Author(s): ,
Marques da Silva, R.
Centro Hospitalar Vila Nova de Gaia Espinho, Anaesthesiology, Vila Nova de Gaia, Portugal
Alves, S.*
Hospital de Braga, Anaesthesiology, Braga, Portugal
Vieira, A.
Hospital de Braga, Anaesthesiology, Braga, Portugal
Fragoso, P.
Hospital de Braga, Anaesthesiology, Braga, Portugal
ESRA Academy. Alves S. Sep 13, 2017; 190919; 331 Topic: Upper Limb Blocks - Brachial Plexus Block
Sara Alves
Sara Alves

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Background and Aims:

Interscalene brachial plexus blocks are an important part of the peri-operative treatment in shoulder surgery.
Madelung's Disease is characterized by benign, non-encapsulated accumulations of fat in a symmetrical manner, primarily in the neck and shoulder regions. Patients present a difficult airway and abnormal anatomy that may be challenging for loco-regional anaesthesia, specifically for interscalene brachial plexus blocks.


We report a case of a 57-year-old male, with dilated cardiomyopathy, left ventricular systolic dysfunction, chronic obstructive pulmonary disease and Madelung’s Disease, admitted for surgical treatment of a proximal humerus fracture.
Preanaesthetic evaluation revealed a IV Mallampati score, restricted neck mobility, and multiple fat accumulations in the upper trunk and neck.


Patient was monitored according to ASA standards, depth of anesthesia and invasive blood pressure monitoring. An interscalene brachial plexus block was performed using 0.5% ropivacaine (15mL).

An awake fiberoptic intubation was done and a total intravenous anaesthesia was performed with propofol-remifentanil and neuromuscular blockade with rocuronium. Intravenous paracetamol 1g was administered. Reversal of neuromuscular blockade with sugammadex was done at the end of the procedure. Surgery and immediate postoperative period was uneventful. Patient was discharged from hospital 48 hours after the procedure.


Anatomical changes characteristic of Madelung's Disease make it impossible to identify anatomical landmarks, increasing the risk of technical failure, vascular puncture or nerve damage. In this case, only the use of an in-plane ultrasound guided technique allowed successful execution of the interscalene plexus block.
The patient was deemed as having a difficult airway, and an awake fiberoptic intubation was planned and used successfully.

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