Most hand traumas and elective surgical disorders of the hand can be treated quickly, easily, inexpensively, and effectively in an outpatient clinic. Although many surgeons prefer general anesthesia, the senior author routinely uses local anesthesia without sedation almost exclusively for carpal and cubital tunnel release, fasciectomy, arthrodesis, arthroplasty, synovectomy, and trauma, including the repair of tendons, nerves, ligaments, fractures, and soft tissue defects. After completing more than 10,000 procedures, the authors have found great benefits through the use of local anesthesia, which are detailed in the article.
Key points
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Local anesthesia as a field block or regional nerve block is a simple and useful tool and an adjuvant in the management of hand surgery problems.
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Many patients can tolerate local anesthesia procedures in the hand with a tourniquet time of up to 30 minutes.
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A wide variety of hand surgery problems, both elective and traumatic, can be treated with local anesthesia without the need for any sedation and general anesthesia.
Introduction
Hand surgery is unique because it is a field whereby the OHIO principle can be easily applied: only handle it once. This is a simple principle that is applicable to many aspects of life, including hand surgery. A once-in-and-once-out approach is a simple way to treat most hand traumas in a weekly fracture clinic. It is easier for patients to be assessed and treated in one visit without undergoing the inconvenience of preoperative fasting, taking time from work, or rescheduling family commitments.
What proportion of our day is spent in bringing patients into procedure rooms, asking them when they last ate, whether they have allergies, and in moving to different rooms for terminal cleaning and changeover? Trainees and staff can help leverage our time. Perhaps we focus on how we can explain postoperative care, prescriptions, and follow-up visits during the course of operating under local anesthesia. The authors use 3 procedure rooms and a consultation room concurrently in a fully accredited private facility. This practice allows a surgeon to perform a high number of new consultations annually and operate on most of these individuals, often on the same day, which permits direct and internal marketing for a minimal external marketing budget. Most of the authors’ overhead expenses are spent on staff salaries to help ensure high-quality patient-centered care. A comprehensive electronic medical record system helps in scheduling, tracking outcomes, managing specimens, dictating consultation and operative reports, submitting billings, and communicating to other health care providers.
The World is Flat: A Brief History of the 21st Century by Thomas Friedman (2007) explains how and why the world has changed in the last 2 decades. The Internet permits almost anyone to research their diagnosis, treatment, and even their surgeon. Patients as consumers or customers are now more informed than ever before.
In a time of fiscal restraint in the health care profession, it behooves us all to provide timely and effective care in a cost-effective manner. Surgery of the hand under local anesthetics can not only avoid the adverse effects of general anesthesia and the hospital cost of both preoperative and postoperative care as well as the administration and paperwork but there is also great convenience for both the surgeon and patients. Many common hand surgical procedures can be performed under local anesthesia in a minor operative suite with minimal intervention and monitoring.
Simple, elective surgery is not likely to threaten a person’s life, but it is the general anesthetic that poses the greater overall health risk. Readers are directed to the article by Chung and Harris elsewhere in this issue. The avoidance of general anesthesia when reasonably possible may be, at times, uncomfortable for patients; however, the relative trade for a lower health risk is worthwhile if the patients’ health demands it. Present patients with all options.
Introduction
Hand surgery is unique because it is a field whereby the OHIO principle can be easily applied: only handle it once. This is a simple principle that is applicable to many aspects of life, including hand surgery. A once-in-and-once-out approach is a simple way to treat most hand traumas in a weekly fracture clinic. It is easier for patients to be assessed and treated in one visit without undergoing the inconvenience of preoperative fasting, taking time from work, or rescheduling family commitments.
What proportion of our day is spent in bringing patients into procedure rooms, asking them when they last ate, whether they have allergies, and in moving to different rooms for terminal cleaning and changeover? Trainees and staff can help leverage our time. Perhaps we focus on how we can explain postoperative care, prescriptions, and follow-up visits during the course of operating under local anesthesia. The authors use 3 procedure rooms and a consultation room concurrently in a fully accredited private facility. This practice allows a surgeon to perform a high number of new consultations annually and operate on most of these individuals, often on the same day, which permits direct and internal marketing for a minimal external marketing budget. Most of the authors’ overhead expenses are spent on staff salaries to help ensure high-quality patient-centered care. A comprehensive electronic medical record system helps in scheduling, tracking outcomes, managing specimens, dictating consultation and operative reports, submitting billings, and communicating to other health care providers.
The World is Flat: A Brief History of the 21st Century by Thomas Friedman (2007) explains how and why the world has changed in the last 2 decades. The Internet permits almost anyone to research their diagnosis, treatment, and even their surgeon. Patients as consumers or customers are now more informed than ever before.
In a time of fiscal restraint in the health care profession, it behooves us all to provide timely and effective care in a cost-effective manner. Surgery of the hand under local anesthetics can not only avoid the adverse effects of general anesthesia and the hospital cost of both preoperative and postoperative care as well as the administration and paperwork but there is also great convenience for both the surgeon and patients. Many common hand surgical procedures can be performed under local anesthesia in a minor operative suite with minimal intervention and monitoring.
Simple, elective surgery is not likely to threaten a person’s life, but it is the general anesthetic that poses the greater overall health risk. Readers are directed to the article by Chung and Harris elsewhere in this issue. The avoidance of general anesthesia when reasonably possible may be, at times, uncomfortable for patients; however, the relative trade for a lower health risk is worthwhile if the patients’ health demands it. Present patients with all options.
Local anesthetic in hand surgery
The use of a local anesthetic in hand surgery has recently increased, as indicated by increasing published reports in the literature. The advantages are its increased safety profile, ease of use, and effectiveness in providing painless anesthesia. Wide-awake surgery also allows surgeons to check their work, as in gapping in flexor tendon repairs. In addition, a recent study shows that patients preferred local anesthetic to intravenous regional anesthesia in a randomized controlled trial for carpal tunnel release because of better intraoperative and postoperative pain control.
An important consideration when using local anesthetic is hemostasis control. Although tourniquets can still be applied and used, local anesthetic with epinephrine has repeatedly been shown to be efficacious and safe. A prospective multicenter study following 3110 patients showed no complications of epinephrine (1:100,000 concentration or less) when used in finger and hand surgery. If a tourniquet is preferred, a randomized controlled study of forearm versus upper arm tourniquet showed that the former is better tolerated even with a mean time of 25 minutes. In addition, the use of topical or injectable anesthetic under the tourniquet can be used to reduce tourniquet-associated pain.
Digital blocks
Numerous techniques have been described for digital block. These techniques include transthecal versus 2 dorsal or web space injections.
Chiu originally described the transthecal technique in 1990. He injected 2 mL of lidocaine into the potential space of the flexor tendon sheath at the level of the palmar crease. Of the 420 patients, only 4 required supplemental local anesthetic infiltration; there were no observable complications. In 1991, Harbison described a variation of this technique whereby lidocaine was injected into the subcutaneous tissues of the proximal flexion crease of the target finger. A randomized control study comparing these two techniques showed that injection into the subcutaneous tissues was easier to administer and better tolerated by patients.
The 2-injection dorsal or web space injection was advocated to be less painful than the volar injections. The local anesthetic is injected into the web space on either side of the finger to be anesthetized ( Fig. 1 ). The question of whether it is less painful was recently contraindicated by a study showing that 27 volunteer patients preferred the single volar subcutaneous injection versus the 2-injection dorsal method.
Wrist block
There are variations of how the median, ulna, and radial nerves contribute to sensory innervation of the hand. A comprehensive wrist block must anesthetize all 3, including their cutaneous branches.
A study of 825 patients by Klezl and colleagues (2001) showed that partial wrist blocks led to more failures than complete wrist blocks, 18% in the former versus 2% in the latter. Knowing the anatomic landmarks of where these nerves are located is essential to providing a good block. In addition, a good technique includes aspirating before injecting, stopping if you feel resistance or patients complain of radiating pain, injecting the anesthetic slowly, and infiltrating the skin around the injection site ( Fig. 2 ).
Blockade of the median nerve is done by the injection of local anesthetic between the palmaris longus (PL) and the flexor carpi radialis (FCR) or ulnar to the FCR if the PL is absent. The nerve is deep to the fascia. For the palmar cutaneous branch, this branches from the radial side of the median nerve at an average of 4.9 cm from the wrist flexion crease range, with a range of 4.1 to 7.8 cm. In the same study, 3 variations of the palmar cutaneous branch of the ulna nerve were described in frequency: the classic palmar branch arising approximately 4.6 cm proximal to the pisiform (4 of 25 specimens), the nerve of Henle (14 of 25 specimens), and a transverse branch that originates distal to the proximal wrist flexion crease. A local anesthetic injection to block the ulnar nerve can be done by injecting deep and ulnar to the flexor carpi ulnaris (FCU) tendon. An additional injection to the subcutaneous tissue radial to the FCU should also be done to block the ulnar cutaneous branch to the palm. In a cadaveric study of 32 specimens, the dorsal branch of the ulnar nerve originated approximately 5.1 cm proximal to the ulnar styloid, crossing the subcutaneous border about 0.2 cm proximal to ulnar process. Therefore, infiltration of the subcutaneous tissues just proximal to the ulnar styloid process should provide anesthesia to the dorsal ulna aspect of the hand. A field block is usually recommended for the superficial branch of the radial nerve because of its variation in anatomy and multiple divisions into smaller cutaneous branches.
Field block
Infiltrative field block can be done using tumescent or a large amount of local anesthetic. This technique helps to spread the local anesthetic to as much tissues as possible and should be done by using diluted local anesthetic. Lalonde (2009) advises starting from proximal to distal, infiltrating the subcutaneous tissues and recommends waiting at least 15 minutes so the epinephrine can have its maximum effect.
The senior author routinely performs approximately 1000 local anesthetic blocks per year, with a combination of 9 mL of 1% lidocaine with epinephrine followed by 0.25% bupivacaine with epinephrine about 2 minutes later. Surgery is started within minutes after the second block, and it is very rare to have any difficulty with this method because the second injection is testing the field treated by the first block.
Fractures
Overview
The total annual incidence of hand fractures has been estimated to be about 36 per 10,000 per year. In the same study, metacarpals were the most affected, and there was an 8% incidence of multiple fractures in the hand. Operative management for unstable patterns may be necessary to obtain and maintain an acceptable reduction. A variety of anesthetic options are available, including local anesthesia. Most closed hand fractures can be very successfully treated without the need for open reduction. In the authors’ institute, they open less than 1% of all closed hand fractures.
Operative Technique
Local anesthesia can be sufficient to perform operative management of most metacarpal or phalangeal fractures. Adequate anesthesia is crucial to obtain the reduction because relaxation of deforming muscle forces is necessary. For middle and distal phalanx fractures, a digital block with epinephrine or digital tourniquet can be performed. For proximal phalanx and metacarpal fractures, a wrist or elbow block can be performed. Supplemental infiltrative local anesthetic and/or sedation can also be used to ensure adequate anesthesia.
Obtaining anatomic reduction can be obtained by several methods. Closed reduction maneuvers can be performed to reduce shaft or neck fractures. Other adjuncts to obtaining reduction include the manipulation of the fragments using reduction clamps, or Kirschner (K) wires as joysticks.
Metacarpal Fractures
Certain indications for fixation of metacarpal fractures include intraarticular incongruity of more than 1 mm, shortening of more than 3 mm because this can create an extensor lag, scissoring as shown on clinical examination indicating malrotation, any subluxation at the carpal metacarpal (CMC) joint, and an unacceptable angulation of the fracture. For metacarpal neck and shaft fractures, the intrinsic muscles cause an apex dorsal angulation. The Jahss reduction maneuver was first described in 1938 and involves flexion of the metacarpophalangeal joint (MCPJ) and proximal interphalangeal joint (PIPJ) while a dorsally directed force is applied to reduce the metacarpal neck fracture. Traction with a dorsal-to-volar directed force can also be used to correct CMC dislocations and shaft fractures. Often, the manipulation of intraarticular fractures can be successfully done with a K-wire joystick to help anatomically reduce the fragment under fluoroscopic guidance. Metacarpal head fractures can be fixed with K-wire or screw fixation. A variety of options exists for neck and shaft fractures. Closed reduction with the Jahss maneuver allows the reduction and correction of rotational deformity while percutaneous pinning can be accomplished. K-wire fixation to the adjacent metacarpals requires at least one, preferably 2, pins in each of the fragments. Cross K-wire fixation can also be done, ensuring that the pins do not cross at the fracture site in order to avoid rotational instability. Intramedullary (IM) nailing with IM rods or multiple K wires can be accomplished with minimal soft tissue damage. However, intramedullary K-wire fixation has described complications, including pin tract infections, extensor tendon ruptures, shortening, and malrotation. CMC dislocations or subluxations may require transarticular pinning to maintain the reduction. Open reduction internal fixation (ORIF) can be done with plate and screws or with 2 screws alone in oblique fractures whereby the length is twice the diameter of the metacarpal shaft. Fixation with plates and screws offers the most rigid construct. A recent study favored bicortical screw fixation showing that they were significantly stronger than unicortical screws in a cyclical loading biomechanical study.
Fractures at the thumb metacarpal and small metacarpal base have distinct patterns. Bennett fractures are simple intraarticular fractures whereby the volar ulnar corner fragment is held in the joint via the anterior oblique ligament while the rest of the metacarpal fragment is pulled proximally and dorsal via the abductor pollicis longus and adducts because of the adductor pollicis muscle. A closed reduction maneuver involves traction, abduction, and pronation with a simultaneous volar-directed force on the fragment. The fragments are then held with K-wire fixation inserted in a percutaneous manner. The K wires can be transfixed into the second metacarpal and/or in a transarticular manner into the trapezium. Alternatively, ORIF can also be performed. Reverse Bennett fractures are also prone to subluxation because of the deforming force of the extensor carpi ulnaris. Closed reduction is, thus, achieved by traction, ulnar deviation, and radially directed pressure on the subluxed metacarpal fragment.
Proximal and Middle Phalanx
Proximal and middle phalangeal fractures can be classified according to their anatomic location: condylar (unilateral or bilateral), neck, shaft, or base fractures. Displaced condylar fractures can often be manipulated with K wires and fixed with the K wires or with percutaneous screws. Should the condylar fracture be very comminuted, one can contemplate arthrodesis of the joint. Shaft and neck fractures can be described according to the fracture pattern: transverse, oblique, spiral, or comminuted. Similar to the metacarpal fractures, indications to operate include marked angulation or displacement at the fractures site, any clinical malrotation, articular incongruity, and marked comminution leading to shortening. A variety of treatment options are available and include closed reduction and percutaneous pinning (CRPP), intramedullary nailing devices, ORIF with screw or plates, and external fixator devices.
Fractures of the base can be volar, dorsal, or involve the entire articular surface (pilon fractures). Dorsal base fractures of the middle phalanx compromise the integrity of the central slip and can lead to instability. Operative fixation can be accomplished through screws, hook plate devices, K wires, and intraosseous (IO) suture fixation. Supplemental transarticular pinning is also usually performed to help maintain joint reduction. Because of the more distal flexor digitorum superficialis (FDS) insertion on the middle phalanx, volar base fractures can lead to dislocation because of the loss of the bony buttress and dissociation of the dorsal fragment from the volar plate/collateral complex. Operative fixation options include dorsal blocking pin, transarticular pinning, volar plate arthroplasty, hemihamatearthroplasty, articulated external fixator devices, CRPP, or ORIF.
Intraarticular PIPJ fractures can be a very challenging aspect of hand surgery. Although many of the aforementioned techniques have been used, closed reduction and dynamic traction have recently been described with comparable outcomes ( Fig. 3 ). Final active and passive range of motion was similar to other studies, and there is no need for an operating room or even a K-wire insertion and subsequent removal ( Fig. 4 ).
Distal Phalanx Fractures
Distal phalanx fractures can be classified according to their anatomic location, such as tuft, shaft, or intraarticular, and whether they are simple or comminuted.
Tuft fractures may or may not result in nail bed injuries. Treatment of nail bed injuries usually involves removing the nail and suturing any nail bed laceration with fine absorbable sutures under loupe magnification and administration of antibiotics and tetanus immunization, if necessary. One can also drill a hole into the nail plate to decompress the hematoma. One study of open distal phalanx fractures managed operatively with and without antibiotics showed an infection rate of 3% and 30%, respectively. These injuries can be splinted up to, but not including, the PIPJ to avoid stiffness at that joint for 2 to 3 weeks. The authors have very rarely ever taken these injuries to a main operating room, and their infection rate is well less than 2% without the use of antibiotics in most cases.
Shaft fractures can be classified according to the fracture pattern: longitudinal, transverse, or comminuted. If the fracture pattern is stable and undisplaced, a mallet type of splint can be used. For unstable fractures, antegrade cross K-wire pinning, retrograde transarticular pinning through the distal interphalangeal joint (DIPJ), or screw fixation can all be considered ( Figs. 5–8 ).
