by injecting 1 ml of saline through the catheter under US visualization. Successful motor and sensory block of the upper limb occurred within 30 min of the injection.

The patient underwent an open reduction and internal fixation of the proximal ulna with a dynamic compression plate. After surgery, the patient was transported to the recovery room. The patient was pain free and comfortable. A 0.1% ropivacaine perineural infusion was initiated with a basal rate of 3 ml/h, a patient-controlled bolus dose of 2 ml, and lockout interval of 20 min via a small, light, portable electronic infusion pump (Accumate® 1000, Wooyoung Medical, Korea).

The patient only experienced pain 12 h after the initial injection of local anesthesia. The pain was controlled using IM diclofenac 30 mg. On the second postoperative day, she complained of an insensate extremity, which resolved spontaneously after discontinuing the local anesthetic for 2 hours. After discontinuing the infusion, she complained of pain, and a decision was made to continue the infusion. She did not complain of any pain or insensate limbs. The catheter was removed on the third postoperative day.