Wide Awake Hand Surgery

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6JNM-UE82-3884-64DY

Wid e Aw ake
H an d Su r g er y

(Trang không có chữ)

Ed it ed by
D o n al d H . Lal o n d e, H o n s BSc , MD , MSc , FRCSC
Pr o f es s o r , D ivisio n o f Pl as t ic
an d Rec o n s t r u c t ive Su r g er y, D epar t men t
o f Su r g er y, D al h o u sie Un iver sit y,
Sain t Jo h n , N ew Br u n s w ic k, Can ad a
Wid e Aw ake
H an d Su r g er y

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eISBN 978-1-62623-750-6

v
Co n t r i b u t o r s
Julie E. Adams, MD
Associate Pro essor o Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
Peter C. Amadio, MD
Lloyd A. and Barbara A. Amundson Pro essor o Orthopedic Surgery, Mayo Clinic,
Rochester, Minnesota
Mark E. Baratz, MD
Clinical Pro essor and Vice Chairman, Department o Orthopaedics, University o
Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Geoff Cook, MD, FRCSC
Assistant Pro essor, Division o Plastic and Reconstructive Surgery, Department o
Surgery, Dalhousie University, Saint John, New Brunswick, Canada
Günter Germann, MD, PhD
Pro essor o Plastic Surgery–Hand Surgery, University o Heidelberg; Founder and
Medical Director, Ethianum Clinic or Plastic, Reconstructive and Aesthetic Surgery,
Heidelberg, Baden-Württemberg, Germany
Andrew W. Gurman, MD
Altoona Hand and Wrist Surgery, Altoona, Pennsylvania
Elisabet Hagert, MD, PhD
Associate Pro essor, Department o Clinical Science and Education, Karolinska
Institutet; Chie o Hand Surgery, Hand and Foot Surgery Center, Stockholm, Sweden
Amanda Higgins, BSc, OT
Rothesay, New Brunswick, Canada
Nikolas Alan Jagodzinski, MBChB, FHEM, FRCS (Tr & Orth)
Department o Orthoplastics Hand Surgery, Ox ord University Hospitals NHS Trust,
Ox ord, United Kingdom
Susan Kean, PT, CHT
Rothesay, New Brunswick, Canada
Carolyn L. Kerrigan, MD, MHCDS
Pro essor, Department o Surgery, Dartmouth-Hitchcock Medical Center, Lebanon,
New Hampshire
Donald H. Lalonde, HonsBSc, MD, MSc, FRCSC
Pro essor, Division o Plastic and Reconstructive Surgery, Department o Surgery,
Dalhousie University, Saint John, New Brunswick, Canada

vi
Co n t r ibu t o r s
Duncan McGrouther, MD
Senior Consultant Hand Surgeon, Department o Hand Surgery, Singapore General
Hospital, Singapore
Michael W. Neumeister, MD, FRCSC, FACS
Pro essor and Chairman, Department o Surgery, Southern Illinois University o
Medicine, Spring eld, Illinois
Alistair Phillips, MD
Department o Trauma and Orthopaedic Surgery, University Hospital Southampton
NHS Foundation Trust, Southampton, Hampshire, United Kingdom
Michael Sauerbier, MD, PhD
Pro essor, Department o Plastic, Hand and Reconstructive Surgery, BG Trauma Center
Frank ort am Main, Academic Hospital o Goethe University, Frank urt am Main,
Germany
Robert M. Szabo, MD, MPH
Pro essor o Orthopaedics and Plastic Surgery; Chie o Hand, Microvascular and
Upper Extremity Surgery, Department o Orthopaedics, University o Cali ornia, Davis,
Sacramento, Cali ornia
Jin Bo Tang, MD
Pro essor and Chair, Department o Hand Surgery, A liated Hospital o Nantong
University, Nantong, Jiangsu, China
Robert E. Van Demark, Jr., MD, FACS
Section Head and Clinical Pro essor, Department o Orthopedic Surgery, San ord
School o Medicine, The University o South Dakota, Vermillion, South Dakota
Jason Wong, MBChB, FHEA, PhD, FRCS(Plast)
Honorary Senior Clinical Lecturer and Consultant in Plastic Surgery, University Hospital
o South Manchester, Manchester, United Kingdom
Shu Guo Xing, MD
Attending Surgeon, Department o Hand Surgery, A liated Hospital o Nantong
University, Nantong, Jiangsu, China
Jeffrey Yao, MD
Associate Pro essor, Department o Orthopaedic Surgery, Stan ord University Medical
Center, Palo Alto, Cali ornia

vii
P r e f a c e
It has been my great privilege to share in the development o this exciting new way
o per orming hand surgery with many o my colleagues in Canada and around the
world. It is an even greater thrill to be able to convey the elements o this technique
to the rest o the world’s hand surgeons with this f rst “recipe cookbook” on How To
Do It.
The goal o this book is that any hand surgeon can pick it up and be able to per orm
most operations in hand surgery with the wide awake approach in very little time
and with very little patient discom ort. To accompany the brie bullet-style text, there
are more than 150 short instructional video clips, and the whole package is also avail-
able as an e-book or use on the go.
All author royalties rom the sale o this book will go to the Lean and Green project
o the American Association or Hand Surgery, which promotes less wasted cost and
garbage production in hand surgery.
Donald H. Lalonde
dlalonde@drlalonde.ca

a Ck n o w l e d g m e n t s
I owe the greatest debt o gratitude to my wi e, Jan. Her never-ending support and
encouragement has made this book possible, with all the research that went into the
work behind it.
I also want to thank the many hand surgeons, therapists, and patients in Saint John,
New Brunswick, Canada, and the rest o the world who contributed their thoughts
and experience into the development o this technique.
viii

ix
c o n t e n t s
PART I ATLAS OF TUMESCEN T LOCAL AN ESTH ESIA
WITH FOREARM, WRIST, H AN D , AN D FIN GER
IN JECTION S
1 Atlas of Images of Local Anesthetic Diffusion Anatomy 3
Donald H. Lalonde
PART II GEN ERAL PRIN CIPLES OF WID E AWAKE
H AN D SURGERY
2 What Is Wide Awake Hand Surgery? 17
Alistair Phillips, Nik Jagodzinski, Donald H. Lalonde
Video Clips 2-1, 2-2
3 Safe Epinephrine in the Finger Means No Tourniquet 23
Donald H. Lalonde
Video Clips 3-1, 3-2
4 Tumescent Local Anesthesia 29
Donald H. Lalonde, Alistair Phillips, Duncan McGrouther
Video Clip 4-1
5 How to Inject Local Anesthetic With Minimal Pain 37
Donald H. Lalonde, Nik Jagodzinski, Alistair Phillips
Video Clips 5-1, 5-2, 5-3, 5-4, 5-5, 5-6
6 Dealing With Systemic Adverse Reactions to Lidocaine
and Epinephrine 49
Donald H. Lalonde
Video Clips 6-1, 6-2

Co n t en t s
x
7 Tips on Talking to Your Patients About WALANT 55
Nik Jagodzinski, Alistair Phillips, Donald H. Lalonde
Video Clips 7-1, 7-2, 7-3
8 Talking With Patients During Surgery Saves Time 59
Donald H. Lalonde, Duncan McGrouther
Video Clips 8-1, 8-2, 8-3, 8-4, 8-5
9 WALANT Hand Surgery in In ants and Children 65
Donald H. Lalonde
Video Clips 9-1, 9-2, 9-3, 9-4
10 Field Sterility or Simple Cases Makes Sense 69
Donald H. Lalonde
Video Clip 10-1
11 Revenues Increase and Costs Decrease With WALANT 75
Donald H. Lalonde
12 The “Buy-In”: Administration, Anesthesiology, Nursing,
and Payers 79
Julie E. Adam s, Michael W. Neum eister, Robert E. Van Dem ark, Jr.,
Carolyn L. Kerrigan, Peter C. Am adio, Donald H. Lalonde
Video Clip 12-1
13 Per orming Your First Cases With WALANT 99
Andrew W. Gurm an, Robert E. Van Dem ark, Jr., Günter Germ ann,
Jason Wong, Donald H. Lalonde
14 Scheduling Fi teen or More Hand Surgery Cases per Day 107
Donald H. Lalonde
Video Clip 14-1
15 Integrating Hand Therapists Into WALANT 111
Susan Kean, Am anda Higgins, Donald H. Lalonde
Video Clips 15-1, 15-2, 15-3, 15-4, 15-5, 15-6, 15-7, 15-8

Co n t en t s
xi
16 Minor Procedure Room Setup 117
Donald H. Lalonde, Geo Cook
Video Clips 16-1, 16-2, 16-3
PART III SPECIFIC D ETAILS OF H OW TO PERFORM
WID E AWAKE H AN D SURGERY FOR COMMON
OPERATION S
Se c t io n A Am pu t At io n
17 Finger and Ray Amputation 125
Donald H. Lalonde
Video Clips 17-1, 17-2
Se c t io n B n e r v e De c o m pr e SSio n
18 Carpal Tunnel Decompression o the Median Nerve 129
Carolyn L. Kerrigan, Donald H. Lalonde, Shu Guo Xing, Jin Bo Tang
Video Clips 18-1, 18-2, 18-3, 18-4, 18-5, 18-6, 18-7, 18-8, 18-9, 18-10
19 Cubital Tunnel Decompression o the Ulnar Nerve 137
Donald H. Lalonde, Alistair Phillips
Video Clips 19-1, 19-2, 19-3, 19-4, 19-5, 19-6, 19-7
20 Lacertus Syndrome: Median Nerve Release at the Elbow 141
Elisabet Hagert, Donald H. Lalonde
Video Clips 20-1, 20-2, 20-3, 20-4, 20-5
Se c t io n c t e n Do n De c o m pr e SSio n
21 Trigger Finger 145
Donald H. Lalonde
Video Clips 21-1, 21-2, 21-3, 21-4
22 De Quervain Release 149
Donald H. Lalonde, Alistair Phillips
Video Clip 22-1

Co n t en t s
xii
Se c t io n D Du pu y t r e n ’S c o n t r Ac t u r e An D So f t
t iSSu e e x c iSio n
23 Dupuytren’s Contracture 151
Duncan McGrouther, Jason Wong, Donald H. Lalonde
Video Clips 23-1, 23-2
24 Flexor Sheath Ganglion 155
Donald H. Lalonde
25 Small So t Tissue Operations 157
Donald H. Lalonde, Jason W ong, Shu Guo Xing, Jin Bo Tang
Video Clips 25-1, 25-2
Se c t io n e Ar t h r it iS Su r g e r y
26 Arthroplasty o the Proximal Interphalangeal Joint 161
Donald H. Lalonde
Video Clip 26-1
27 Trapeziectomy With or Without Ligament Reconstruction
or Thumb Basal Joint Arthritis 165
Donald H. Lalonde, Peter C. Am adio, Geo Cook
Video Clips 27-1, 27-2, 27-3, 27-4, 27-5, 27-6, 27-7, 27-8
28 Thumb Metacarpophalangeal Joint Fusion and Ulnar
Collateral Ligament Repair 171
Donald H. Lalonde
Video Clips 28-1, 28-2, 28-3
29 Proximal Interphalangeal Joint Fusion 175
Donald H. Lalonde
Se c t io n f Wr iSt Su r g e r y
30 Wrist Arthroscopy 179
Elisabet Hagert, Donald H. Lalonde
Video Clip 30-1

Co n t en t s
xiii
31 Open Triangular Fibrocartilage Complex Repair 183
Elisabet Hagert, Donald H. Lalonde
Video Clip 31-1
Se c t io n g LAc e r At e D t e n Do n S An D t e n o Ly SiS
32 Flexor Tendon Repair o the Finger 187
Jin Bo Tang, Shu Guo Xing, Jason Wong, Je rey Yao, Donald H. Lalonde
Video Clips 32-1, 32-2, 32-3, 32-4, 32-5, 32-6, 32-7, 32-8, 32-9, 32-10,
32-11, 32-12, 32-13, 32-14, 32-15, 32-16, 32-17, 32-18
33 Flexor Tendon Repair o the Hand 199
Donald H. Lalonde
34 Flexor Tendon Repair o the Forearm 205
Donald H. Lalonde
Video Clip 34-1
35 Extensor Tendon Repair o the Finger 209
Donald H. Lalonde
Video Clips 35-1, 35-2, 35-3, 35-4, 35-5
36 Extensor Tendon Repair o the Hand 213
Donald H. Lalonde, Geo Cook
Video Clips 36-1, 36-2
37 Extensor Tendon Repair o the Forearm 217
Donald H. Lalonde
Video Clip 37-1
38 Tenolysis 221
Jason W ong, Michael Sauerbier, Peter C. Am adio, Donald H. Lalonde
Video Clips 38-1, 38-2, 38-3, 38-4, 38-5

Co n t en t s
xiv
Se c t io n h t e n Do n t r An Sf e r S
39 Tendon Trans ers 227
Donald H. Lalonde, Robert M. Szabo, Mark E. Baratz
Video Clips 39-1, 39-2, 39-3, 39-4, 39-5, 39-6, 39-7, 39-8
Se c t io n i LAc e r At e D n e r v e S
40 Lacerated Nerves 233
Donald H. Lalonde
Video Clip 40-1
Se c t io n J f r Ac t u r e S
41 Finger Fractures 237
Donald H. Lalonde
Video Clips 41-1, 41-2, 41-3, 41-4, 41-5, 41-6, 41-7, 41-8, 41-9, 41-10
42 Reduction and Internal Fixation o Metacarpal Fractures 243
Shu Guo Xing, Jin Bo Tang, Donald H. Lalonde
Video Clips 42-1, 42-2, 42-3, 42-4, 42-5, 42-6, 42-7, 42-8
PART IV COMPLEX RECON STRUCTION S
43 Complex Reconstructions in Hand Surgery 249
Donald H. Lalonde, Jason W ong, Alistair Phillips, Nik Jagodzinski
Video Clips 43-1, 43-2, 43-3, 43-4, 43-5, 43-6, 43-7, 43-8, 43-9, 43-10,
43-11

Index 253

xv
Vi d e o Co n t e n t s
PART II GEN ERAL PRIN CIPLES OF WID E AWAKE
H AN D SURGERY
2 What Is Wide Awake Hand Surgery?
Alistair Phillips, Nik Jagodzinski, Donald H. Lalonde
Clip 2-1 Introduction to wide awake hand surgery.
Clip 2-2 Washing a contaminated hand in a wide awake patient in the
emergency department.
3 Sa e Epinephrine in the Finger Means No Tourniquet
Donald H. Lalonde
Clip 3-1 History o the rise and all o the epinephrine danger myth.
Clip 3-2 How to reverse epinephrine vasoconstriction with phentolamine
injection in the nger.
4 Tumescent Local Anesthesia
Donald H. Lalonde, Alistair Phillips, Duncan McGrouther
Clip 4-1 Principles o tumescent local anesthesia.
5 How to Inject Local Anesthetic With Minimal Pain
Donald H. Lalonde, Nik Jagodzinski, Alistair Phillips
Clip 5-1 How to inject local anesthetic with minimal pain.
Clip 5-2 Patient’s pain impressions a ter a “hole-in-one” local anesthetic
injection or carpal tunnel surgery.
Clip 5-3 How and why to bu er lidocaine with epinephrine.
Clip 5-4 Cannula injection o tumescent local anesthetic or synovectomy
and tendon trans er.
Clip 5-5 How to per orm a SIMPLE block.
Clip 5-6 A two dorsal injection block hurts more than a SIMPLE block.
6 Dealing With Systemic Adverse Reactions to Lidocaine
and Epinephrine
Donald H. Lalonde
Clip 6-1 Lowered epinephrine concentration or cardiac issues.
Clip 6-2 Managing the vasovagal ainting attack.

xvi
Vid eo Co n t en t s
7 Tips on Talking to Your Patients About WALANT
Nik Jagodzinski, Alistair Phillips, Donald H. Lalonde
Clip 7-1 Explaining WALANT to a patient.
Clip 7-2 When patients are unsure about remaining awake.
Clip 7-3 Patient impression o pain o a local anesthetic needle versus
an intravenous needle.
8 Talking With Patients During Surgery Saves Time
Donald H. Lalonde, Duncan McGrouther
Clip 8-1 Advice to patient during skin cancer excision in the hand.
Clip 8-2 During surgery the patient can veri y that the de ormity
has been corrected.
Clip 8-3 Advice to a patient while K-wiring a nger racture.
Clip 8-4 Advice to a 10-year-old during f exor tendon repair.
Clip 8-5 Giving intraoperative advice during carpal tunnel release.
9 WALANT Hand Surgery in In ants and Children
Donald H. Lalonde
Clip 9-1 Flexor tendon repair in a 6-year-old girl.
Clip 9-2 Flexor tendon repair in a 10-year-old girl.
Clip 9-3 Excision o a th nger nubbin in a 4-week-old in ant.
Clip 9-4 Numbing a proximal phalanx racture in a boy.
10 Field Sterility or Simple Cases Makes Sense
Donald H. Lalonde
Clip 10-1 Sa ety and value o eld sterility or hand surgery.
12 The “Buy-In”: Administration, Anesthesiology, Nursing,
and Payers
Julie E. Adam s, Michael W. Neum eister, Robert E. Van Dem ark, Jr.,
Carolyn L. Kerrigan, Peter C. Am adio, Donald H. Lalonde
Clip 12-1 Why patients love WALANT.
14 Scheduling Fi teen or More Hand Surgery Cases per Day
Donald H. Lalonde
Clip 14-1 Three carpal tunnel procedures per ormed per hour.
15 Integrating Hand Therapists Into WALANT
Susan Kean, Am anda Higgins, Donald H. Lalonde
Clip 15-1 Hand therapists in preoperative therapy consultation.
Clip 15-2 Patient watching structures being repaired.

xvii
Vid eo Co n t en t s
Clip 15-3 Intraoperatively the surgeon and therapist teach the patient about
postoperative care.
Clip 15-4 Therapist teaching a patient during f exor tendon repair surgery.
Clip 15-5 Allowing wrist extension and active f exion a ter f exor tendon
repair.
Clip 15-6 Relative motion extension splinting or extensor tendon repair.
Clip 15-7 Early protected active motion a ter K-wired repair o nger
ractures decided with the therapist during surgery.
Clip 15-8 Therapist teaching early movement 3 days a ter K-wiring
nger ractures.
16 Minor Procedure Room Setup
Donald H. Lalonde, Geo Cook
Clip 16-1 Clinic consultation and minor procedure room setup at the Saint
John Regional Hospital.
Clip 16-2 Clinic consultation and minor procedure room setup at St. Joseph’s
Hospital.
Clip 16-3 Minor procedure accredited operating room at Dr. Lalonde’s o ce.
PART III SPECIFIC D ETAILS OF H OW TO PERFORM
WID E AWAKE H AN D SURGERY FOR COMMON
OPERATION S
Se c t io n A Am pu t At io n
17 Finger and Ray Amputation
Donald H. Lalonde
Clip 17-1 Local injection or proximal phalanx nger amputation.
Clip 17-2 SIMPLE block or distal phalanx squamous cell cancer amputation.
Se c t io n B n e r v e De c o m pr e SSio n
18 Carpal Tunnel Decompression o the Median Nerve
Carolyn L. Kerrigan, Donald H. Lalonde, Shu Guo Xing, Jin Bo Tang
Clip 18-1 Patient impression o tourniquet with sedation versus WALANT or
endoscopic carpal tunnel surgery.
Clip 18-2 A “hole-in-one” minimal pain local anesthetic injection or open
carpal tunnel release.
Clip 18-3 Blunt-tipped cannula injection o local anesthetic or carpal tunnel
surgery.
Clip 18-4 Injecting local anesthetic or endoscopic carpal tunnel release.
Clip 18-5 Patient consultation or carpal tunnel surgery.
Clip 18-6 Advising the patient a ter injection o local anesthetic or carpal
tunnel release.
Clip 18-7 Intraoperative advice to the patient during carpal tunnel surgery.

xviii
Vid eo Co n t en t s
Clip 18-8 Field sterility setup or open carpal tunnel release.
Clip 18-9 Carpal tunnel surgery (Lalonde).
Clip 18-10 Endoscopic carpal tunnel surgery.
19 Cubital Tunnel Decompression o the Ulnar Nerve
Donald H. Lalonde, Alistair Phillips
Clip 19-1 Checking or ulnar nerve subluxation with active movement during
surgery.
Clip 19-2 How to inject local anesthetic or cubital tunnel release at the
elbow.
Clip 19-3 Real-time injection o local anesthetic or cubital tunnel release.
Clip 19-4 Injecting or both cubital tunnel and carpal tunnel release in the
same operation.
Clip 19-5 57 mm blunt-tipped 22-gauge cannula injection o local anesthetic
or cubital tunnel release.
Clip 19-6 Prepping and draping or a WALANT cubital tunnel ulnar nerve
release.
Clip 19-7 Cubital tunnel surgery with WALANT.
20 Lacertus Syndrome: Median Nerve Release at the Elbow
Elisabet Hagert, Donald H. Lalonde
Clip 20-1 What is lacertus syndrome?
Clip 20-2 Clinical examination o lacertus syndrome.
Clip 20-3 Local anesthetic injection or lacertus and carpal tunnel release.
Clip 20-4 Surgical release o lacertus brosus by Dr. Elisabet Hagert.
Clip 20-5 Lacertus and carpal tunnel injection and surgery by Dr. Don
Lalonde.
Se c t io n c t e n Do n De c o m pr e SSio n
21 Trigger Finger
Donald H. Lalonde
Clip 21-1 Trigger nger and thumb injection and surgery overview.
Clip 21-2 Injection o local anesthetic or trigger thumb surgery.
Clip 21-3 Trigger thumb surgery.
Clip 21-4 Wide awake trigger nger surgery
22 De Quervain Release
Donald H. Lalonde, Alistair Phillips
Clip 22-1 Injection and surgery or De Quervain synovitis. (Note that
lignocaine is the same as lidocaine.)

xix
Vid eo Co n t en t s
Se c t io n D Du pu y t r e n ’S c o n t r Ac t u r e An D So f t
t iSSu e e x c iSio n
23 Dupuytren’s Contracture
Duncan McGrouther, Jason Wong, Donald H. Lalonde
Clip 23-1 Veri ying active extension with active movement a ter cord
resection.
Clip 23-2 Injecting local anesthetic or Dupuytren’s surgery.
25 Small So t Tissue Operations
Donald H. Lalonde, Jason W ong, Shu Guo Xing, Jin Bo Tang
Clip 25-1 Surgical sequence and result in an 89-year-old patient.
Clip 25-2 Excision lipoma on the orearm.
Se c t io n e Ar t h r it iS Su r g e r y
26 Arthroplasty o the Proximal Interphalangeal Joint
Donald H. Lalonde
Clip 26-1 PIP arthroplasty.
27 Trapeziectomy With or Without Ligament Reconstruction
or Thumb Basal Joint Arthritis
Donald H. Lalonde, Peter C. Am adio, Geo Cook
Clip 27-1 Intraoperative decision-making about the appropriate procedure.
Clip 27-2 A patient with medical comorbidities compares local and general
anesthesia.
Clip 27-3 Mixing the local anesthetic solution or a trapeziectomy.
Clip 27-4 Real-time 8-minute injection o a patient.
Clip 27-5 Cannula injection o local anesthetic or a trapeziectomy.
Clip 27-6 Ligament reconstruction with APL.
Clip 27-7 Watching the metacarpal move without grinding on scaphoid.
Clip 27-8 Patient impressions during trapeziectomy.
28 Thumb Metacarpophalangeal Joint Fusion and Ulnar
Collateral Ligament Repair
Donald H. Lalonde
Clip 28-1 Local anesthetic injection or thumb MP usion or UCL repair.
Clip 28-2 Thumb MP usion in the same patient in Clip 28-1.
Clip 28-3 Thumb UCL repair.

xx
Vid eo Co n t en t s
Se c t io n f Wr iSt Su r g e r y
30 Wrist Arthroscopy
Elisabet Hagert, Donald H. Lalonde
Clip 30-1 Wrist arthroscopy.
31 Open Triangular Fibrocartilage Complex Repair
Elisabet Hagert, Donald H. Lalonde
Clip 31-1 Wide awake TFCC.
Se c t io n g LAc e r At e D t e n Do n S An D t e n o Ly SiS
32 Flexor Tendon Repair o the Finger
Jin Bo Tang, Shu Guo Xing, Jason Wong, Je rey Yao, Donald H. Lalonde
Clip 32-1 How WALANT has improved f exor tendon repair results.
Clip 32-2 Decreasing the rupture rate with intraoperative testing.
Clip 32-3 Tenolysis rate decreased by ensuring the repair ts through
all pulleys.
Clip 32-4 Hal a st o true active movement.
Clip 32-5 Intraoperative patient education decreases rupture and tenolysis
rates.
Clip 32-6 Determining whether to repair the super cialis.
Clip 32-7 How to inject local anesthetic or f exor tendon repair.
Clip 32-8 Dr. Je rey Yao has the patient see the ngers f ex and extend.
Clip 32-9 Retrieving the tendon rom the proximal f exor sheath.
Clip 32-10 Delivering a misdirected FDP proximal stump between both slips
o FDS.
Clip 32-11 Suturing tendon inside f exor tendon sheath.
Clip 32-12 Total A4 pulley venting with no bowstringing.
Clip 32-13 Testing f exor pollicis longus repair during surgery.
Clip 32-14 Where and how to dissect in pulp o distal phalanx to avoid
numbness.
Clip 32-15 Passive and active nger movement up to hal a st a ter surgery.
Clip 32-16 Pro undus glides 1 cm o tendon when patient makes hal a st.
Clip 32-17 Tendon repair caught on proximal edge o A4 pulley.
Clip 32-18 Fiona Peck Manchester short splint and Gwen van Strien scratch
movement or true active movement a ter f exor tendon repair.
34 Flexor Tendon Repair o the Forearm
Donald H. Lalonde
Clip 34-1 “Spaghetti wrist.” Active movement in proximal orearm identi es
which proximal tendons belong to which distal tendon ends.

xxi
Vid eo Co n t en t s
35 Extensor Tendon Repair o the Finger
Donald H. Lalonde
Clip 35-1 Relative motion extension splint decreases excursion in extensor
tendon repair in the proximal nger.
Clip 35-2 Merritt relative motion f exion splinting or boutonniere de ormity.
Clip 35-3 WALANT mallet racture management.
Clip 35-4 Percutaneous extensor tendon repair.
Clip 35-5 Pencil test or relative motion splinting.
36 Extensor Tendon Repair o the Hand
Donald H. Lalonde, Geo Cook
Clip 36-1 Hand extensor repair revolutionized by Merritt relative motion
extension splinting.
Clip 36-2 Extensors ref exively relax when patient is asked to actively f ex the
nger.
37 Extensor Tendon Repair o the Forearm
Donald H. Lalonde
Clip 37-1 Three di erent extensor tendon repairs o the orearm.
38 Tenolysis
Jason W ong, Michael Sauerbier, Peter C. Am adio, Donald H. Lalonde
Clip 38-1 Dr. Jason Wong per orms tenolysis a ter nger amputation.
Clip 38-2 Dr. Michael Sauerbier per orms tenolysis.
Clip 38-3 Tenolysis a ter nger racture.
Clip 38-4 Tenolysis in a 63-year-old woman who had been unable to f ex her
long and ring ngers since a tendon repair at age 3.
Clip 38-5 Patient ruptures her own adhesions in the extensor tendons a ter
wrist usion.
Se c t io n h t e n Do n t r An Sf e r S
39 Tendon Trans ers
Donald H. Lalonde, Robert M. Szabo, Mark E. Baratz
Clip 39-1 EI to EPL: getting the trans er tension right; clinical experience.
Clip 39-2 Dr. Robert Szabo per orms a wide awake EI to EPL trans er.
Clip 39-3 Dr. Mark Baratz demonstrates a patient watching hersel extend
her thumb.
Clip 39-4 How to inject local anesthetic or EI to EPL trans er.
Clip 39-5 EI to EPL surgery with intraoperative testing o thumb f exion and
extension.
Clip 39-6 Another video o EI to EPL surgery with intraoperative testing o
thumb f exion and extension.

xxii
Vid eo Co n t en t s
Clip 39-7 FDS4 to FPL trans er with radius plate removal.
Clip 39-8 84-year-old man with cardiac issues was given a lowered
epinephrine concentration.
Se c t io n i LAc e r At e D n e r v e S
40 Lacerated Nerves
Donald H. Lalonde
Clip 40-1 Relative motion f exion splint.
Se c t io n J f r Ac t u r e S
41 Finger Fractures
Donald H. Lalonde
Clip 41-1 Early protected movement 3 days a ter K-wiring middle phalanx
racture.
Clip 41-2 Two nger ractures: numbing, intraoperative testing o unction-
ally stable xation o K-wire reduction, early protected movement
demonstration, and nal result.
Clip 41-3 Augmented eld sterility setup or inserting K-wires in a minor
procedure room.
Clip 41-4 Real-time minimal pain local injection or proximal phalanx
racture.
Clip 41-5 Advice to an awake patient at the end o nger racture reduction
surgery.
Clip 41-6 Testing stability o dorsal blocking K-wire or dorsal racture
dislocation o PIP joint.
Clip 41-7 Wide awake operative reduction o a 4-week-old scissoring
malunion o the proximal phalanx.
Clip 41-8 Distraction splint or comminuted PIP and MP ractures.
Clip 41-9 Fracture boutonniere treated with a relative motion f exion splint
only.
Clip 41-10 Mallet ractures involving 50% to 60% o the joint but with
congruous or parallel joint sur aces (not subluxated) can be
treated with mallet splinting only.
42 Reduction and Internal Fixation o Metacarpal Fractures
Shu Guo Xing, Jin Bo Tang, Donald H. Lalonde
Clip 42-1 Fracture dislocation at the base o the thumb metacarpal (Bennett
racture).
Clip 42-2 Fracture dislocation at the base o the th metacarpal.
Clip 42-3 Local anesthesia or ourth and th metacarpal operative
reduction.
Clip 42-4 Local anesthetic injection or WALANT metacarpal plate removal.
Clip 42-5 Operative reduction o ourth and th metacarpal ractures in the
patient injected with local anesthetic seen in Clip 42-3.

xxiii
Vid eo Co n t en t s
Clip 42-6 Early protected movement 3 days a ter K-wire xation o a meta-
carpal racture.
Clip 42-7 A 3-month-old malunion o a metacarpal with intraoperative test-
ing o ull f exion and extension a ter reduction and plating.
Clip 42-8 Checking scissoring a ter dynamic compression bone clamp meta-
carpal racture reduction.
PART IV COMPLEX RECON STRUCTION S
43 Complex Reconstructions in Hand Surgery
Donald H. Lalonde, Jason W ong, Alistair Phillips, Nik Jagodzinski
Clip 43-1 Repair o a 51⁄2-week-old FPL laceration.
Clip 43-2 Change thumb tip pinch a ter adult pollicization.
Clip 43-3 Cleaning a severely contaminated hand wound in the emergency
department.
Clip 43-4 Extensor tendon gra t o the dorsum o the hand.
Clip 43-5 FCR and FCU trans er in a polio case.
Clip 43-6 Finger revascularization with wrist vein gra ts by Dr. Jason Wong.
Clip 43-7 Homodigital island f ap by Dr. Jason Wong.
Clip 43-8 Restoration o thumb extension a ter subtotal amputation.
Clip 43-9 Ruptured FPL repair under the motor branch in the carpal tunnel.
Clip 43-10 Swan neck FDS trans er.
Clip 43-11 Palmaris longus tendon gra t or rupture o ourth and th
extensors.

(Trang không có chữ)

Part I
At l as o f Tu mes c en t Lo c al
An est h esia Wit h Fo r ear m, Wr is t ,
H an d , an d Fin g er In jec t io n s

(Trang không có chữ)

3
Ch a P t e r 1
At l as o f Imag es o f Lo c al An es t h et ic
D if f u sio n An at o my
Donald H. Lalonde
In this atlas, the images you will see are drawn rom photographs o live
human volunteers injected with tumescent local anesthesia to determine
where the solution naturally di uses when you inject it under the skin in
the hand, wrist, and orearm.
Producing tumescing local anesthesia requires injecting enough volume o
anesthetic solution—lidocaine (also called lignocaine) with epinephrine—
under the skin so that you can see its swelling, and you can eel it when
you palpate the area (see Chapter 4). It is a orm o extravascular Bier block
injected only where you intend to operate.
In addition to anatomic maps o where the local anesthetic di uses when
you inject it in one place in the orearm, wrist, and hand, this chapter
also describes the natural barriers to local anesthetic di usion ormed by
creases and glabrous/nonglabrous skin boundaries.
GUID E TO TH E ATLAS
•
Each image answers the ollowing question: Where does the local an-
esthetic di use and have its numbing e ect when you inject it under
the skin without moving the needle in the red injection point o the
illustrated area?
•
The blue areas show the di usion o visible and palpable lidocaine
with epinephrine that usually takes place within 30 minutes a ter in-
jection in most patients. These blue areas will be both numbed and
vasoconstricted.
•
The green areas are blocked by nerve block. They may take up to an
hour or longer a ter injection to achieve the peak nerve block. These
green areas will not be vasoconstricted. Bleeding in the green areas
may be more than in normal skin because o the sympathectomy e ect
o the nerve blocks. To avoid bleeding in the green areas, simply inject
more local anesthetic where you will dissect, as described in Chapter 4.
•
Note that the ligaments at the glabrous/nonglabrous skin junction
act as a di usion barrier to distribution o the local anesthetic. This is
where the volar skin meets the dorsal skin o the hand. This also is the
embryologic boundary/border o many nerve distributions.
•
Ligaments that create creases in the hand and ngers also act as a nat-
ural di usion barrier to local anesthetic. You will usually have to inject
on both sides o the creases.

Par t I ° At l as o f Tu mesc en t Lo c al An es t h esia
4
•
Preexisting scars and lacerations create natural di usion barriers to lo-
cal anesthetic. You will usually have to inject on both sides o preexist-
ing scars and lacerations.
•
As in all anatomy, di erent patients will have small di erences. Not all
patients will get the green distal nerve blocks.
MID LIN E D ORSAL FOREARM
When you inject 20 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) 10 cm proximal to the wrist crease in
the dorsal forearm midline in the red injection point just under the skin without moving the needle,
local anesthetic can be seen and palpated to diffuse in the blue area in an unscarred patient. You
numb the green area by nerve block, but this area has no epinephrine vasoconstriction and may
bleed more because of the sympathectomy of the nerve block.
MID LIN E VOLAR FOREARM
When you inject 20 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) 10 cm proximal to the wrist crease in
the volar forearm midline in the red injection point just under the skin without moving the needle,
local anesthetic can be seen and palpated to diffuse in the blue area in an unscarred patient. You
numb the green area by nerve block, but this area has no epinephrine vasoconstriction and may
bleed more because of the sympathectomy of the nerve block. The median and ulnar nerves may
not be blocked unless the needle gets beneath the deep forearm fascia, since this can act as a
natural barrier to local anesthetic diffusion.

Ch apt er 1 ° At l as o f Imag es o f Lo c al An es t h et ic D if f u sio n An at o my
5
MID LIN E RAD IAL FOREARM
When you inject 20 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) 10 cm proximal to the wrist crease in
the radial forearm midline in the red injection point just under the skin without moving the needle,
local anesthetic can be seen and palpated to diffuse in the blue area in an unscarred patient. You
numb the green area by nerve block, but this area has no epinephrine vasoconstriction and may
bleed more because of the sympathectomy of the nerve block.
MID LIN E ULN AR FOREARM
When you inject 20 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) 10 cm proximal to the wrist crease in
the ulnar forearm midline in the red injection point just under the skin without moving the needle,
local anesthetic can be seen and palpated to diffuse in the blue area in an unscarred patient.

Par t I ° At l as o f Tu mesc en t Lo c al An es t h esia
6
MID LIN E VOLAR WRIST
When you inject 10 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) in the midvolar wrist in the red injec-
tion point just under the skin without moving the needle, local anesthetic can be seen and palpated
to diffuse in the blue area in an unscarred patient. When the injection is under the skin and not
below the forearm fascia, you may not achieve a median or ulnar nerve block, since the deep fore-
arm fascia can act as a natural diffusion barrier to local anesthetic diffusion. You do get a palmar
cutaneous and a dorsal sensory block, as shown in green. More of the local anesthetic tracks
proximally, because the wrist crease acts as a natural barrier to local anesthetic diffusion into the
palm. You numb the green area by nerve block, but this area has no epinephrine vasoconstriction
and may bleed more because of the sympathectomy of the nerve block.
MID LIN E D ORSAL WRIST
When you inject 10 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) in the middorsal wrist in the red injec-
tion point just under the skin without moving the needle, local anesthetic can be seen and palpated
to diffuse in the blue area in an unscarred patient. You numb the green area by nerve block, but
this area has no epinephrine vasoconstriction and may bleed more because of the sympathectomy
of the nerve block.

Ch apt er 1 ° At l as o f Imag es o f Lo c al An es t h et ic D if f u sio n An at o my
7
MID LIN E RAD IAL WRIST
When you inject 10 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) in the midradial wrist in the red injec-
tion point just under the skin without moving the needle, local anesthetic can be seen and palpated
to diffuse in the blue area in an unscarred patient. You numb the green area by nerve block, but
this area has no epinephrine vasoconstriction and may bleed more because of the sympathectomy
of the nerve block.

Par t I ° At l as o f Tu mesc en t Lo c al An es t h esia
8
MID LIN E ULN AR WRIST
When you inject 10 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) in the midulnar wrist in the red injec-
tion point just under the skin without moving the needle, local anesthetic can be seen and palpated
to diffuse in the blue area in an unscarred patient. You numb the green area by nerve block, but
this area has no epinephrine vasoconstriction and may bleed more because of the sympathectomy
of the nerve block.
MID PALMAR H AN D
When you inject 10 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml
of lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) in the midpalm in the red injection
point just under the skin without moving the needle, local anesthetic can be seen and palpated to
diffuse in the blue area in an unscarred patient. The green areas are numbed by nerve block, but
these areas have no epinephrine vasoconstriction and may bleed more because of the sympathec-
tomy of the nerve block.

Ch apt er 1 ° At l as o f Imag es o f Lo c al An es t h et ic D if f u sio n An at o my
9
MID D ORSAL H AN D
When you inject 10 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) in the dorsum of the midhand in the
red injection point just under the skin without moving the needle, local anesthetic can be seen and
palpated to diffuse in the blue area in an unscarred patient. The proximal phalanx dorsal skin may
not be blocked past the web space.
ULN AR H AN D
When you inject 10 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) in the ulnar midhand in the red injec-
tion point just under the skin without moving the needle, local anesthetic can be seen and palpated
to diffuse in the blue area in an unscarred patient. You numb the green area by nerve block, but
this area has no epinephrine vasoconstriction and may bleed more because of the sympathectomy
of the nerve block.

Par t I ° At l as o f Tu mesc en t Lo c al An es t h esia
10
TH UMB MID METACARPAL D ORSAL
When you inject 10 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) in the dorsum of the midmetacarpal
thumb in the red injection point just under the skin without moving the needle, local anesthetic can
be seen and palpated to diffuse in the blue area in an unscarred patient. Note that the ligaments at
the glabrous/nonglabrous skin junction act as a natural diffusion barrier to volar distribution of the
local anesthetic. The interphalangeal thumb crease also acts as a natural barrier to local anesthetic
diffusion. The green areas are numbed by nerve block, but these areas have no epinephrine vaso-
constriction and may bleed more because of the sympathectomy of the nerve block.
TH UMB MID METACARPAL VOLAR
When you inject 10 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) in the volar aspect of the midmetacar-
pal thumb red injection point just under the skin without moving the needle, local anesthetic can be
seen and palpated to diffuse in the blue area in an unscarred patient. Note that the ligaments at the
glabrous/nonglabrous skin junction act as a diffusion barrier to dorsal distribution of the local an-
esthetic. The thenar eminence creases in the palm also act as a barrier to local anesthetic diffusion.
The green areas are numbed by nerve block, but these areas have no epinephrine vasoconstriction
and may bleed more because of the sympathectomy of the nerve block.

Ch apt er 1 ° At l as o f Imag es o f Lo c al An es t h et ic D if f u sio n An at o my
11
SIN GLE SUBCUTAN EOUS IN JECTION IN TH E
MID LIN E PROXIMAL PH ALAN X WITH LID OCAIN E
AN D EPIN EPH RIN E (SIMPLE) FIN GER BLOCK
•
SIMPLE is the acronym or single subcutaneous injection in the midline
proximal phalanx with lidocaine and epinephrine.
•
See the clip o SIMPLE block injection in Chapter 17.
•
Only 2 ml is required or a good digital block.
•
There is level II evidence that patients pre er this block to the two dor-
sal injection block.1
•
There is level I evidence that needle penetration o the palmar skin is
not more pain ul than needle penetration o web space skin.2
•
There is level II evidence that this block hurts less i you inject it over
60 seconds than i you inject it over 10 seconds.3
•
There is level II evidence that lidocaine without epinephrine digital
blocks last 5 hours, whereas lidocaine with epinephrine blocks last
10 hours.4
•
There is level I evidence that the pain-relieving e ect o bupivacaine
blocks lasts 15 hours, whereas the annoying numbness to touch and
pressure lasts more than 30 hours with these blocks.5
When you inject 2 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) in subcutaneous fat in the red injection
point just under the skin without moving the needle, local anesthetic can be seen and palpated to
diffuse in the blue area in an unscarred patient. The two digital nerves always get numb. You numb
the green area by nerve block, but this area has no epinephrine vasoconstriction and may bleed
more because of the sympathectomy of the nerve block.

Par t I ° At l as o f Tu mesc en t Lo c al An es t h esia
12
“SIMPLE” FIN GER BLOCK WITH D ORSAL BLOCK
AUGMEN TATION
When you inject 2 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) in subcutaneous fat in the red injection
point just under the skin without moving the needle, local anesthetic can be seen and palpated to
diffuse in the blue area in an unscarred patient. The green areas are numbed by nerve block, but
these areas have no epinephrine vasoconstriction and may bleed more because of the sympathec-
tomy of the nerve block.
“SIMPLE” TH UMB BLOCK
When you inject 2 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) in subcutaneous fat in the red injection
point just under the skin without moving the needle, local anesthetic can be seen and palpated to
diffuse in the blue area in an unscarred patient. The two digital nerves always get numb. You numb
the green area by nerve block, but this area has no epinephrine vasoconstriction and may bleed
more because of the sympathectomy of the nerve block.

Ch apt er 1 ° At l as o f Imag es o f Lo c al An es t h et ic D if f u sio n An at o my
13
D ORSAL TH UMB PROXIMAL PH ALAN X BLOCK
When you inject 2 ml of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 ml of
lidocaine/epinephrine to 1 ml of 8.4% sodium bicarbonate) in subcutaneous fat in the red injection
point just under the skin without moving the needle, local anesthetic can be seen and palpated to
diffuse in the blue area in an unscarred patient. You numb the green area by nerve block, but this
area has no epinephrine vasoconstriction and may bleed more because of the sympathectomy of
the nerve block.
References
1. Williams JG, Lalonde DH. Randomized comparison of the single-injection volar subcuta-
neous block and the two-injection dorsal block for digital anesthesia. Plast Reconstr Surg
118:1195, 2006.
2. Wheelock ME, Leblanc M, Chung B, Williams J, Lalonde DH. Is it true that injecting pal-
mar finger skin hurts more than dorsal skin? New level I evidence. Hand (N Y) 6:47, 2011.
3. Hamelin ND, St-Amand H, Lalonde DH, Harris PG, Brutus JP. Decreasing the pain of finger
block injection: level II evidence. Hand (N Y) 8:69, 2013.
4. Thomson CJ, Lalonde DH. Randomized double-blind comparison of duration of anes-
thesia among three commonly used agents in digital nerve block. Plast Reconstr Surg
118:429, 2006.
5. Calder K, Chung B, O’Brien C, Lalonde DH. Bupivacaine digital blocks: How long is the
pain relief and temperature elevation? Plast Reconstr Surg 131:1098, 2013.

(Trang không có chữ)

Gen er al Pr in c ipl es o f Wid e Aw ake
H an d Su r g er y
Part II

(Trang không có chữ)

17
Ch a p t e r 2
Wh at Is Wid e Aw ake
H an d Su r g er y?
Alistair Phillips, Nik Jagodzinski, Donald H. Lalonde
Wide awake hand surgery is well described by its other name, W ALANT,
which stands or w ide awake local anesthesia no tourniquet. The only
two medications most patients are given or wide awake hand surgery
are lidocaine or anesthesia and epinephrine or hemostasis. We inject
tumescent lidocaine and epinephrine in large enough volumes to be vis-
ible or palpable wherever dissection will be done (see Chapter 3). This is a
orm o extravascular Bier block injected only where you need it, but
without the pain ul tourniquet.
•
Lidocaine and epinephrine are probably two o the sa est and most
widely tested injectable drugs that are used in humans (see Chapters
3 and 6). Dentists have injected billions o doses o these two medica-
tions in their o f ces since 1950 with no preoperative testing, no moni-
toring, no intravenous insertion, and very ew adverse events.
•
Like dental procedures, we can per orm wide awake hand surgery
with no preoperative testing, no insertion o an intravenous line, and
no monitoring, because the only medications we inject are lidocaine
and epinephrine. A ter the procedure, the patient simply gets up and
goes home.
Cubital tunnel release with WALANT.
Clip 2-1 Introduction
to wide awake hand
surgery.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
18
Traditional surgery performed with general anesthesia and a tourniquet.
PATIEN TS LOVE WALAN T
•
They have no nausea, vomiting, urinary retention, or other unwanted
side e ects associated with opiates or sedation.
•
They spend less time at the hospital or the procedure, because post-
operative recovery time is just minutes, since they receive no sedation
and no opioid medications. They can just get up and go home, as they
would do a ter a visit to the dentist.
•
They have no need to have someone stay with them the evening a ter
the surgery. Following outpatient procedures with general anesthe-
sia in many acilities, patients are required to have a responsible adult
stay with them or 12 to 24 hours. This is di cult or many patients,
especially i they have children.
•
Patients get to know and talk to their surgeon during the surgery or
advice on how to care or the hand postoperatively, time o work,
and other issues.
•
There is no downtime rom work or need or a babysitter when they
go or preoperative testing or sedation on a day be ore the surgery.
•
Hand surgery under pure local anesthesia is not expensive. Many pa-
tients in developing countries could a ord hand surgery i they did
not have to pay the large costs associated with sedation and general
anesthesia in the main operating room.
•
Patients do not have to obtain an unnecessary ECG or chest radio-
graphs, attend an anesthesia consultation, or undergo preoperative
blood tests.

Ch apt er 2 ° Wh at Is Wid e Aw ake H an d Su r g er y?
19
•
There is no unnecessary insertion with a 20-gauge intravenous can-
nula. All the patient will eel is a single brie prick with a 27- or
30-gauge needle in the hand when the local anesthetic is injected (see
Chapter 5).
•
Patients can see repaired structures working during the surgery a ter
a loss o unction such as tendon laceration, tenolysis, tendon trans er,
hand racture, or Dupuytren’s contracture. This visual memory helps
motivate them throughout postoperative therapy and recovery.
•
Patients do not need to endure a tourniquet or even 5 minutes. We
tell all our trainees that they need to put a tourniquet on their own
arm or orearm or 5 minutes be ore they ever say, “Patients tolerate
it well.” The true meaning o this phrase might be, “Patients let me do
it, even though it hurts.”
•
The act that there is no need or a tourniquet is advantageous in pa-
tients who have lymphedema or arteriovenous shunts in the orearm.
•
Patients do not need to ast or change medication schedules be ore
the procedure, which is particularly help ul or diabetic patients.
•
Patients with sore elbows, shoulders, or backs can position themselves
com ortably or hand and elbow surgery, because there is no tourni-
quet or anesthesiology equipment preventing them rom shi ting out
o an uncom ortable position. They can easily turn on their side during
the procedure.
•
Patients do not need to get undressed or surgery when we use eld
sterility.
•
WALANT is sa er or patients than sedation, especially or individuals
with medical comorbidities. All anesthesiologists agree that less seda-
tion is sa er sedation. The sa est sedation is no sedation.
•
Surgeons are less likely to operate on the wrong hand or the wrong
nger i the patient is wide awake with no sedation.
•
Trauma patients can undergo surgery during the day in minor proce-
dure rooms instead o in the middle o the night in the main operat-
ing room. They do not need hospital admission to wait or or recover
rom sedation. Surgeons and nurses are more likely to be able to per-
orm surgery well when rested during daytime hours than while tired
at night.
•
There is no need to discontinue anticoagulation medication in most
cases, because the epinephrine provides enough hemostasis that the
wound dries up nicely.
•
It is possible to see a patient in consultation and operate on him or her
the same day, because there is little to no preoperative workup re-
quired or pure local anesthesia. This is much less expensive and more
convenient or patients who have to travel long distances to the sur-
geon’s clinic or o ce.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
20
SURGEON S LOVE WALAN T
•
We can make adjustments on repaired tendons and nger ractures a -
ter seeing active movement in com ortable, cooperative patients and
make certain everything is working well be ore we close the skin. This
decreases the rate o rupture and tenolysis a ter f exor tendon repair.
•
Patients help to rupture adhesions in tenolysis and remember what
they achieve in motion at surgery when they are unsedated.
•
We have an easier time setting proper tension on tendon trans ers
be ore we close the skin by watching the patient move the trans er to
test the tension.
•
We see what is happening with active movement during the surgery in
complex reconstructive cases to improve results.
•
We do not have to look a ter patients who must be admitted to the
hospital a ter hand surgery because o sedation complications such as
nausea and vomiting.
•
We can operate on patients with multiple medical problems sa ely
and easily, because we give them no sedation. They walk in, have their
hand surgery, and then get up and go home with their medical issues
unchanged. The act that they are morbidly obese, diabetic, or have
severe lung disease has no bearing on the hand surgery itsel , only on
the sedation.
•
We do not have to use cautery or most cases because epinephrine he-
mostasis is very good. We only open cautery as required, not as a rou-
tine. The epinephrine and natural clotting typically dries up the eld
by the time we get to skin closure. This can reduce operative time and
the cost o cautery equipment, and possibly even prevent postopera-
tive hematoma.
•
There is no need to stop let-down bleeding rom a tourniquet, be-
cause we do not use one.
•
We do not need to stop anticoagulation therapy in many i not most
cases, because epinephrine hemostasis is good. This is sa er or the pa-
tient and decreases the liability or the surgeon.
•
We have an easier time in patients with lymphedema, dialysis access,
or previous vascular surgery in which a tourniquet might cause prob-
lems.
•
We get to educate the patient during the surgery or better outcomes
and ewer complications. Time spent on intraoperative patient edu-
cation can decrease the time spent in the o ce on patient education
(see Chapters 7 and 8). Patients tend to remember the intraoperative
advice, which leads to ewer complications.
•
Patient compliance is improved. When you personally tell patients to
keep their hand elevated and immobile at the end o the surgery, they
are more likely to comply than i a nurse tells them this in the recovery
room when they are still under the inf uence o sedatives.
•
We only need one nurse or most simple hand operations, such as
carpal tunnel release. This greatly increases e ciency and productiv-

Ch apt er 2 ° Wh at Is Wid e Aw ake H an d Su r g er y?
21
ity and reduces costs (see Chapter 14). We can per orm more cases in
the same amount o time at less cost. It is never necessary to wait or
the slowest member o a big team to nish his or her work so we can
proceed.
•
Simple operations such as carpal tunnel and trigger nger can be
moved out o the main operating room. We can per orm them in the
clinic or o ce with eld sterility or greatly improved turnover time
and patient convenience (see Chapter 10).
•
We can per orm hand trauma procedures such as tendon repair and
nger racture with K-wiring during the day in minor procedure rooms
instead o in the middle o the night in the main operating room.
•
We can use lidocaine with epinephrine injection to f ood the area,
even in sedated or sleeping patients, to decrease bleeding and pain at
the end o surgery. Many o us use lidocaine and epinephrine without
a tourniquet, even when we have patients under general anesthesia.
•
We can wash very dirty hand injuries in the emergency department
with tap water a ter numbing the hand. The concentration o bacteria
in running tap water is negligibly higher than sterile saline solution in
countries where water cleanliness is highly regulated.
WH Y N O SED ATION ?
•
There is no need or sedation or many i not most patients: the only
two reasons patients needed sedation in the past or hand surgery
were (1) to tolerate the pain o the tourniquet and (2) to tolerate
the pain o injection o the local anesthetic. Those reasons are no
longer valid, because the use o epinephrine has removed the need
or a tourniquet (see Chapter 3), and local anesthetic can be reliably
injected in an almost pain- ree manner (see Chapter 5).
•
Sedated patients cannot remember intraoperative teaching rom their
surgeon and will miss this excellent communication opportunity be-
cause o the amnestic drugs.
•
Some patients become uninhibited and harder to manage with small
amounts o sedation and end up requiring general anesthesia, with all
its inconveniences.
•
Pain- ree, unsedated, cooperative patients can move their recon-
structed ngers through a ull range o motion during the surgery and
remember how well the reconstructed hand unctions. The surgeon
can make changes during the procedure to improve the outcome, and
patients are motivated to achieve the same movement they remember
seeing on the operating table.
Clip 2-2 Washing
a contaminated
hand in a wide
awake patient in
the emergency
department.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
22
CON CLUSION
Wide awake hand surgery is being practiced by an increasing number o
hand surgeons in most countries o the world. This will only increase in
the uture, because this technique is sa er, more convenient or patients
and surgeons, and much more a ordable. Most surgeons who have tried
it continue to use it.

23
TH E RISE AN D FALL OF TH E MYTH OF TH E D AN GER
OF IN JECTIN G EPIN EPH RIN E IN TH E FIN GER
In the period be ore 1950, the belie developed among surgeons that
epinephrine causes nger necrosis. This dogma became entrenched in
medical school teachings, where we were told that we should not inject
epinephrine into “ ngers, nose, penis, and toes.” Evidence-based medi-
cine has now altered that misconception. This chapter tells the story o
how it happened.
TH E LON G H ISTORY OF SAFE USE OF EPIN EPH RIN E
IN TH E FIN GER BY CAN AD IAN SURGEON S
•
When I was a medical student at Queen’s University in Kingston, On-
tario, rom 1975 to 1979, there was an excellent hand surgeon, Dr. Pat
Shoemaker, who used epinephrine in the nger all o the time. He did
wide awake f exor tendon repair with eld sterility in the emergency
department and got good results. Some o his colleagues were skepti-
cal and taught medical students the traditional view that epinephrine
in the nger was dangerous and could cause nger necrosis as a re-
sult o vasoconstriction. Only Dr. Shoemaker was “allowed” to do it,
because he was a hand surgeon who did not have trouble—“yet!” He
never did get into trouble, and has long since retired and passed away.
•
Dr. Bob MacFarlane o London, Ontario, past president o the Ameri-
can Society or Surgery o the Hand, became amous or his Dupuy-
tren’s research. He regularly per ormed wide awake Dupuytren’s sur-
gery with lidocaine and epinephrine hemostasis.
•
Dr. John Fielding, the rst plastic surgeon in Ottawa, pioneered use
o wide awake hand surgery with epinephrine hemostasis in that city.
Many Ottawa surgeons ollowed his lead and used the technique rou-
tinely long be ore I did.
Clip 3-1 History
of the rise and fall
of the epinephrine
danger myth.
Ch a P t e r 3
Saf e Epin eph r in e in t h e Fin g er
Mean s N o To u r n iq u et
Donald H. Lalonde

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
24
•
Many other Canadian hand surgeons in other cities adopted the same
technique.
SIX TH IN GS STIMULATED MY IN TEREST IN BEGIN N IN G
ROUTIN E ELECTIVE EPIN EPH RIN E H EMOSTASIS USE
IN TH E FIN GER FOR EVERY CASE IN 20 0 1
1. I knew o well over 100 surgeon-years o clinical sa ety in the practices
o Drs. Shoemaker, MacFarlane, Fielding, and others who routinely
injected epinephrine in ngers. These were good surgeons. I trusted
and respected their clinical judgment.
2. I knew I could use phentolamine as an epinephrine vasoconstriction
rescue agent i I needed it.
3. I had been using epinephrine or carpal tunnel, f exor sheath gan-
glion, and trigger nger procedures or many years with no problems.
4. I had used epinephrine in the nger many times be ore 2001, but not
routinely, and I had not encountered any problems.
5. We had great di culty getting the main operating room or our hand
trauma cases because o a chronic shortage o anesthesiologists in
Saint John. Epinephrine hemostasis meant no tourniquet was re-
quired. It also meant we could operate on a patient with a traumatic
hand injury outside the main operating room at our convenience,
Monday through Friday, 9 to 5, without having to admit patients or
wait or an anesthesiologist.
6. Dr. Keith Denkler published his landmark paper in 2001.1 Dr. Denkler
painstakingly reviewed 120 years o literature rom 1880 to 2000, most
o it by hand through Index Medicus volumes, and did not f nd one
case o lidocaine with epinephrine nger necrosis in the world litera-
ture. This was my tipping point. A ter reading his paper, I decided to
use epinephrine in every nger with good capillary re ll on ngertip
pulp palpation until I needed phentolamine rescue.
FOUR MAIN CON CEPTS TH AT SUPPORT TH E FALL
OF TH E MYTH
1. We can reliably reverse epinephrine vasoconstriction with phentol-
amine in the human nger.2
2. There were no lost ngers and not one case required phentolamine
rescue in a prospective study o 3110 consecutive cases o elective
Clip 3-2 How to
reverse epinephrine
vasoconstriction
with phentolamine
injection in the
finger.