Surgical anaesthesia of the lower arm, from the elbow to the hand, may be readily achieved by local anaesthetic blockade of the bundle of nerves passing from the spinal cord through to the top of the arm (the brachial plexus) (Cousins 1998). This avoids the need for a general anaesthetic and its accompanying risks (airway injuries, postoperative nausea and vomiting, postoperative drowsiness, etc). Control of postoperative pain is also excellent, as the arm remains numb for several hours following blockade of the brachial plexus. The numbness gradually resolves, allowing ample time for the introduction of oral analgesics to control pain. Commonly used approaches include the interscalene block, the supraclavicular block and the axillary block

The brachial plexus can be approached from various points with a needle, and located using surface landmarks and, sometimes, stimulation with a low‐amplitude current. Such stimulation produces tingling, movement, or both, in the part of the arm supplied by any nerve approached closely by the tip of the needle. Commonly used approaches include the interscalene block (where the needle passes between the scalene muscles after piercing the skin in the front of the neck); the supraclavicular block (where the skin is pierced lower and more laterally above the collar bone) and the axillary block (where the skin is pierced in the armpit). More recently, another approach, the infraclavicular block (where the skin is pierced in the area below the collarbone), has enjoyed a resurgence of interest.

Bazy (Bazy 1917) introduced the infraclavicular approach in 1917 as an alternative to the axillary and supraclavicular approaches. However the method failed to gain popularity and remained largely forgotten for several decades. Spiegel (Spiegel 1967) described an infraclavicular technique in 1967, but it was not until 1973, when Raj et al (Raj 1973) described their infraclavicular block, that interest in this approach was re‐ignited. Despite good results it again failed to gain widespread acceptance. This may have been due to a perceived lack of significant advantages over the axillary block, concern over the risk of pneumothorax (a punctured lung), as well as the requirement for a nerve stimulator (which was not widely available at the time). Subsequently, Sims (Sims 1977) published a modification to the Raj approach in 1977, and Whiffler (Whiffler 1981) described the first coracoid block in 1981. However, it was not until Kilka and colleagues (Kilka 1995) described their vertical infraclavicular plexus block in 1995 that interest in the infraclavicular approach really blossomed. Since then, several other variants of the infraclavicular block have been described and adopted into clinical practice (Borgeat 2001; Jandard 2002; Kapral 1999; Minville 2004; Salazar 1999; Wilson 1998).

The infraclavicular region can be visualized as a pyramidal space, containing the brachial plexus, the subclavian‐axillary artery and vein, lymph nodes and loose fatty tissue. The apex is a triangular surface formed by the confluence of the clavicle, scapula and first rib; the base is the skin and subcutaneous tissue of the armpit. The posterior wall is formed by the scapula and its associated muscles; the anterior wall by the pectoralis major and minor, together with their investing fasciae. The humerus, and the converging muscles and tendons of the anterior and posterior walls that insert into it, constitute the lateral wall. The bony thoracic cage, with its overlying layer of serratus anterior muscle and fascia, forms the medial wall. At the level of the infraclavicular space, the brachial plexus is organized as three cords (lateral, medial and posterior) surrounding the axillary artery. None of the major terminal branches arise at this level.

The touted advantages of the infraclavicular approach are as follows. Firstly, it provides comprehensive anaesthesia of the upper limb, equalled only by the supraclavicular approach. The axillary approach often fails to block the axillary nerve and musculocutaneous nerves (which branch off at a higher level), whilst the interscalene and supraclavicular approaches often may fail to provide anaesthesia in the distribution of the ulnar nerve (Cousins 1998). Secondly, unlike the interscalene and supraclavicular approaches, the risk of inadvertent lung or pleural puncture is minimal (Cousins 1998). Thirdly, by piercing the skin below the collarbone, injury to the neurovascular structures in the neck are avoided (unlike the interscalene approach). Finally, it is an ideal site for long‐term brachial plexus blockade. The bulk of the pectoralis muscle firmly anchors the catheter, arm movement is not impaired, and hygiene is easily maintained (Brown 1993).

Given these advantages, the infraclavicular block would appear to be the regional anaesthetic technique of choice for surgery of the lower arm. Whether or not it is indeed a more effective and safer technique for brachial plexus blockade in clinical practice remains to be established.