Anterior cutaneous nerve block for analgesia in anterior chest trauma: is the parasternal approach necessary?

Abstract

In recent years, several techniques of regional anesthesia have been proposed to provide analgesia to the anterior thoracic cage; notably, most of these techniques require a parasternal approach. However, in this context, the potential role of a more common and well-established technique, namely the modified pectoral nerve block (known as PECS II block), has been poorly investigated. Here, we describe a case involving a patient with bilateral anterolateral multiple rib fractures associated with sternum fracture, who was successfully treated using bilateral PECS II blocks. Our experience indicates that the PECS II block can provide excellent analgesia in cases involving anterior rib and sternum fractures. Because it is easier to perform and may be safer than other parasternal techniques, the PECS II block should be considered when providing analgesia for traumatic injuries of the anterior thorax.

Keywords: Anesthesia and analgesia; Nerve block; Rib fractures; Sternum.

Fig. 1.

Three-dimensional reconstruction of the patient’s thoracic cage, showing sternal and rib fractures (some fractures are indicated by arrows). S, superior; R, right; I, inferior; L, left.

Fig. 2.

Images show the correct positioning of the linear probe, which should be placed on the chest immediately below the lateral one-third of the clavicle (A). At this location, the anatomical landmarks can be easily identified: the pectoralis major (PM), pectoralis minor (Pm), and serratus anterior muscle (Sm), as well as the third and fourth ribs (R3, R4) (B). The needle should be inserted using the in-plane approach, and the anesthetic should be injected both in the fascial plane between PM/Pm (PECS I) and in the fascial plane between Pm/Sm (PECS II). The procedure should be performed under sterile conditions. Pictures were taken from a healthy volunteer who provided written consent for publication.