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Background and Aims The potential block of the phrenic nerve whilst performing an interscalene plexus block can be devastating in certain patient groups. We present a report where close communication with surgeons and the patient as well as an unconventional approach can help in such cases.

Methods Consent from the (deceased) patients next of kin was obtained. A 72 – year old woman presented with a pathologic midhumeral fracture due to a metastasized lung cancer. The patients history included oxygen – dependent COPD with a 58 – PY – smoking habit. CT showed a large mass in the right lung, saturation was 85% with 2 l/min oxygen, Hb 86. Proximal intramedullary nailing was indicated due to fracture displacement. Given the risks of controlled ventilation on the one hand and diaphragm paralysis on the other hand we opted for a rather unconventional approach.

Results In order to provide good pain relieve for operation without compromising phrenic nerve function we identified the phrenic nerve, followed its couse along the anterior scalene muscle and opted for a low – volume – supraclavicular nerve block in combination with a suprascapular nerve block and local anesthesia. The patient received additional intravenous Midazolam. The operation was uneventful and the patient recovered well from the fracture.

Conclusions Our case report shows that it is possible to provide sufficient surgical analgesia without compromising respiratory function for humeral surgery by thoroughly considering anatomical aspects and by having an open dialogue with our orthopedic colleagues.