Regional Anesthetic Management

of Clavicular and Rib Fractures in

an Elderly Patient with Continuous

Erector Spinae Plane Block

PRESENTER:

Nicholas Mangano, MD

BACKGROUND: Rib fractures, often

accompanied by pleuritic pain, can reduce a

patient's inspiratory effort, leading to atelectasis

and an increased risk of pneumonia, especially in

elderly and immobile populations.

CASE

• Patient: An 80-year-old woman with multiple

sclerosis and multiple falls, presenting with left

clavicle fracture and left 2nd, 3rd, and 4th rib

fractures.

• Admission: The patient was deemed not to

require inpatient surgical repair and was

admitted to the surgical ICU due to concern for

developing respiratory compromise.

• Treatment: Left erector spinae plane (ESP)

block at the level of T3 with 20mL of 0.25%

ropivacaine for pain relief, followed by a

perineural catheter that infused 0.2%

ropivacaine at 7mL/hr.

• Outcome: Patient had immediate and near 

complete pain relief, allowing adequate

respiratory function.

• Discharge: Patient discharged to rehabilitation

facility two days after the block placement.

The ESP block shows

promise for treating

clavicle fracture pain,

minimizing risks of

decreased respiratory

effort while accelerating

recovery.

ESP

Ventral

ramus Dorsal

ramus

Discussion

• ESP Block: Injection of local anesthetic

in the fascial plane between the erector

spinae and paravertebral space to inhibit

nociceptive neurotransmission from the

dorsal and ventral rami of local spinal

nerves.

• ESP Block Applications: Used for pain

relief in various procedures, including rib

fractures, thoracotomies, percutaneous

nephrolithotomies, ventral hernia

repairs, and lumbar fusions.

• ESP Block for Clavicle Fracture: The

spread of the anesthetic across 3-4

levels cranially (and caudally) during

both initial injection and continuous

delivery is hypothesized to enable

blockade of the high thoracic and

cervical spinal nerves that supply the

clavicle and neighboring tissue.

Non-Cognitive Predictors of Student Success:

A Predictive Validity Comparison Between Domestic and International Students

• In this case, injection at T3 immediately

relieved the patient’s pain at the ribs and

the clavicle, enabling expedient

discharge from the hospital without the

development of respiratory compromise.

References

• References available on request,

correspondence to

Nicholas.Mangano@stonybrook.edu

Nicholas Mangano, MD, Nicholas

Bitonti, BS, Amruta Desai, DO

Department of Anesthesiology

Stony Brook University Hospital