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Technique Forearm (Ultrasound, preferred location compared with wrist) Images Ultrasound-Guidance High frequency linear probe in short axis Use standard Ultrasound-guided Regional Anesthesia technique Linear probe is transverse to mid-Forearm Median Nerve, Ulnar artery and Ulnar Nerve lie in a plane between the superficial and deep flexors Ultrasound at wrist can easily identify ulnar artery and Ulnar Nerve Slide probe up Forearm, proximally, until Ulnar Nerve and ulnar artery separate Needle Insertion Both Ulnar Nerve and Median Nerve can be blocked in same Ultrasound view, with needle redirection Approaching from ulnar aspect, rounded Forearm edge allows needle to be perpendicular to probe Technique Images Position Patient seated Forearm supinated (palm up) Ultrasound Probe Position Transverse to Forearm, over the wrist crease See Landmarks above Injection Insert needle at proximal palmar wrist crease Direct needle from distal to proximal at 30 degree angle, perpendicular to probe (out-of-plane) Technique Landmark Images Position Patient seated Forearm supinated (palm up) Injection site 1: Palmar branch of the Ulnar Nerve (typical insertion site) Direct needle from ulnar aspect of wrist towards radial wrist at 45 degree angle Insert at proximal wrist crease (or 1-2 cm proximal), between flexor carpi ulnaris tendon and ulnar artery Inject under flexor carpi ulnaris tendon Advance needle deeper towards ulna and inject additional 3 ml of Anesthetic while withdrawing needle Injection site 2: Dorsal branch of the Ulnar Nerve Distal aspect of ulnar styloid process (dorsum) Infiltrate 3-4 ml subcutaneously Warning: Distal Paresthesias with needle with injection Indicates needle is at Ulnar Nerve Do not inject here
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