Median and Ulnar Nerve Blocks


    Median and Ulnar Nerve Blocks

    Injuries to the hands are a frequent complaint in the emergency department. When the injury isn’t limited to a single digit, or involves larger areas of the hand such as a burn or deep laceration, a nerve block can be an effective option for general pain control as well as any procedures you may need to do. It also reduces or eliminates the need for opiates.

    As with most nerve blocks, you typically want to use lidocaine (with or without epi), bupivacaine, or a mix of the two. Lidocaine has a faster onset but only lasts ~60 minutes, while bupivacaine has a slower onset but provides 2-4 hours of relief. Mixing the two can give you the best of both worlds. Use a 25 or 27-gauge needle for injection, and be sure to clean the overlying skin.

    The median nerve provides sensory innervation to the palmar aspect of the thumb, index, middle, and half the ring fingers as well as the majority of the palm. This is the easiest procedure to do based on landmarks alone as it runs between flexor carpi radialis and palmaris longus tendon. However, ultrasound can increase your accuracy as the nerve is fairly superficial and you may go too deep. If going by landmarks, inject 3-5cc of anesthetic between the flexor carpi radialis and palmaris longus 2-3cm proximal to the wrist crease, at a depth of ~1cm.

    The ulnar nerve sensory distribution includes the dorsal AND palmar aspects of the lateral hand (ulnar half of the 4th and the entire 5th digit). It runs along the ulnar artery just deep to the flexor carpi ulnaris. You should approach the nerve laterally (as opposed to volarly as you may hit the ulnar artery), and inject 1-2cc just under the flexor carpi ulnaris. Then angle your needle deeper, towards the ulna, and inject 3-5cc of anesthetic as you withdraw.

    Here is a video of ultrasound-guided median and ulnar nerve blocks. Note that they go more proximally in the arm than you would going based off landmarks alone.

    Thanks to Judah for the inspiration for this pearl, and for letting me do an ultrasound-guided median nerve block on him.



    • Roberts and Hedges’ Clinical Procedures in Emergency Medicine
    • (written by our very own David Cisewski, Ahra Joh, and Stephen Alerhand!)


    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • To bicarb or not to bicarb

      When, if ever, should we be giving bicarbonate in patients with metabolic acidosis? A study published in The Lancet in July 2018 involved a multicentre RCT in 26 ICUs with 400 patients, called the BICAR-ICURead more

    • PTSD in EM Residents

      Winter is here. It’s colder. Sometimes we don’t see the sun for days. Let’s take a moment to think about some mental health issues. Published in Annals of Emergency Medicine in December 2017 was a piece byRead more

    • Foot vs Bus

      In a totally hypothetical situation, imagine a resident’s foot got run over by a bus and looked like this after arriving in your ED… What sort of things should you be concerned about in injuriesRead more

    • The Golden S Sign

      Shoutout to the awesome David Cisweski for following up this tidbit from conference and giving us this pearl. Remember in conference when Dr. Jacobi was going over chest X-rays, was talking about the Golden S sign, andRead more

    • SVT and Paranasal Etripamil

      Have you had one of those resus shifts where everyone and their mother seems to be in an arrhythmia? Have some of them been older patients with SVT that just make you a little antsyRead more

    • Air Pollution and Stroke?

      One growing global health issue is ambient air pollution. One of the leading risk factors for disease is fine particulate matter in outdoor air. The WHO states 1 in 8 deaths is due to airRead more

    • Nursemaid’s Elbow Reduction

      Radial head subluxation, more commonly known as nursemaid’s elbow, can be seen more frequently in the pediatric population. Imagine a parent quickly pulling a child’s arm (usually 1-4 years old) that was held in extensionRead more

    • Tis the season – for rhinosinusitis

      It’s an intake shift and yet another person comes in saying, “I feel congested doc. I need antibiotics for sinusitis.” A recent Cochrane review published in September 2018 that included 15 trials involving 3057 patientsRead more