Wide Awake Hand Surgery

Sec t io n A ° Ampu t at io n
126
Dorsal injections: Inject 4 ml of 1%
lidocaine with 1:100,000 epinephrine
(buffered with 0.4 ml of 8.4% sodium
bicarbonate) in the proximal red injection
dot on the dorsal hand. Do the two pal-
mar injections next, and then inject
2 ml in the middle of the dorsal proximal
and middle phalanges in the subcutane-
ous fat.
•
See Chapter 1, Atlas, or more illustrations o the anatomy o tumes-
cent local anesthetic in the orearm, wrist, and hand.
MIN IMALLY PAIN FUL IN JECTION OF LOCAL
AN ESTH ETIC FOR FIN GER AMPUTATION
•
Inject just under the skin. There is no need to inject into the sheath; it
would only add unnecessary pain. The local anesthetic will di use into
the sheath.
•
Inject the patient on a stretcher in a waiting area be ore he or she
comes into the operating room a minimum o 30 minutes be ore sur-
gery to allow the epinephrine to take optimal e ect and to provide an
adequately dry working eld, as outlined in Chapters 4, 5, and 14.
•
Inject the patient lying down to decrease the risk o ainting (see
Chapter 6).
•
To minimize the pain o injection, inject with a ne 27-gauge needle
(not a 25-gauge) into the most proximal injection point (red dot).
•
Ask the patient to look away. Press with a ngertip just proximal to
the injection site be ore you put in the needle to add the sensory
“noise” o pressure to decrease the pain.
•
Insert the rst needle perpendicularly into the subcutaneous at. Sta-
bilize the syringe with two hands to avoid pain rom needle wobble
until the skin needle site is numb. Inject the rst visible 0.5 ml bleb and
then pause. Wait 15 to 45 seconds until the patient tells you that all
needle pain is gone. Inject the rest o the 10 ml slowly (over 3 minutes)
without moving the needle.
•
In this operation, inject the 10 ml in the most proximal part o the
palm rst, and then inject 4 ml in the most proximal part o the dorsal
hand right a ter that. This will give at least a little time or the distal
injection points to become numb be ore you inject them.
•
The distal injections are or the epinephrine vasoconstriction e ect;
the skin is already numb rom the proximal nerve blocks.
•
There is no need to inject the palm i the nger amputation is at a
more distal level than the proximal phalanx, as shown in Clip 17-2 o
a nger amputation at the distal interphalangeal (DIP) joint.
Clip 17-1 Local
injection for proximal
phalanx finger
amputation.

Ch apt er 17 ° Fin g er an d Ray Ampu t at io n
127
•
Clip 17-2 shows a SIMPLE block or a distal phalanx squamous cell
cancer amputation o the distal phalanx o the long nger (see Chap-
ters 1 and 5 or details o the SIMPLE block).
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC FOR RAY
AMPUTATION
m in imALLy pAin f u L in Jec t io n o f Lo c AL An eSt h et ic f o r r Ay
Ampu t At io n
•
Inject 10 ml in the most proximal palmar red dot injection point in
the subcutaneous at and under the super cial palmar ascia without
moving the needle. Then inject 10 ml in the most proximal red dorsal
dot o in the subcutaneous at over the dorsal proximal hand without
moving the needle.
For ray amputation, inject 20 ml of 1% lidocaine with 1:100,000 (buffered with 10 ml lido/epi:1 ml
of 8.4% sodium bicarbonate) epinephrine on each of the palmar and dorsal sides of the ray to be
amputated, for a total of 40 ml.
Palmar injection, 20 ml
Dorsal injection, 20 ml
Ulnar view
•
See Chapter 1, Atlas, or more illustrations o the anatomy o di usion
o tumescent local anesthetic in the orearm, wrist, and hand.
Clip 17-2 SIMPLE
block for distal
phalanx squamous
cell cancer
amputation.

Sec t io n A ° Ampu t at io n
128
•
I it is convenient, wait 15 to 30 minutes or the distal palmar and dor-
sal hand to get numb so the patient does not eel the distal injections.
•
Then inject 8 ml in each o the palmar and dorsal central red dot injec-
tion points at the head o the metacarpal level in the subcutaneous at
between the digital nerves without moving the needle.
•
Finally, inject 2 ml in the palmar and dorsal distal red dot injection
points in the subcutaneous at o the proximal phalanx.
•
To decrease the pain o injections, use the other tips discussed in the
nger amputation section above (also see Chapter 5).
TIPS AN D TRICKS FOR PERFORMIN G FIN GER AN D RAY
AMPUTATION WITH TH E WID E AWAKE APPROACH
•
Wait 30 minutes a ter the last injection or the epinephrine to reach
maximal vasoconstrictive e ect, and then operate. Part o these
30 minutes can be spent bringing the patient into the operating room,
prepping, draping, and other tasks.
•
Warn the patient that he or she will hear sounds o bone and joint
manipulation but will not eel pain. The patient may choose to listen
to music on earphones.
•
Get the patient to observe his or her hand going through a ull range
o active movement a ter you have cleansed the hand at the end o
the operation. The patient will know that he or she can regain ull
movement again a ter the pain and sti ness o healing subside.
•
Use the opportunity to educate the patient on postoperative care o
the injured hand (see Chapter 8).
•
Use the intraoperative opportunity while closing the skin to educate
the patient on what to expect or recovery and uture hand unction.
For example, you can discuss time out o work, phantom limb pain,
etc. This can go a long way toward helping the patient adapt to his or
her new hand.

129
Ch a P t e r 1 8
Car pal Tu n n el D ec o mpr es sio n
o f t h e Med ian N er ve
Carolyn L. Kerrigan, Donald H. Lalonde, Shu Guo Xing, Jin Bo Tang
n e r v e D e c o m p r e S S i o n
AD VAN TAGES OF WALAN T VERSUS SED ATION AN D
TOURN IQUET IN CARPAL TUN N EL D ECOMPRESSION
•
When you per orm wide awake hand surgery, you do not have to
deal with your patient’s medical comorbidities, which would only be
a problem i the patient has been sedated. It is sa er or your patients
to have no sedation. They just get up and go home a ter surgery, like
when they have had a lling at the dentist.
•
A major advantage o eliminating sedation or carpal tunnel surgery
is that you do not need to per orm the procedures in the main oper-
ating room. You can do all o your carpal tunnel surgeries in minor
treatment rooms in the clinic outside the main operating room with
evidence-based eld sterility (see Chapter 10).
•
You can easily per orm 15 or more carpal tunnel releases in 1 day with
only one nurse using eld sterility in the o ce or clinic. You can also
see consultation and recheck patients between operations (see Chap-
ter 14).
•
You avoid tourniquet let-down bleeding.
•
You do not need to use a cautery, particularly i you inject the epi-
nephrine 30 minutes be ore the rst incision. We have not opened a
cautery or over 25 years or carpal tunnel release. Hematoma has not
been a problem, even in patients on anticoagulants.
•
Your patient remains pain ree with the median and ulnar nerve block
or up to 5 hours using the technique described below.1 Nausea and
vomiting do not occur, because you have given the patient no periop-
erative narcotic agents.
•
Although patients can “tolerate” 7 minutes o tourniquet control,
they will not experience any tourniquet pain at all i you simply use
epinephrine with the lidocaine. There is high-level published evidence
that the tourniquet hurts twice as much as the injection o a local an-
esthetic in carpal tunnel surgery.2,3 Patients appreciate the tourniquet-
ree experience.
Clip 18-1 Patient
impression of
tourniquet with
sedation versus
WALANT for
endoscopic carpal
tunnel surgery.

Sec t io n B ° N er ve D ec o mpr essio n
130
•
Dr. Kerrigan notes: “For years I used to do endoscopic carpal tunnel
releases with a local anesthetic and with an upper arm tourniquet. I
would o ten ask patients what bothered them the most, i anything,
at the end o the procedure. The most common response I got was
that the tourniquet was uncom ortable. Now (since I switched to the
WALANT technique) when I ask the question, the most common re-
sponse I get is, ‘It really wasn’t bad at all, not even as bad as going to
the dentist.’”
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC
FOR AN OPEN CARPAL TUN N EL RELEASE
For carpal tunnel release, 20 ml of 1% lidocaine with 1:100,000 (buffered with 10 ml lido/epi:1 ml
of 8.4% sodium bicarbonate) is injected.
•
See Chapter 1, Atlas, or more illustrations o the anatomy o di usion
o tumescent local anesthetic in the orearm, wrist, and hand.
SPECIFICS OF MIN IMALLY PAIN FUL IN JECTION OF
LOCAL AN ESTH ETIC IN OPEN CARPAL TUN N EL RELEASE
•
We inject the anesthetic solution a minimum o 30 minutes be ore sur-
gery to allow the epinephrine to take optimal e ect and provide an
adequately dry working eld.4
•
We inject supine patients on stretchers in a waiting area to decrease
the risk o their ainting (see Chapter 6).
•
To minimize the pain o injection, use a ne 27-gauge needle (not a
25-gauge) into the most proximal red dot injection point.
Clip 18-2 A “hole-
in-one” minimal
pain local anesthetic
injection for open
carpal tunnel release.

Ch apt er 18 ° Car pal Tu n n el D ec o mpr essio n o f t h e Med ian N er ve
131
•
Ask the patient to look away. Press with a ngertip just proximal to
the injection site be ore you put in the needle to add the sensory
“noise” o touch and pressure to decrease the pain.
•
Insert the rst needle perpendicularly into the subcutaneous at. Sta-
bilize the syringe with two hands and have your thumb ready on the
plunger to avoid the pain rom needle wobble until the skin needle
site is numb. Inject the rst visible 0.5 ml bleb and then pause. Ask the
patient to tell you when the needle pain is all gone. A ter he tells you
the pain is gone, inject the rest o the rst 10 ml slowly (over 2 min-
utes) without moving the needle.
•
Ask the patient to tell you i he or she eels urther episodes o pain
during the injection so you can score your injection technique, as out-
lined in Chapter 5. I the patient eels pain twice, you score an eagle,
three times a birdie, our times a bogie, and so on. It takes 5 minutes
to per orm the injection or a carpal tunnel release and consistently
get a hole-in-one, where the patient eels only the stick o the rst
27-gauge needle in the injection process.5-7
•
Inject 10 ml o bu ered 1% lidocaine with 1:100,000 epinephrine just
ulnar to the palmaris longus at the proximal injection point, as shown
in the gure on p. 130. This should be near the median nerve, but
never in the nerve. Do not elicit paresthesias (electric shock eeling).
•
The rst 2 ml is injected just subcutaneous in the at. Notice the loca-
tion o small subcutaneous veins and avoid them.
•
Advance slowly and more deeply to get under super cial ascia o the
orearm to inject the remaining 8 ml or the median nerve block. This
will also numb the ulnar nerve. I you are not under the orearm as-
cia, you may not block the nerve.
•
A ter the initial 10 ml, come back to the subcutaneous plane with the
needle tip and slowly in ltrate 10 ml rom proximal to distal in an an-
tegrade direction down the palm between the skin and the super cial
palmar ascia. Blow the local anesthetic slowly ahead o the needle
so there is always at least 1 cm o visible or palpable local anesthetic
ahead o the sharp needle tip that the patient would eel i you ad-
vanced it into “live” nerves. Follow the rule o “Blow slow be ore you
go.” (See Chapter 5 or urther tips on how to inject local anesthetic
with minimal pain.)
•
When reinserting the needle, do so into skin that is within 1 cm o
clearly vasoconstricted white skin that has unctioning lidocaine and
epinephrine so the needle reinsertion is pain ree.
•
To avoid all pain in suturing the wound, be sure to have visible or pal-
pable local anesthetic at least 1 cm on either side and 1 cm past the
distal end o the palmar incision.
•
You can also inject with a blunt-tipped cannula to increase the speed
o painless injection compared with sharp needle tip injection (Clip
18-3 shows this blunt-tipped cannula injection or carpal tunnel sur-
gery; also see Chapter 5). The blunt needle tip can push quickly with
no pain past “live” unanesthetized nerves by gliding in the at. Sharp
Clip 18-3 Blunt-
tipped cannula
injection of local
anesthetic for carpal
tunnel surgery.

Sec t io n B ° N er ve D ec o mpr essio n
132
needle tips will pierce nerves and cause pain i the local anesthetic is
not bathing the nerve well ahead o the needle tip and i the operator
is not moving slowly enough to let the local anesthetic work be ore
the needle tip reaches the nerves. For this operation, insert a 37 mm
long 27-gauge cannula into a needle hole created in numbed skin
with a 25-gauge needle.
•
Previous publications have documented the use o 10 ml or the
median/ulnar nerve block and then another 10 ml in the palm.6-8 Some
surgeons think that 10 ml is an unnecessarily large volume or the
median nerve block. Dalhousie New Brunswick medical students have
recently per ormed a level I evidence study in which volunteers had
bilateral median nerve blocks with 5 ml on one side and 10 ml on the
other side. There were clearly more median nerve block ailures in the
5 ml group than the 10 ml group (to be published).
•
In some patients, the orearm ascia acts as a barrier to local anesthe-
sia di usion. I you only inject subcutaneously in the wrist, and do not
have the needle under the orearm ascia, you may not get a median
nerve block as the local may not penetrate the orearm ascia.
•
Some people only inject under the skin with no intention o getting
a median nerve block, and routinely success ully do carpal tunnel sur-
gery under local this way. This works well. However, a possible dis-
advantage o this approach is that patients sometimes eel “electric
jolts” when the live nerve is stimulated during the surgery.
•
When you per orm wide awake carpal and cubital (see Chapter 19) or
lacertus tunnel (see Chapter 20) releases at the same time, simply de-
crease the concentration o the local anesthetic to 0.5% lidocaine with
1:200,000 epinephrine. For a cubital tunnel release, inject 60 ml at the
elbow, as described in Chapter 19, and 20 ml in the hand or the car-
pal tunnel. For a lacertus tunnel release, inject 30 ml over the median
nerve at the elbow, as described in Chapter 20, and 20 ml in the carpal
tunnel.
A comfortable position for the patient when performing an injection for a carpal tunnel release with
local anesthetic is with the hand beside the patient’s head on the pillow (elbow flexed).

Ch apt er 18 ° Car pal Tu n n el D ec o mpr essio n o f t h e Med ian N er ve
133
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC FOR AN
EN D OSCOPIC CARPAL TUN N EL RELEASE
For an endoscopic carpal tunnel release procedure, 20 ml of 1% lidocaine with 1:100,000 epineph-
rine (buffered with 10 ml lido/epi:1 ml of 8.4% sodium bicarbonate) is injected.
•
See Chapter 1, Atlas, or more illustrations o the anatomy o di usion
o tumescent local anesthetic in the orearm, wrist, and hand.
SPECIFICS OF MIN IMALLY PAIN FUL IN JECTION
OF LOCAL AN ESTH ETIC IN EN D OSCOPIC CARPAL
TUN N EL RELEASE
Carolyn L. Kerrigan
•
A ter injecting a skin wheal, inject a urther 2 to 3 ml o the local anes-
thetic solution under the orearm ascia 5 to 6 cm proximal to the
wrist crease to block the median nerve.
•
Inject 7 to 8 ml subcutaneously at three or our points rom this rst
proximal orearm point to the wrist crease. The three or our orearm
injection points will be 1 to 1.5 cm apart. Always reinsert the needle in
a place where there is clearly visible tumescent local anesthetic under-
neath the skin, and where it has had time to work. In this way, the pa-
tient will only eel the single rst stick o a 27-gauge needle or pain
throughout the whole injection and operation.
•
Staying subcutaneous (instead o sub ascial) or the nal orearm 7 to
8 ml o solution prevents f ooding the endoscopic eld with too much
water which could impede visibility.
•
The nal 10 ml is injected subcutaneously in the palm rom the wrist
crease to the distal end o the transverse carpal ligament.
•
The injection takes longer than the procedure, but the patients are
amazed at how little pain they eel when it is per ormed this way.
Clip 18-4 Injecting
local anesthetic for
endoscopic carpal
tunnel release.

Sec t io n B ° N er ve D ec o mpr essio n
134
TIPS AN D TRICKS FOR PERFORMIN G OPEN CARPAL
TUN N EL PROCED URES WITH TH E WID E AWAKE
APPROACH
•
Managing patient expectations o WALANT carpal tunnel surgery be-
gins with a calm, matter-o - act approach about WALANT during the
consultation.
•
You can educate the patient during the local anesthetic injection
(5 minutes) and during the surgery. This gives you 10 to 15 minutes
o patient education time, which will decrease your complication rate
and decrease the time you have to spend educating the patient in the
o ce (see Chapter 8).
•
For another video and additional discussion about giving intraopera-
tive advice during carpal tunnel surgery, see Chapter 8.
•
Inject two to our patients with local anesthetic outside the operating
room be ore operating on the rst one. This will give at least hal
an hour or the local anesthetic to work on these waiting patients,
both or lidocaine numbing and or epinephrine vasoconstriction. It
takes 26 minutes to achieve peak vasoconstriction in humans a ter
1:100,000 epinephrine injection (level I evidence).4
•
A ter you inject the rst patient, he or she will usually eel well
enough to go sit in the waiting area with their injected arm raised un-
til their surgery. You can then inject the second patient, then the third
one. Then you can per orm the surgery on the rst one. While the
nurse turns over the room a ter the rst procedure, you can inject the
ourth patient.
•
In Canada, most carpal tunnel procedures are per ormed with eld
sterility in the manner shown in Clip 18-8. The cost is much less, and
the patient convenience and satis action are much higher with eld
sterility outside the main operating room than with ull sterility in the
main operating room (see Chapter 10).
•
Field sterility permits one hand surgeon and one nurse to per orm
15 or more carpal tunnel procedures per day at a very leisurely pace
(see Chapter 14).
•
Get your assistant to pull very rmly on the Senn retractors to decrease
the little bleeding that sometimes occurs, especially i the patient is
hypertensive or receiving anticoagulants.
•
Never cut or suture w here the skin is not w hite. I there are no epi-
nephrine molecules there causing vasoconstriction, there will likely not
be any lidocaine molecules there either.
Clip 18-5 Patient
consultation for
carpal tunnel
surgery.
Clip 18-6 Advising
the patient after
injection of local
anesthetic for carpal
tunnel release.
Clip 18-7
Intraoperative
advice to the patient
during carpal tunnel
surgery.
Clip 18-8 Field
sterility setup for
open carpal tunnel
release.

Ch apt er 18 ° Car pal Tu n n el D ec o mpr essio n o f t h e Med ian N er ve
135
With WALANT, visibility is good with little bleed-
ing, even with a 2 to 3 cm incision (Shu Guo
Xing and Jin Bo Tang).
Early bruising with 10 ml of local anesthetic injected in the wrist can appear red and may make
patients think they have an infection. This was not an infection but a bruise seen the day after
surgery.
•
Clip 18-9 shows carpal tunnel surgery, which includes prepping, drap-
ing, the operation, intraoperative advice, and a bandage or the open
approach.
•
O er patients a guided tour o their carpal tunnel surgery. Many will
accept and be delighted that they were given the opportunity to ex-
perience seeing the inside o their hand.
IF YOU ARE WORKIN G WITH AN AN ESTH ESIOLOGIST
•
Ask him or her to use only propo ol. Inject the lidocaine with epineph-
rine as soon as the propo ol permits pain- ree injection o local an-
esthetic. The anesthesiologist can then wake the patient right away
while you are scrubbing, prepping, and draping so you can get the
bene t o intraoperative patient teaching (see Chapter 8). This will
give the epinephrine a little time to become more e ective. Suggest
that the anesthesia provider avoid administering opiates and amnes-
tics to prevent nausea and permit the patient to remember your intra-
operative advice.
Clip 18-9 Carpal
tunnel surgery
(Lalonde).

Sec t io n B ° N er ve D ec o mpr essio n
136
TIPS AN D TRICKS FOR PERFORMIN G EN D OSCOPIC
CARPAL TUN N EL SURGERY WITH TH E WID E AWAKE
APPROACH
Carolyn L. Kerrigan
I have been per orming endoscopic carpal tunnel releases since 1991.
Be ore I discontinued the use o a tourniquet, my conversion rate to an
open procedure was 1 o 80 consecutive cases. I have done just over
80 WALANT cases, with a higher conversion rate during my learning
curve. I have had eight conversions, mostly because o a lack o complete
division o the distal margin o the transverse carpal ligament on palpa-
tion o the canal a ter I withdrew the scope. When I reintroduce the scope
in this setting, the bleeding makes it di cult to see sa ely, and I have had
to convert to an open approach. Most recently, I have made extra e orts
to ully divide the most distal edge o the ligament and thus avoided the
need or reintroduction o the scope a ter palpation with a dilator. The
conversion approach has not required a ull open exposure but rather a
short counterincision in the palm, much like what one would make or a
two-portal approach.
•
Waiting at least 20 minutes on a timer is important, because this
will result in a more pro ound anesthesia or the patient and visible
blanching o the surgical site. The latter is important to minimize
bleeding or oozing at the surgical site and into the endoscopic eld.
•
The greatest bleeding problems come rom the incision site i you cut
a super cial vein, which can then ooze into the wound and even into
the scope device when you introduce it. Being cautious to avoid those
super cial bleeders is extremely help ul to obviate that problem. The
transverse carpal ligament itsel is very avascular, and there will not be
many problems with bleeding rom the ligament itsel .
References
1. Chandran GJ, Chung B, Lalonde J, Lalonde DH. The hyperthermic effect of a distal volar
forearm nerve block: a possible treatment of acute digital frostbite injuries? Plast Recon-
str Surg 126:946, 2010.
2. Braithwaite BD, Robinson GJ, Burge PD. Haemostasis during carpal tunnel release under
local anaesthesia: a controlled comparison of a tourniquet and adrenaline infiltration. J
Hand Surg Br 18:184, 1993.
3. Ralte P, Selvan D, Morapudi S, Kumar G, Waseem M. Haemostasis in open carpal tunnel
release: tourniquet vs local anaesthetic and adrenaline. Open Orthop J 4:234, 2010.
4. McKee DE, Lalonde DH, Thoma A, Glennie DL, Hayward JE. Optimal time delay between
epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg 131:811,
2013.
5. Lalonde DH, Wong A. Local anesthetics: what’s new in minimal pain injection and best
evidence in pain control? Plast Reconstr Surg 134(4 Suppl 2):40S, 2014.
6. Lalonde DH. “Hole-in-one” local anesthesia for wide awake carpal tunnel surgery. Plast
Reconstr Surg 126:1642, 2010.
7. Farhangkhoee H, Lalonde J, Lalonde DH. Teaching medical students and residents how to
inject local anesthesia almost painlessly. Can J Plast Surg 20:169, 2012.
8. Lalonde DH, Wong A. Dosage of local anesthesia in wide awake hand surgery. J Hand
Surg Am 38:2025, 2013.
Clip 18-10
Endoscopic carpal
tunnel surgery.

137
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN CUBITAL TUN N EL
D ECOMPRESSION SURGERY
•
Positioning patients with their elbow above their head is much eas-
ier or your access as the surgeon. The anesthesiologist and his or her
equipment will not be occupying your valuable surgical access space.
•
There is no tourniquet, so you have much easier access to the proximal
incision.
•
Patients can position themselves com ortably so the elbow and the
shoulder are not sore during the surgery. They do not wake up rom
general anesthesia with shoulder pain that we caused by putting their
shoulder in a position it does not like.
•
You can see whether the ulnar nerve subluxates with active movement
by watching patients actively f ex and extend the elbow through a ull
range o motion be ore you close the skin. I the nerve subluxates, you
can transpose it i required.
•
You can per orm cubital tunnel decompression with eld sterility or
augmented eld sterility (see Chapter 10).
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
This patient with a stiff elbow and
a sore shoulder has been placed in
a comfortable position for a cubital
tunnel release. We negotiated differ-
ent positions until he found this one
worked best to accommodate his
stiff elbow and sore shoulder from
old injuries.
Clip 19-1 Checking
for ulnar nerve
subluxation with
active movement
during surgery.
Ch a P t e r 19
Cu bit al Tu n n el D ec o mpr es sio n
o f t h e Ul n ar N er ve
Donald H. Lalonde, Alistair Phillips

Sec t io n B ° N er ve D ec o mpr essio n
138
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC
FOR CUBITAL TUN N EL D ECOMPRESSION
Inject 60 ml of 0.5% lidocaine with
1:200,000 epinephrine buffered with
3 ml of 8.4% sodium bicarbonate for
a ratio of 10 ml lido/epi:1 ml of 8.4%
sodium bicarbonate.
•
See Chapter 1, Atlas, or more illustrations o the anatomy o di usion
o tumescent local anesthetic in the orearm, wrist, and hand.
SPECIFICS OF MIN IMALLY PAIN FUL IN JECTION
OF LOCAL AN ESTH ETIC FOR CUBITAL TUN N EL
D ECOMPRESSION
•
Inject 20 ml subcutaneously in the most proximal part o the incision,
ollowed by 20 ml in the middle o the incision, and then 20 ml at the
end o the incision.
•
Inject the anesthetic solution a minimum o 30 minutes be ore surgery
to allow the epinephrine to take optimal e ect and provide an ade-
quately dry working eld.
•
We inject supine patients on stretchers in a waiting area to decrease
the risk o their ainting (see Chapter 6).
•
To minimize pain o injection, start with a ne 27-gauge needle (not a
25-gauge) into the most proximal injection point (red dot).
•
Ask the patient to look away. Press with a ngertip just proximal to
the injection site be ore you put in the needle to add the sensory
“noise” o touch pressure to decrease the pain.
•
Mix 30 ml o 1% lidocaine with 3 ml o 8.4% bicarbonate into a
50 ml bag o saline solution that contains only 30 ml. (You remove
20 ml rom the 50 ml bag be ore adding the lidocaine.) This gives you
63 ml o 0.5% lidocaine with 1:200,000 epinephrine bu ered 10:1 with
8.4% sodium bicarbonate.
•
Insert the rst needle perpendicularly into the subcutaneous at. Stabi-
lize the syringe with two hands to avoid causing pain rom needle
Clip 19-2 How
to inject local
anesthetic for cubital
tunnel release at the
elbow.
Clip 19-3 Real-time
injection of local
anesthetic for cubital
tunnel release.

Ch apt er 19 ° Cu bit al Tu n n el D ec o mpr essio n o f t h e Ul n ar N er ve
139
wobble until the skin needle site is numb. Inject the rst visible 0.5 ml
bleb and then pause. Wait 15 to 45 seconds until the patient tells you
that all needle pain is gone. Inject the rest o the rst 10 ml slowly
(over 2 minutes) without moving the needle.
•
Inject 20 ml at the proximal injection point o the incision, 20 ml at
the middle injection point, and 20 ml at the distal injection point. Al-
ways reinsert injection needles into an area with 1 cm o blanched skin
around it to ensure that needle reinsertion does not hurt.
•
Inject just under the skin. There is no need to inject into the cubital
tunnel; it would only add unnecessary pain. The local anesthetic will
di use into the tunnel.
•
I you want to per orm endoscopic cubital tunnel decompression that
goes arther distally in the orearm, you can inject another 20 ml or
more distally in the orearm so that you have at least 2 cm o palpable
or visible local anesthetic beyond your area o dissection.
•
For those who pre er anterior transposition, the so t tissue in the
new nerve path will need to be more extensively f ooded with another
20 ml o local anesthetic. The image on p. 138 shows local anesthetic
injection or simple cubital tunnel release.
•
We have not worked out the technique or submuscular transposition
at this time, since we do not do that operation. You would likely need
to inject beneath the deep orearm ascia to accomplish that opera-
tion as a wide awake procedure.
TIPS AN D TRICKS FOR PERFORMIN G CUBITAL TUN N EL
D ECOMPRESSION WITH TH E WID E AWAKE APPROACH
•
Many patients have a sore shoulder and wake up rom general anes-
thesia with more shoulder pain a ter cubital tunnel release. When you
per orm an awake procedure, you can adjust their position or local
anesthetic injection and surgery so you do not worsen their shoulder
problem.
The elbow and shoulder are positioned at 90 degrees for injection of local anesthetic and surgery.
Clip 19-4 Injecting
for both cubital
tunnel and carpal
tunnel release in the
same operation.
Clip 19-5
57 mm blunt-tipped
22-gauge cannula
injection of local
anesthetic for cubital
tunnel release.
Clip 19-6 Prepping
and draping for a
WALANT cubital
tunnel ulnar nerve
release.
Clip 19-7 Cubital
tunnel surgery with
WALANT.

Sec t io n B ° N er ve D ec o mpr essio n
140
The surgery can be per-
formed from behind with
the patient on his side if he
cannot abduct the shoulder.
•
When the elbow is f exed, the nerve is tight in the canal, and there is
less space to get your scissors in to open the roo o the canal. Ask the
patient to extend the elbow until that maneuver is easy, then return
the arm to elbow f exion. The awake cooperative patient makes this
easy.
•
Whether you use our towels with eld sterility or hal sheets or en-
hanced eld sterility or ull sterility, apply the drapes loosely enough
to allow active ull elbow f exion and extension.
•
I we per orm carpal tunnel release and cubital tunnel release at the
same time, we inject the cubital tunnel with local anesthetic rst and
operate on it a ter the carpal tunnel release. This gives the epineph-
rine longer to work at the cubital tunnel, where hemostasis is more
important.
•
We do not routinely need cautery or cubital tunnel release, because
we wait at least hal an hour or the epinephrine to work. An hour is
even better.
•
A ter cubital tunnel release, get the patient to actively f ex and extend
the elbow to see i the nerve is subluxating. I you eel that a subluxat-
ing nerve will be a problem or the patient, you can tack it anteriorly
on the orearm ascia as in anterior transposition.

141
Ch a P t e r 2 0
Lac er t u s Syn d r o me: Med ian
N er ve Rel ease at t h e El bo w
Elisabet Hagert, Donald H. Lalonde
Lacertus syndrome is characterized by compression o the median nerve
under the lacertus brosus (bicipital aponeurosis) at the elbow. You can
easily release this with good results in the right patients, as described in
Clip 20-1. It is a simple procedure, similar to carpal tunnel release with
WALANT.
You make the diagnosis o lacertus syndrome on a clinical examination
triad consisting o :
1. Weakness in the f exor carpi radialis (FCR), f exor pollicis longus (FPL),
and f exor digitorum pro undus muscles o the index nger (FDP2)
2. Pain over the median nerve at the medial edge o the lacertus
brosus1
3. A positive scratch collapse test over the median nerve at the elbow
Clip 20-2 demonstrates clinical examination o lacertus syndrome showing
weakness o FCR, FDP2, FPL, tenderness under lacertus brosis, and posi-
tive scratch collapse test.
• Although less prominent than motor signs, sensory symptoms in the
median nerve distribution are present in some patients, especially in
the palmar cutaneous branch distribution.
•
Consider this diagnosis i patients complain o weakness or numbness in
the palmar cutaneous distribution, or a ter ailed carpal tunnel release.
• You will not make this diagnosis with nerve conduction studies. You
make the diagnosis o lacertus syndrome through a history and a thor-
ough physical motor examination.2
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN MED IAN N ERVE RELEASE
AT TH E ELBOW
•
You can see that you have solved your patient’s problem by watching
him get the power back to his FPL, FDP2, and FCR on the operating
table be ore you close the skin, as shown in our videos in this chapter.
•
Your patient can see that you have solved his problem when he
watches power return to his FPL, FDP2, and FCR on the operating table.
Clip 20-1 What is
lacertus syndrome?
Clip 20-2 Clinical
examination of
lacertus syndrome.

Sec t io n B ° N er ve D ec o mpr essio n
142
•
Your ngertip can eel the super cialis sling actively f ex over the
median nerve inside the wound. You ask the patient to f ex the long
and ring ngers and eel the e ect on the super cialis sling. You can
choose to divide it i you eel it is a problem.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC FOR
LACERTUS TUN N EL RELEASE AT TH E ELBOW
Lacertus
fibrosis
Inject at least 30 ml of 1% lidocaine
with epinephrine 1:100,000 (available in
North America) or 1:200,000 (available
in Sweden) with 3 ml 8.4% sodium
bicarbonate solution.
•
See Chapter 1, Atlas, or more illustrations o the anatomy o di usion
o tumescent local anesthetic in the orearm, wrist, and hand.
SPECIFICS OF MIN IMAL PAIN IN JECTION OF LOCAL
AN ESTH ETIC IN LACERTUS TUN N EL RELEASE AT
TH E ELBOW
•
Inject in the at just under the skin and super cial ascia rom proximal
to distal. There is no need to inject under the deep orearm muscle as-
Clip 20-3 Local
anesthetic injection
for lacertus and
carpal tunnel release.

Ch apt er 20 ° Lac er t u s Syn d r o me: Med ian N er ve Rel ease at t h e El bo w
143
cia. The goal is to leave the median nerve motor branches unanesthe-
tized so you can test muscle power a ter you divide the lacertus.
•
We inject the anesthetic solution a minimum o 30 minutes be ore sur-
gery to allow the epinephrine to take optimal e ect and provide an
adequately dry working eld,3 as outlined in Chapter 4.
•
We inject supine patients lying down on stretchers in a waiting area to
decrease the risk o ainting (see Chapter 6).
•
Since the skin on the volar aspect o the elbow is quite thin and elas-
tic, pinch it lightly and insert the needle into the pinched and elevated
skin to add the sensory “noise” o pressure to decrease the pain rom
the rst needle insertion. You can also move the skin into the needle
tip. Ask the patient to look away.
•
Slowly inject to f ood the incision area, and then advance obliquely to
cover the course o the median nerve over a distance o at least 10 cm.
•
To minimize pain o injection, start with a ne 27-gauge needle (not a
25-gauge) into the most proximal injection point (red dot).
•
Inject the rest o the rst 10 ml slowly (over 2 minutes) without mov-
ing the needle.
•
Continue injecting rom proximal to distal, blowing the local anes-
thetic slowly ahead o the needle. There should always be at least
1 cm o visible or palpable local anesthetic ahead o the sharp needle
tip that would hurt the patient i you advanced it into “live” nerves.
“Blow slow be ore you go.” (See Chapter 5 or urther tips on how to
inject the local anesthetic with minimal pain.)
•
Reinsert the needle arther distally into skin that is within 1 cm o
clearly white and vasoconstricted tissue. I the epinephrine is working,
so is the lidocaine. Needle reinsertion will not hurt.
•
The more volume you inject, the greater the odds that no additional
anesthetic will be required a ter you start to dissect. Try to avoid the
need to “top-up” the anesthetic. The usual culprit is insu cient vol-
ume o tumescent local anesthetic.
•
The anesthesia should cover the area between the medial epicondyle
and biceps tendon, as well as distally past the lacertus brosus and the
super cialis sling.
IF YOU ARE WORKIN G WITH AN AN ESTH ESIOLOGIST
•
Ask him or her to use only propo ol. Inject the lidocaine with epineph-
rine as soon as the propo ol permits injection o pain- ree local an-
esthetic. The anesthesiologist can then wake the patient right away
while you are scrubbing, prepping, and draping. This will give you the
bene t o intraoperative patient teaching (see Chapter 8) and ully co-
operative pain- ree movement. This will also allow a little time or the
epinephrine to become more e ective. Suggest that the anesthesia
provider avoid administering opiates and amnestics to prevent nausea
and permit the patient to remember your intraoperative advice.

Sec t io n B ° N er ve D ec o mpr essio n
144
TIPS AN D TRICKS FOR PERFORMIN G LACERTUS TUN N EL
RELEASE AT TH E ELBOW WITH TH E WID E AWAKE
APPROACH
•
Resisted active elbow f exion during the surgery helps identi y the bi-
ceps and lacertus brosus with your ngertip in the wound.
•
In this condition, the brachial artery is requently not palpable with
a nger in the wound be ore you cut the thickened lacertus. A ter
la certus release, the brachial artery should be easily palpable rom
above the elbow to past the super cialis sling.
•
When manipulating the lacertus, warn the patient that he or she may
eel pressure.
•
Be care ul not to touch the median nerve, because the patient may
eel unnecessary paresthesias. However, it may be help ul to warn the
patient that he or she may eel a temporary pain akin to an “electrical
current” out into the orearm and/or hand and that this is not danger-
ous. It just means that you are releasing the nerve.
•
Once you have divided the lacertus brosus and released the median
nerve, care ully let your nger slide distally and proximally over the
nerve to rule out other compression points. I there is doubt as to pos-
sible entrapment o the median nerve at the super cialis sling, ask the
patient to f ex the ring and then the long ngers while you palpate at
the level o the super cialis arcade. I you eel a constriction, consider
releasing the super cialis arcade through a separate small transverse
skin incision. You have already numbed this area.
•
When you have adequately released the nerve, test the strength o
the FPL and FDP2 to check or immediate improvement (see Clips 20-1
and 20-4). Ask patients to look at their hand as you test the strength,
so they can see the action in the thumb and index nger. You can
cover the wound with a towel i they do not want to see it. Patients
will be pleased to see the power o their thumb and index nger re-
turn.
References
1. Hagert E. Clinical diagnosis and wide-awake surgical treatment of proximal median nerve
entrapment at the elbow: a prospective study. Hand (N Y) 8:41, 2013.
2. Hagert CG, Hagert E. Manual muscle testing—a clinical examination technique for di-
agnosing focal neuropathies in the upper extremity. In Slutsky DJ, ed. Upper Extremity
Nerve Repair: Tips and Techniques. A Master Skills Publication. Rosemont, IL: American
Society for Surgery of the Hand, 2008.
3. McKee DE, Lalonde DH, Thoma A, Glennie DL, Hayward JE. Optimal time delay between
epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg 131:811,
2013.
Clip 20-4 Surgical
release of lacertus
fibrosus by Dr.
Elisabet Hagert.
Clip 20-5 Lacertus
and carpal tunnel
injection and surgery
by Dr. Don Lalonde.

145
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN TRIGGER FIN GER SURGERY
•
Patients are able to see that the triggering action is gone as they
watch themselves moving their ngers through a ull range o motion
be ore skin closure. They can see and anticipate that their hand will
work well once they get past the postoperative discom ort and sti -
ness.
•
You only need to divide the part o the pulley that is required to solve
the problem as seen by active f exion, not the entire A1 pulley.
•
A ter you release the pulley, you will occasionally see a band o brous
tissue proximal to the pulley still causing triggering with active move-
ment. You can release it and veri y that you have solved the problem
with ull active f exion.
•
A major advantage o eliminating sedation or trigger nger surgery
is that you do not need to per orm the procedure in the main oper-
ating room. We per orm all trigger nger procedures in minor treat-
ment rooms in the clinic outside the main operating room with eld
sterility (see Chapter 10).
•
Many o these patients have diabetes, and because no sedation is
given, you do not have to deal with their medical comorbidities, which
are only a problem with sedation.
•
You can easily per orm 15 or more carpal tunnel releases mixed with
trigger nger procedures in 1 day with only one nurse with eld ste-
rility in the o ce or clinic. You can also see consultation and recheck
patients between operations (see Chapter 14).
•
Although patients can “tolerate” 7 minutes o tourniquet use, they
don’t have to have any tourniquet pain at all i you simply use epi-
nephrine with the lidocaine solution. There is ample high-level evi-
dence that the tourniquet hurts twice as much as the local anesthetic
injection in carpal tunnel surgery.1,2 Patients appreciate the tourniquet-
ree experience.
•
You avoid tourniquet let-down bleeding.
•
You do not need cautery, particularly i you inject the lidocaine-
epinephrine solution hal an hour be ore you make an incision.
We have not opened a cautery or 25 years or trigger ngers, and
hematoma has not been a problem, even in patients receiving antico-
agulants.
Clip 21-1 Trigger
finger and thumb
injection and surgery
overview.
t e n D o n D e c o m p r e S S i o n
Ch a P t e r 2 1
Tr ig g er Fin g er
Donald H. Lalonde

Sec t io n C ° Ten d o n D ec o mpr essio n
146
•
Your patients remain pain ree or at least 3 to 5 hours using the tech-
nique described below.
•
There is no nausea and vomiting.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC FOR
TRIGGER FIN GER AN D TRIGGER TH UMB
Inject 4 ml of 1% lidocaine with 1:100,000 epinephrine (buffered with 10 ml lido/epi:1 ml of
8.4% sodium bicarbonate) under the skin at the red injection dot site.
•
See Chapter 1, Atlas, or more illustrations o the anatomy o di usion
o tumescent local anesthetic in the orearm, wrist, and hand.
SPECIFICS OF MIN IMALLY PAIN FUL IN JECTION OF
LOCAL AN ESTH ETIC FOR TRIGGER FIN GER SURGERY
•
Inject just under the skin. There is no need to inject into the sheath;
this would only add unnecessary pain. The local anesthetic will di use
into the sheath.
•
I you inject into the sheath, the local anesthetic will di use up the
sheath into the whole nger or thumb. With enough pressure, the
sheath will “explode” or burst. This will cause pain and send the epi-
nephrine and lidocaine to the very end o the digit. This can cause a
white ngertip. As with almost all white ngertips, it will eventually
pink up. However, phentolamine can be injected to reverse the vaso-
constriction (see Chapter 3).
Clip 21-2 Injection
of local anesthetic
for trigger thumb
surgery.

Ch apt er 21 ° Tr ig g er Fin g er
147
•
Inject the anesthetic solution a minimum o 30 minutes be ore surgery
to allow the epinephrine to take optimal e ect and provide an ade-
quately dry working eld, as outlined in Chapters 4 and 14.
•
We inject supine patients lying down on stretchers to decrease the risk
o their ainting (see Chapter 6).
•
To minimize the pain o injection, start with a ne 27-gauge needle
(not a 25-gauge).
•
Ask the patient to look away. Press with a ngertip just proximal to
the injection site be ore you put in the needle to add the sensory
“noise” o pressure to decrease the pain.
•
Insert the needle perpendicularly into the subcutaneous at. Stabi-
lize the syringe with two hands and have your thumb ready on the
plunger to avoid the pain o needle wobble until the skin needle site
is numb. Inject the rst visible 0.5 ml bleb and then pause. Wait 15 to
45 seconds until the patient tells you that all needle pain is gone. In-
ject the rest o the 4 ml slowly (over 2 minutes) without moving the
needle.
TIPS AN D TRICKS FOR PERFORMIN G TRIGGER
TH UMB OR FIN GER SURGERY WITH TH E WID E
AWAKE APPROACH
•
The patient needs to look at the ngers to get them to move, since he
or she cannot eel the numbed digit. Although most patients don’t
mind looking at the wound, you can cover the wound with a towel as
the patient f exes all ngers together while looking at them.
•
Many patients are interested in looking at the tendon to understand
the nature o their problem. O er patients a guided tour o their
trigger nger surgery. Many will accept and be delighted that they
were given the opportunity to experience seeing the inside o their
hand. You can put a mask on the patient, show him the tendon and
have him watch it move. Many patients love this. Some patients have
told others it is something they need to put on their bucket list!
•
Outside the operating room, inject two to our patients who will un-
dergo relatively straight orward procedures such as trigger nger or
thumb release, carpal tunnel release, and excision o a ganglion cyst
outside the operating room be ore operating on the rst patient.
This gives at least hal an hour or the local anesthetic to work both
or lidocaine numbing and or epinephrine vasoconstriction. It takes
26 minutes to achieve peak vasoconstriction in humans a ter 1:100,000
epinephrine injection (level I evidence).3
•
A ter you inject the rst patient, most o them usually eel well
enough to go sit in the waiting area or their surgery. You can then in-
ject the second patient, then the third one. Next you can per orm the
surgery on the rst patient. While the nurse turns over the room a ter
the rst one, you can inject the ourth patient.
Clip 21-3 Trigger
thumb surgery.
Clip 21-4 Wide
awake trigger finger
surgery

Sec t io n C ° Ten d o n D ec o mpr essio n
148
We use Desmarres or vein retractors,
which help to keep the fat out of the way
and show the sheath.
•
Have your assistant push down on the Desmarres retractors to keep
the at out o the way and decrease the small amount o bleeding
that sometimes occurs, especially i the patient is hypertensive or re-
ceiving anticoagulants.
•
You can educate the patient during the local anesthetic injection
(3 minutes) and during the surgery and bandage application (10 min-
utes). This gives you 13 minutes o patient education time, which will
serve to decrease your complication rate and decrease the time you
would spend educating the patient in the o ce (see Chapter 8).
References
1. Braithwaite BD, Robinson GJ, Burge PD. Haemostasis during carpal tunnel release under
local anaesthesia: a controlled comparison of a tourniquet and adrenaline infiltration. J
Hand Surg Br 18:184, 1993.
2. Ralte P, Selvan D, Morapudi S, Kumar G, Waseem M. Haemostasis in open carpal tunnel
release: tourniquet vs local anaesthetic and adrenaline. Open Orthop J 4:234, 2010.
3. McKee DE, Lalonde DH, Thoma A, Glennie DL, Hayward JE. Optimal time delay between
epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg 131:811,
2013.

149
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN D E Q UERVAIN RELEASE
•
You can see active movement di erentiating the abductor pollicis lon-
gus (APL) and the extensor pollicis brevis (EPB) so you can identi y and
release both compartments.
•
A De Quervain release is such a short and simple operation that elimi-
nating the tourniquet and sedation, with their associated discom orts
and inconveniences, is good or both you and the patient.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC
FOR D E Q UERVAIN RELEASE
Inject 10 ml of 1% lidocaine with 1:100,000 epinephrine (buffered with 10 ml lido/epi:1 ml of 8.4%
sodium bicarbonate) subcutaneously in the center of the incision area.
•
See Chapter 1, Atlas, or more illustrations o the anatomy o di usion
o tumescent local anesthetic in the orearm, wrist, and hand.
Ch a P t e r 2 2
D e Q u er vain Rel ease
Donald H. Lalonde, Alistair Phillips

Sec t io n C ° Ten d o n D ec o mpr essio n
150
SPECIFICS OF MIN IMAL PAIN IN JECTION OF LOCAL
AN ESTH ETIC IN D E Q UERVAIN RELEASE
•
Inject just under the skin. There is no need to inject into the sheath;
this would only add unnecessary pain. The local anesthetic will di use
into the sheath i you wait hal an hour.
•
Since the skin on the radial wrist is thin and elastic, you can pinch it
lightly and insert the needle into the pinched and elevated skin to
add the sensory “noise” o pressure to decrease the pain rom the rst
needle insertion. You can also move the skin into the needle tip. Ask
the patient to look away.
•
There is no need to move the needle rom the initial placement site
under the skin. The local anesthetic will go everywhere it needs to go.
Think o it as an extravascular Bier block injected only where you need it.
•
We inject the anesthetic solution a minimum o 30 minutes be ore sur-
gery to allow the epinephrine to take optimal e ect and provide an
adequately dry working eld, as outlined in Chapters 4 and 14.
•
We inject supine patients lying down on stretchers in a waiting area to
decrease the risk o their ainting (see Chapter 6).
•
To minimize the pain o injection, inject with a ne 27-gauge needle
(not a 25-gauge) into the red dot injection point at the center o the
incision.
•
Insert the rst needle perpendicularly into the subcutaneous at. Have
your thumb ready on the plunger to avoid needle wobble pain un-
til the skin needle site is numb. Inject the rst visible 0.5 ml bleb and
then pause. Ask the patient to tell you when the needle pain is all
gone. When he or she says the pain is gone, inject the rest o the 10 ml
slowly (over 2 to 3 minutes) without moving the needle.
TIPS AN D TRICKS FOR PERFORMIN G D E QUERVAIN
RELEASE WITH TH E WID E AWAKE APPROACH
•
The patient may need to look at the thumb to get it to move, since
it is partially numbed. Although most patients do not mind looking
at the wound, you can cover the wound with a towel as the patient
f exes and extends the thumb.
•
Many patients are interested in looking at the tendon to understand
the nature o their problem. You can put a mask on them, then show
them the tendon and watch it move. Many patients love this. Some
will tell others it is something they need to put on their bucket list!
•
Desmarres or vein retractors help to keep the at away and show the
sheath (see Chapter 21).
•
Field sterility is well suited to this brie operation to increase e ciency
(see Chapters 10 and 14).
Clip 22-1 Injection
and surgery for
De Quervain
synovitis. (Note that
lignocaine is the
same as lidocaine.)

151
Ch a P t e r 2 3
D u pu yt r en ’s Co n t r ac t u r e
Duncan McGrouther, Jason Wong, Donald H. Lalonde
D u p u y t r e n ’S c o n t r A c t u r e A n D S o f t t i S S u e e x c i S i o n
AD VAN TAGES OF WALAN T VERSUS SED ATION AN D
TOURN IQUET IN D UPUYTREN ’S CON TRACTURE
•
With the wide awake approach, you can see how much active exten-
sion the patient can really achieve a ter cord resection and be ore the
skin is closed. You and the patient both nd out during surgery
whether or not the patient is likely to regain ull active extension, thus
avoiding the patient’s having unrealistic expectations a ter surgery.
•
Many o these patients are older and could have problems with gen-
eral anesthesia and sedation because o medical comorbidities. With
WALANT, they will just get up and go home as they do a ter they have
a dental procedure.
•
Patients get to see that the cord and nodule are gone as they watch
themselves moving their ngers through a ull range o motion be ore
the skin is closed. They realize that their ngers can work well once
they get past the postoperative discom ort and sti ness.1,2
•
Procedures requiring correction o multiple digits and revisions are not
time limited by the use o a tourniquet.
•
When a patient is being treated or recurrent Dupuytren’s contracture,
his or her mindset may be quite di erent than during a primary sur-
gery or the condition. The patient may eel that during the initial re-
pair there was minimal ollow-up and perhaps not enough discussion
about the act that the disease would likely recur in the uture. The
wide awake procedure allows you to have a prolonged consultation
with the patient during the surgery to discuss the recurrent nature o
this condition and postoperative rehabilitation options.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
Clip 23-1 Verifying
active extension with
active movement
after cord resection.

Sec t io n D ° D u pu yt r en ’s Co n t r ac t u r e an d So f t Tiss u e Exc isio n
152
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC FOR
D UPUYTREN ’S CON TRACTURE
Inject up to 25 ml of 1% lidocaine with 1:100,000 epinephrine (buffered with 10 ml lido/epi:1 ml of
8.4% sodium bicarbonate).
•
See Chapter 1, Atlas, or more illustrations o the anatomy o di usion
o tumescent local anesthetic in the orearm, wrist, and hand.
SPECIFICS OF MIN IMALLY PAIN FUL IN JECTION OF
LOCAL AN ESTH ETIC IN D UPUYTREN ’S CON TRACTURE
•
Inject supine patients lying down on stretchers be ore they come into
the operating room, as outlined in Chapters 4, 5, and 14, to give the
lidocaine and epinephrine time to work optimally and to decrease the
risk o their ainting (see Chapter 6).
•
To minimize the pain o injection, start with a ne 27-gauge needle
(not a 25-gauge).
•
Ask the patient to look away. Press with a ngertip just proximal to
the injection site be ore you put in the needle to add the sensory
“noise” o pressure to decrease the pain.
•
Insert the needle perpendicularly into the subcutaneous at in the
most proximal point o the palm where you are likely to dissect. Sta-
bilize the syringe with two hands and have your thumb ready on the
plunger to avoid the pain o needle wobble until the skin needle site
is numb. Inject the rst visible 0.5 ml bleb and then pause. Wait 15 to
45 seconds until the patient tells you that all the needle pain is gone.
Inject the rest o the rst 10 ml slowly (over 2 to 3 minutes).
•
Slowly advance the needle down below the ascia a ter putting the
rst 2 to 3 ml under the skin, and inject the last 7 ml there a ter aspi-
rating to be sure the needle is not in a large vessel. It is ideal to wait
30 minutes while you do something else that is a good use o your
time; this will allow ull anesthesia o all o the distal nerves, and the
epinephrine has time to vasoconstrict maximally.

Ch apt er 23 ° D u pu yt r en ’s Co n t r ac t u r e
153
•
Inject another 9 ml in the distal palm (3 ml on either side o and be-
tween the two cords) now that the distal palm and digital nerves are
numb.
•
The cords can act as a barrier to the di usion o local anesthetic. This
is why you may need to inject on both sides o a cord. You should be
able to see and palpate the local anesthetic under the skin at the site
where you will make an incision and dissect.
•
Inject another 2 ml in the middle o each proximal and middle phalanx
wherever you are going to dissect. I you are going to dissect into the
distal phalanx, you will only need 1 ml in the middle o the subcutane-
ous at there.
•
I you are going to be doing orce ul joint manipulation or joint dis-
section, you may well need another 4 ml proximal to the dorsal MP
joint as well as on the ulnar side o the small nger to make sure all
dorsal joint branches are blocked.
TIPS AN D TRICKS FOR PERFORMIN G D UPUYTREN ’S
CON TRACTURE SURGERY WITH TH E WID E AWAKE
APPROACH
•
Your rst WALANT case should not be a Dupuytren’s procedure. Sec-
ondary Dupuytren’s surgeries are clearly even harder. This operation
can be di cult or novice surgeons and trainees and can increase the
risk o nerve damage. You should be com ortable with both WALANT
and Dupuytren surgery be ore embarking on this procedure with the
wide awake approach.
•
WALANT surgery is not bloodless surgery. Dupuytren’s, especially re-
current Dupuytren’s, is the least dry operation in wide awake surgery.
This is because the cords requently wrap around the digital arteries,
which are still pumping blood when bathed with 1:100,000 epineph-
rine. Their little branches bleed when avulsed by cord dissection. We
recommend that you not per orm Dupuytren’s with WALANT until you
are com ortable using WALANT or other procedures.
•
One concern with per orming Dupuytren’s asciectomy with this tech-
nique is that the blood in the eld o view can obscure the disease. It
is possible that you can leave disease behind that you might have re-
moved under a bloodless eld approach.
•
You can apply a loose, uninf ated tourniquet to the upper arm as a
sa ety net.
•
Patients need to look at the ngers to get them to move, since they
cannot eel the numbed ngers. Although most patients do not mind
looking at the wound, you can cover the wound with a towel as they
f ex all ngers together while looking at them.
•
For dermo asciectomy, our pre erred ull-thickness skin gra t donor
site is the inner upper arm, 5 cm above the medial epicondyle and
below the tourniquet (i you apply one). Clearly, this area will require
urther local anesthesia.
Clip 23-2 Injecting
local anesthetic for
Dupuytren’s surgery.

Sec t io n D ° D u pu yt r en ’s Co n t r ac t u r e an d So f t Tiss u e Exc isio n
154
•
Also or dermo asciectomy, we restrict the resection to the proximal
segment o the digit, whereas Logan’s group 3 has generally recom-
mended extending urther proximally. We remove a short segment o
longitudinal cord at the distal palmar crease to release a contracted
MP joint. However, we leave Dupuytren’s tissues proximal and distal to
the gra ted area as, relieved rom tension, they regress.
References
1. Denkler K. Dupuytren’s fasciectomies in 60 consecutive digits using lidocaine with epi-
nephrine and no tourniquet. Plast Reconstr Surg 115:802, 2005.
2. Nelson R, Higgins A, Conrad J, Bell M, Lalonde D. The wide-awake approach to Dupuy-
tren’s disease: fasciectomy under local anesthetic with epinephrine. Hand (N Y) 5:117,
2010.
3. Armstrong JR, Hurren JS, Logan AM. Dermofasciectomy in the management of Dupuy-
tren’s disease. J Bone Joint Surg Br 82:90, 2000.

155
Ch a P t e r 2 4
Fl exo r Sh eat h Gan g l io n
Donald H. Lalonde
AD VAN TAGES OF WALAN T VERSUS SED ATION AN D
TOURN IQUET IN FLEXOR SH EATH GAN GLION SURGERY
•
Patients no longer have to go through all the inconveniences o seda-
tion, a tourniquet, or general anesthesia or such a minor operation.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC
FOR FLEXOR SH EATH GAN GLION SURGERY
Inject 2 ml of 1% lidocaine with 1:100,000
epinephrine (buffered with 10 ml lido/epi:
1 ml of 8.4% sodium bicarbonate) in each
of the two red injection points shown on
the distal palm and proximal phalanx. First
inject the palmar red dot injection point,
then the proximal phalanx.
Flexor sheath ganglion
•
See Chapter 1, Atlas, or more illustrations o the anatomy o di usion
o tumescent local anesthetic in the orearm, wrist, and hand.
SPECIFICS OF MIN IMALLY PAIN FUL IN JECTION
OF LOCAL AN ESTH ETIC IN FLEXOR SH EATH
GAN GLION SURGERY
•
The palmar/digital crease ligaments create a natural barrier to di u-
sion o local anesthetic. This is why you need to inject on both sides o
the crease.

Sec t io n D ° D u pu yt r en ’s Co n t r ac t u r e an d So f t Tiss u e Exc isio n
156
•
Inject in the at just under the skin, aiming midway between the two
digital nerves so you do not damage either one. There is no need to
inject into the sheath; this would only add unnecessary pain. The local
anesthetic will di use into the sheath during the waiting period.
•
I you inject into the sheath, the local anesthetic will di use up the
sheath into the whole nger or thumb. With enough pressure, the
sheath will “explode” or burst. This will cause pain and send the epi-
nephrine and lidocaine to the very end o the digit. This can cause a
white ngertip. As with almost all white ngertips, it will eventually
pink up. However, phentolamine can be injected to reverse the vaso-
constriction (see Chapter 3).
•
We inject the anesthetic solution a minimum o 30 minutes be ore sur-
gery to allow the epinephrine to take optimal e ect and provide an
adequately dry working eld, as outlined in Chapters 4 and 14.
•
We inject supine patients lying down on stretchers in a waiting area
be ore they come into the procedure room to decrease the risk o
their ainting (see Chapter 6).
•
To minimize the pain o injection, start with a 27-gauge needle (not a
25-gauge).
•
Ask the patient to look away. Press with a ngertip just proximal to
the injection site be ore you put in the needle to add the sensory
“noise” o pressure to decrease the pain.
•
First inject 2 ml in the palmar red dot injection point, then 2 ml in the
proximal phalanx.
•
Insert the needle perpendicularly into the subcutaneous at. Stabi-
lize the syringe with two hands and have your thumb ready on the
plunger to avoid the pain o needle wobble until the skin needle site
is numb. Inject the rst visible 0.5 ml bleb and then pause. Wait 15 to
45 seconds until the patient tells you that all needle pain is gone. In-
ject the rest o the rst 2 ml slowly (over 1 minute) without moving
the needle. Then inject the proximal phalanx red dot injection point.
TIPS AN D TRICKS FOR PERFORMIN G FLEXOR SH EATH
GAN GLION SURGERY WITH TH E WID E AWAKE
APPROACH
•
Desmarres or vein retractors help to keep the at away and show the
sheath with the ganglion.
•
Field sterility is ideal or this brie operation and will increase e -
ciency (see Chapter 10).

157
Ch a P t e r 2 5
Smal l So f t Tis s u e Oper at io n s
Donald H. Lalonde, Jason Wong, Shu Guo Xing, Jin Bo Tang
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN SKIN CAN CER EXCISION
•
The large volume o tumescent local anesthetic used in this technique
actually hydrodissects the tumor o the paratenon or you. This pro-
motes the take o a skin gra t and creates a nice tissue plane, permit-
ting you to get under the cancer or complete excision o the tumor.
•
Many o these patients are older and may have problems with gen-
eral anesthesia and sedation because o medical comorbidities. With
WALANT, they will simply get up and go home a ter the procedure,
just like a ter they have a dental procedure.
•
You can educate patients during surgery about how important it is
that they keep their hand elevated and “on strike,” doing absolutely
nothing with it or the next week while the skin gra t takes. At the
end o the procedure, patients can sit up and elevate their hand with
total understanding o what to do. I patients are sedated or undergo
general anesthesia, they may not understand what to do and may be
too groggy during postoperative recovery to grasp patient teaching.
They may well keep their hand dependent and may even have prob-
lems with vomiting, which could lead to urther hematoma under the
gra t. They may require hospital admission or the procedure to get
sa e general anesthesia and monitoring.
Squamous cell skin cancer in an
89-year-old man who was receiving
anticoagulants.

Sec t io n D ° D u pu yt r en ’s Co n t r ac t u r e an d So f t Tiss u e Exc isio n
158
•
See Chapter 8 or a clip on giving a patient advice while excising skin
cancer rom the hand.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC FOR SKIN
CAN CER EXCISION
In this patient we injected at least
20 ml of buffered 1% lidocaine with
1:100,000 epinephrine (buffered with
10 ml lido/epi:1 ml of 8.4% sodium
bicarbonate). We injected from proxi-
mal to distal all around and under the
tumor edge. We let the tumescent
local anesthetic lift the tumor away
from the tendons.
SPECIFICS OF MIN IMALLY PAIN FUL IN JECTION OF
LOCAL AN ESTH ETIC IN SKIN CAN CER EXCISION
•
We inject the anesthetic solution a minimum o 30 minutes be ore sur-
gery to allow the epinephrine to take optimal e ect and provide an
adequately dry working eld, as outlined in Chapters 4 and 14.
•
We inject supine patients on stretchers in a waiting area outside the
procedure room to decrease the risk o their ainting (see Chapter 6).
We then operate on other patients while waiting or the epinephrine
to work.
•
To minimize the pain o injection, start with a ne 27-gauge needle
(not a 25-gauge) into the most proximal injection point. This point
is marked at least 1 cm proximal to the most proximal place you are
likely to dissect.
•
Ask the patient to look away. Press with a ngertip just proximal to
the injection site be ore you put in the needle to add the sensory
“noise” o pressure to decrease the pain.
•
Insert the rst needle perpendicularly into the subcutaneous at. Sta-
bilize the syringe with two hands to avoid needle wobble pain until
the skin needle site is numb. Inject the rst visible 0.5 ml bleb and then
pause. Wait 15 to 45 seconds until the patient tells you that all needle
pain is gone. Inject the rest o the rst 10 ml slowly (over 2 minutes)
without moving the needle.

Ch apt er 25 ° Smal l So f t Tis su e Oper at io n s
159
•
Reinsert the needle arther distally into skin that is within 1 cm o
clearly vasoconstricted white skin that has unctioning lidocaine and
epinephrine so that needle reinsertion is pain ree.
•
Continue injecting rom proximal to distal, blowing the local anes-
thetic slowly ahead o the needle so there is always at least 1 cm o
visible or palpable local anesthetic ahead o the sharp needle tip that
the patient would eel i you advanced it into “live” nerves. “Blow
slow be ore you go.” (See Chapter 5 or urther tips on how to inject
the local anesthetic with minimal pain.)
•
Do not insert the needle in the tumor itsel . Blow all around it rst,
rom proximal to distal. You will elevate the tumor o the tendons
with the large volume o tumescent local anesthetic.
•
The more volume that you inject, the greater the loose tissue between
the epitenon and the cancer will be elevated so that you will be able
to retain epitenon and yet completely excise the cancer.
TIPS AN D TRICKS FOR PERFORMIN G SKIN CAN CER
EXCISION WITH TH E WID E AWAKE APPROACH
•
We per ormed a wide awake skin cancer excision in an 89-year-old
man in a minor procedure room with eld sterility (see Chapter 10).
•
We waited or at least a hal an hour between local anesthetic injec-
tion and excision o the tumor to allow the epinephrine to reach maxi-
mal vasoconstriction. We per ormed a couple o carpal tunnel releases
on other patients a ter injecting this patient and while we were wait-
ing or clotting a ter his cancer excision, so we used our time produc-
tively throughout.
•
We marked the incision line be ore injecting the local anesthetic. The
skin is healthy where it is so t and olds as you push it into the rigid
cancer with your nger. The healthy skin becomes tumescent and no
longer olds readily a ter you have injected the local anesthetic.
•
We harvested a split-thickness skin gra t with a 10 blade on the loose
skin o the arm. We then excised the exposed dermis o the donor site
and closed the wound primarily with buried dermal sutures. No suture
removal was required. It healed nicely as a line scar much more quickly
than it would have healed as a split-thickness donor site.
•
A ter excising the skin cancer, we covered the wound with a saline-
soaked gauze and wrapped it with a 3-inch Kling bandage. The pa-
tient (who was receiving anticoagulants) held it in elevation without
moving his ngers. We waited another 45 minutes or the bleeding
to stop completely, per orming other small hand surgery cases while
waiting. We removed the bandage and the clots over the epitenon
and applied skin gra t to most o the wound on the epitenon over the
tendons. In this case, we used no cautery and tied o no veins, be-
cause we did not have to. We do have cautery in our minor procedure
rooms but seldom use it, since the epinephrine vasoconstriction is usu-
ally adequate. We immobilized the hand with a volar splint or a week
and reminded the patient that he should keep his hand “on strike,” el-
Clip 25-1 Surgical
sequence and result
in an 89-year-old
patient.

Sec t io n D ° D u pu yt r en ’s Co n t r ac t u r e an d So f t Tiss u e Exc isio n
160
evated without movement during the week. We got a ull take o the
gra t we applied and a complete excision o the cancer.
TIPS AN D TRICKS FOR PERFORMIN G LIPOMA EXCISION
ON TH E FOREARM WITH TH E WID E AWAKE APPROACH
•
We use the same injection technique as described above and in Chap-
ters 4 and 5.
•
I less than 50 ml is required, we use premixed 1% lidocaine with
1:100,000 epinephrine. I 50 to 100 ml is required, we dilute with sa-
line solution to a concentration o 0.5% lidocaine with 1:200,000 epi-
nephrine. I 100 to 200 ml is required, we dilute with saline solution
to a concentration o 0.25% lidocaine with 1:400,000 epinephrine (all
solutions bu ered with 10 ml 1% lido/1:100,000 epi:1 ml o 8.4% so-
dium bicarbonate).
The goal of the injection is to get at least 1 cm of firm, white, tumesced skin and fat on either side
of any incision or surrounding any dissection area. In this case, we used 20 ml of 1% lidocaine
with 1:100,000 epinephrine buffered with 2 ml of 8.4% sodium bicarbonate.
Clip 25-2 Excision
lipoma on the
forearm.

161
AD VAN TAGES OF WALAN T VERSUS SED ATION AN D
TOURN IQUET IN ARTH ROPLASTY OF TH E PROXIMAL
IN TERPH ALAN GEAL (PIP) JOIN T
•
I you choose a dorsal approach, you can see that you have repaired
the extensor mechanism properly to get the best possible active ex-
tension without rupture o the repair. You watch the patient take the
nger through a com ortable pain- ree range o motion be ore skin
closure. Sometimes the closing sutures in the extensor tendon will
burst with intraoperative testing o ull f exion and extension o the
PIP joint. It is better to know that and x it be ore you close the skin
so that a boutonniere de ormity does not develop later.
•
Patients get to see that their previously sti joint now moves as they
watch themselves f exing their nger be ore the skin is closed. They
realize that their hand will work well once they get past the postop-
erative discom ort and sti ness.
•
Through intraoperative teaching and patients’ ability to observe the
repair, they will have a realistic expectation o the best possible out-
come o range o movement when they leave the operating room.
•
You are sure that the motion is optimal be ore closing the wound. You
can adjust the tissues around the implant based on what you see with
active movement.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
Ch a P t e r 2 6
Ar t h r o pl as t y o f t h e Pr o ximal
In t er ph al an g eal Jo in t
Donald H. Lalonde
A r t h r i t i S S u r g e r y

Sec t io n E ° Ar t h r it is Su r g er y
162
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC FOR PIP
JOIN T ARTH ROPLASTY
Palmar injections: Inject 4 ml of 1% lidocaine with 1:100,000 epinephrine (buffered with 10 ml
lido/epi:1 ml of 8.4% sodium bicarbonate) in the most proximal red injection point on the palmar
side. Do the most proximal dorsal injection next, and then inject 2 ml in the middle of the palmar
proximal and middle phalanges in the subcutaneous fat. Dorsal injections: Inject 4 ml of 1% lido-
caine with 1:100,000 epinephrine (buffered with 10 ml lido/epi:1 ml of 8.4% sodium bicarbonate)
in the proximal red injection dot on the dorsal hand. Do the two palmar injections next, and then
inject 2 ml in the middle of the dorsal proximal and middle phalanges in the subcutaneous fat.
•
See Chapter 1, Atlas, or more illustrations o the anatomy o di usion
o tumescent local anesthetic in the orearm, wrist, and hand.
SPECIFICS OF MIN IMALLY PAIN FUL IN JECTION OF
LOCAL AN ESTH ETIC IN PIP JOIN T ARTH ROPLASTY
•
Inject just under the skin. There is no need to inject into the sheath. It
would only add unnecessary pain. The local anesthetic will di use into
the sheath.
•
Inject the anesthetic solution a minimum o 30 minutes be ore surgery
to allow the epinephrine to take optimal e ect and provide an ade-
quately dry working eld as outlined in Chapters 4 and 14.
•
We inject supine patients lying down on stretchers to decrease the risk
o their ainting (see Chapter 6).
•
To minimize the pain o injection, start with a ne 27-gauge needle
(not a 25-gauge).
•
Ask the patient to look away. Press with a ngertip just proximal to
the injection site be ore you put in the needle to add the sensory
“noise” o pressure to decrease the pain.
•
Insert the rst needle perpendicularly into the subcutaneous at. Sta-
bilize the syringe with two hands to avoid the pain o needle wobble
until the skin needle site is numb. Inject the rst visible 0.5 ml bleb and
then pause. Wait 15 to 45 seconds until the patient tells you that all

Ch apt er 26 ° Ar t h r o pl as t y o f t h e Pr o ximal In t er ph al an g eal Jo in t
163
the needle pain is gone. Inject the rest o the 4 ml slowly (over 1 to
2 minutes) without moving the needle.
•
In this operation, inject 4 ml in the most proximal red dot injection
point o the palm rst, and then inject 4 ml in the most proximal red
dot injection point o the dorsal hand right a ter that. This will give at
least a little time or the distal injection points to numb up be ore you
inject them.
•
The distal injections are or the epinephrine vasoconstriction e ect,
since the skin is already numb rom the proximal nerve blocks.
IF YOU ARE WORKIN G WITH AN AN ESTH ESIOLOGIST
•
Ask him or her to use only propo ol. Inject the lidocaine with epineph-
rine as soon as the propo ol permits pain- ree injection o local an-
esthetic. The anesthesiologist can then wake the patient right away
while you are scrubbing, prepping, and draping so you can get the
bene t o intraoperative patient teaching (Chapter 8) and ully co-
operative pain- ree movement. Suggest that the anesthesia provider
avoid opiates and amnestics to prevent nausea and permit the patient
to remember your intraoperative advice and discussions. This allows
the patient to know what kind o result he or she can achieve with
therapy.
TIPS AN D TRICKS FOR PERFORMIN G PIP JOIN T
ARTH ROPLASTY WITH TH E WID E AWAKE APPROACH
•
We do not worry about minor bleeding rom cut skin edges, because
most little bleeders will stop spontaneously.
•
A ter implant placement, get the patient to take the ngers through a
ull range o motion. You may want to make adjustments in the bone
to improve the movement you see be ore you repair the so t tissues.
•
A ter so t tissue closure, ask the patient to take the ngers through a
ull range o motion. You may want to make adjustments in the exten-
sor tendon closure to improve the movement you see be ore you let
the patient leave the operating room.
•
The patient needs to look at the ngers to get them to move, because
he or she cannot eel the numbed nger. Although most patients
do not mind looking at the wound, you can cover the wound with a
towel as the patient f exes all ngers together while looking at them.
•
Many patients are interested in looking at the opened nger to un-
derstand the nature o their problem. You can mask the patients and
show them the tendons and joint. Have them watch their nger move.
They will remember how well it works, and this will motivate them to
achieve that same movement with therapy.
Clip 26-1 PIP
arthroplasty.

(Trang không có chữ)

165
Ch a P t e r 2 7
Tr apez iec t o my Wit h o r Wit h o u t
Lig a men t Rec o n s t r u c t io n f o r Th u mb
Basal Jo in t Ar t h r it is
Donald H. Lalonde, Peter C. Amadio, Geoff Cook
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN TRAPEZIECTOMY
•
A ter you remove the trapezium, you can see whether the base o the
metacarpal impinges on the scaphoid when you ask the patient to
move the thumb all around. I it does, you can then add a ligament
reconstruction in any way that you choose—with the abductor pollicis
longus (APL), f exor carpi radialis (FCR), sutures, tightrope, and so on.
A ter the suspension repair, you can veri y that the reconstruction is
keeping the metacarpal away rom the scaphoid when you ask the pa-
tient to move the thumb again be ore you close the skin.
•
Clip 27-1 discusses intraoperative decision-making about simple trape-
ziectomy versus a ligament reconstruction and tendon interposition
(LRTI) based on what you see with active movement. (Also see the
videos in the Tips and Tricks section o this chapter showing both im-
pinging and nonimpinging metacarpals.)
•
A ter you nish with the basal joint work, you can assess the position
and active movement o the thumb metacarpophalangeal (MP) joint.
I the MP joint is still hyperextending, you can deal with it while the
patient’s hand is numbed. Ask the patient to move the thumb again
a ter whichever MP joint surgery you choose. You can be sure both the
basal and MP joints are actively moving well be ore you close the skin.
•
Movement without impingement a ter the trapeziectomy may help
you to decide to stop there and close the skin without ligament recon-
struction.
•
You can hear the thumb move through a ull active range o motion
a ter you remove the trapezium. You will sometimes hear remaining
osteophytes grinding through the open wound with active movement.
You can then nd and remove them.
•
Patients get to see that the thumb will be able to move through a ull
range o motion be ore the skin is closed. They know that all can work
well once they get past the postoperative discom ort and sti ness.1
Clip 27-1
Intraoperative
decision-
making about
the appropriate
procedure.

Sec t io n E ° Ar t h r it is Su r g er y
166
•
Many o these patients have medical comorbidities. Because they are
not sedated in any way, they simply get up a ter surgery and go home,
as they would a ter a dental procedure.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC
FOR A TRAPEZIECTOMY
Inject a mixture of 40 ml of saline solution plus 40 ml of 1% lidocaine with 1:100,000 epinephrine
(buffered with 10 ml lido/epi:1 ml of 8.4% sodium bicarbonate) plus 10 ml of 0.5% bupivacaine
with 1:200,000 epinephrine.
•
See Chapter 1, Atlas, or more illustrations o the anatomy o di usion
o tumescent local anesthetic in the orearm, wrist, and hand.
Clip 27-2 A patient
with medical
comorbidities
compares local and
general anesthesia.

Ch apt er 27 ° Tr apez iec t o my Wit h o r Wit h o u t Lig amen t Rec o n s t r u c t io n
167
SPECIFICS OF MIN IMALLY PAIN FUL IN JECTION
OF LOCAL AN ESTH ETIC IN A TRAPEZIECTOMY
•
Clip 27-4 shows real-time 8-minute injection o a patient with minimal
pain or a trapeziectomy and ligament reconstruction. Surgery or this
patient is shown in the ligament reconstruction in Clip 27-6, an APL
procedure.
•
Clip 27-5 shows cannula injection o local anesthetic or a trapeziec-
tomy with a 40 mm long blunt-tipped 25-gauge cannula in a hole
made with a 20-gauge needle (also see Chapter 5).
•
We inject the anesthetic solution a minimum o 30 minutes be ore
surgery to allow the epinephrine to take optimal e ect and provide
an adequately dry working eld, as outlined in Chapters 3, 4, and 14.
•
We inject supine patients lying down on stretchers in a waiting area to
decrease the risk o their ainting (see Chapter 6).
•
Start by injecting 10 ml o the mixture under the skin at the proximal
trapeziectomy incision red dot injection point.
•
A ter the rst 10 ml, inject another 10 ml on the dorsal side o the tra-
pezium, staying near the metacarpal base.
•
A ter the second 10 ml on the dorsal side, inject another 10 ml on the
volar side o the trapezium, staying near the metacarpal base.
•
A ter the third 10 ml on the volar side, inject a ourth 10 ml slowly be-
tween the thumb and index metacarpal bases going rom the dorsal
articulation to the volar side where the metacarpals meet the trape-
zium, staying near the bone.
•
Finally, distract (pull on) the thumb and inject 5 ml into the basal
metacarpal trapezial joint. This last 5 ml can also be injected into the
joint capsule under direct vision a ter the skin incision during the sur-
gery.
•
I per orming an LRTI with the f exor carpi radialis, inject 20 to 40 ml
o the mixture rom proximal to distal so there is at least 2 cm o vis-
ible or palpable local anesthetic beyond everywhere you will dissect.
•
I per orming an LRTI with the abductor pollicis longus, you may need
another 10 ml o the mixture over the proximal APL so there is at least
2 cm o visible or palpable local anesthetic outside o everywhere you
will dissect. In Clip 27-6, an APL reconstruction, no urther local anes-
thetic was needed a ter the original 40 ml.
•
To minimize pain o injection, start with a ne 27-gauge needle (not a
25-gauge).
•
Ask the patient to look away. Press with a ngertip just proximal to
the injection site be ore you put in the needle to add the sensory
“noise” o pressure to decrease the pain.
•
Insert the rst needle perpendicularly into the subcutaneous at. Sta-
bilize the syringe with two hands to avoid the pain o needle wobble
until the skin needle site is numb. Inject the rst visible 0.5 ml bleb and
then pause. Wait 15 to 45 seconds until the patient tells you that all
Clip 27-3 Mixing
the local anesthetic
solution for a
trapeziectomy.
Clip 27-4 Real-time
8-minute injection of
a patient.
Clip 27-5 Cannula
injection of local
anesthetic for a
trapeziectomy.

Sec t io n E ° Ar t h r it is Su r g er y
168
the needle pain is gone. Inject the rest o the rst 10 ml slowly (over
2 minutes) without moving the needle.
•
When you have to reinsert the needle, always put it back into skin that
is clearly white with epinephrine. I you reinsert within 1 cm o clearly
white vasoconstricted skin that has unctioning lidocaine and epineph-
rine, needle reinsertion will be pain ree.
•
Continue injecting rom proximal to distal, blowing the local anes-
thetic slowly ahead o the needle so there is always at least 1 cm o
visible or palpable local anesthesia ahead o the sharp needle tip
point that the patient would eel i you advanced it into “live” nerves.
“Blow slow be ore you go.” (See Chapter 5 or urther tips on how to
inject local anesthetic with minimal pain.)
•
The goal o the injection is to bathe local anesthetic 2 cm beyond
wherever you think you even have a small chance o dissecting or in-
serting a K-wire.
•
We keep the total dose o in ltration less than 7 mg/kg. I we need
less than 50 ml o tumescent local anesthetic (see Chapter 4), we use
premixed 1% lidocaine with 1:100,000 epinephrine (bu ered with
10 ml lido/epi:1 ml o 8.4% sodium bicarbonate). I we need 50 to
100 ml, we dilute the 50 ml o 1% lidocaine with 1:100,000 epineph-
rine with 50 ml o saline solution to a concentration o 0.5% lidocaine
with 1:200,000 epinephrine. I we need 100 to 200 ml o volume, we
dilute 50 ml o 1% lidocaine with 1:100,000 epinephrine with 150 ml
o saline solution to get 200 ml o 0.25% lidocaine with 1:400,000 epi-
nephrine, which is clinically very e ective.
IF YOU ARE WORKIN G WITH AN AN ESTH ESIOLOGIST
•
Ask him or her to use only propo ol. Inject the lidocaine with epineph-
rine as soon as the propo ol permits pain- ree injection o local an-
esthetic. The anesthesiologist can then wake the patient right away
while you are scrubbing, prepping, and draping so you can get the
bene t o intraoperative patient teaching (Chapter 8) and ully co-
operative pain- ree movement. Suggest that the anesthesia provider
avoid administering opiates and amnestics to prevent nausea and
permit the patient to remember your intraoperative advice and
discussions.
TIPS AN D TRICKS FOR PERFORMIN G A TRAPEZIECTOMY
WITH TH E WID E AWAKE APPROACH
•
Patients must look at the thumb to get it to move, because they can-
not eel the numbed thumb. Although most patients don’t mind look-
ing at the wound, you can cover the wound with a towel as they move
the thumb i they do mind looking at it.

Ch apt er 27 ° Tr apez iec t o my Wit h o r Wit h o u t Lig amen t Rec o n s t r u c t io n
169
•
I you see the thumb metacarpal impinging on the scaphoid, you can
per orm a ligament reconstruction, as in Clip 27-6.
•
In Clip 27-6, when the patient actively moved the thumb, this revealed
metacarpal grinding on the scaphoid, so we decided to per orm a
Weilby suspension with hal o the abductor pollicis longus.
•
I the thumb metacarpal is not impinging on the scaphoid, you can
stop at the trapeziectomy i you wish to, as in Clip 27-7.
•
Many patients are interested in looking at the joint to understand the
nature o their problem. You can mask the patient and show him or
her the joint and watch it move. Many patients love this. Some pa-
tients will tell others it is something they need to put on their bucket
list!
Reference
1. Farhangkhoee H, Lalonde J, Lalonde DH. Wide-awake trapeziectomy: video detailing local
anesthetic injection and surgery. Hand 6:466, 2011.
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.

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171
Ch a P t e r 2 8
Th u mb Met ac ar po ph al an g eal Jo in t
Fu sio n an d Ul n ar Co l l at er al
Lig a men t Repair
Donald H. Lalonde
AD VAN TAGES OF WALAN T VERSUS SED ATION AN D
TOURN IQUET IN TH UMB METACARPOPH ALAN GEAL
JOIN T FUSION
•
You can walk around the operating table and assess how the thumb
looks with patient active movement a ter you x the metacarpopha-
langeal (MCP) joint with K-wires. You and the patient can compare the
active movement o the K-wired thumb to the normal thumb on the
other hand.
•
Patients can see the thumb position and their thumb move a ter you
place the rst K-wires. They can participate in choosing the nal angle
o xation, because you can reposition the K-wires i you choose to do
so.
•
Both you and the patient leave the operating room with realistic ex-
pectations o nal possible thumb movement.
•
Patients get to see that the thumb will still be able to move be ore the
skin is closed. They know that all can work well once they get past the
postoperative discom ort and sti ness. They will be motivated to re-
gain the movement they saw in the operating room.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN ULN AR COLLATERAL
LIGAMEN T REPAIR
•
You can check the stability o the reconstructed MCP joint by observ-
ing active movement during the surgery.
•
All o the other advantages listed above with usion also apply.

Sec t io n E ° Ar t h r it is Su r g er y
172
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC
FOR TH UMB MCP JOIN T FUSION AN D ULN AR
COLLATERAL LIGAMEN T REPAIR
Injection of the hand for thumb MP
joint fusion and ulnar collateral liga-
ment (UCL) repair. Volar injection:
Inject 12 ml of 1% lidocaine with
1:100,000 epinephrine (buffered with
10 ml lido/epi:1 ml of 8.4% sodium
bicarbonate). Dorsal injection: Inject
12 ml of 1% lidocaine with 1:100,000
epinephrine (buffered with 10 ml lido/
epi:1 ml of 8.4% sodium bicarbonate).
•
See Chapter 1, Atlas, or more illustrations o the anatomy o di usion
o tumescent local anesthetic in the orearm, wrist, and hand.
SPECIFICS OF MIN IMALLY PAIN FUL IN JECTION
OF LOCAL AN ESTH ETIC IN TH ESE OPERATION S
•
Clip 28-1 shows injection o local anesthetic or thumb MCP usion or
UCL repair. (See the surgery or this patient in Clip 28-2.)
•
Inject 10 ml o the mixture under the skin on each o the volar and
dorsal sides o the middle o the thumb metacarpal. Then inject 2 ml
under the skin on each o the volar and dorsal sides o the middle o
the thumb proximal phalanx.
•
We inject the anesthetic solution a minimum o 30 minutes be ore sur-
gery to allow the epinephrine to take optimal e ect and provide an
adequately dry working eld as outlined in Chapters 4 and 14.
•
We inject supine patients lying down on stretchers in a waiting area
be ore they come into the operating room to decrease the risk o their
ainting (see Chapter 6).
•
To minimize the pain o injection (see Chapter 5), start with a
27-gauge needle (not a 25-gauge).
•
Ask the patient to look away. Press with a ngertip just proximal to
the injection site be ore you put in the needle to add the sensory
“noise” o pressure to decrease the pain.
Clip 28-1 Local
anesthetic injection
for thumb MCP
fusion or UCL repair.

Ch apt er 28 ° Th u mb MCP Jo in t Fu sio n an d Ul n ar Co l l at er al Lig a men t Repair
173
•
Insert the rst needle perpendicularly into the subcutaneous at. Sta-
bilize the syringe with two hands and have the thumb ready on the
plunger to avoid needle wobble pain until the skin needle site is
numb. Inject the rst visible 0.5 cc bleb and then pause. Wait 15 to
45 seconds until the patient tells you that all the needle pain is gone.
Inject the rest o the rst 10 ml slowly (over 2 to 3 minutes) without
moving the needle.
•
In this operation, inject the rst 10 ml in the most proximal part o the
palmar thumb rst, and then inject the next 10 ml in the most proxi-
mal part o the dorsal thumb right a ter that. Follow with the distal in-
jections on the palmar and dorsal proximal phalanx, which are or the
epinephrine vasoconstriction e ect.
IF YOU ARE WORKIN G WITH AN AN ESTH ESIOLOGIST
•
Ask him or her to use only propo ol. Inject the lidocaine with epineph-
rine as soon as the propo ol permits pain- ree injection o local an-
esthetic. The anesthesiologist can then wake the patient right away
while you are scrubbing, prepping, and draping so you can get the
bene t o intraoperative patient teaching (Chapter 8) and ully co-
operative pain- ree movement. Suggest that the anesthesia provider
avoid administering opiates and amnestics to prevent nausea and
permit the patient to remember your intraoperative advice and discus-
sions.
TIPS AN D TRICKS FOR PERFORMIN G TH ESE
OPERATION S WITH TH E WID E AWAKE APPROACH
•
Have the patient look at the thumb to veri y that he or she eels the
position is good and that the thumb is straight a ter inserting tempo-
rary K-wires. I you or the patient does not like the position a ter
watching the thumb move, simply remove and replace the K-wires
a ter adjusting the usion position.
•
Have the patient move the other thumb and compare the two thumbs
moving.
•
Patients need to look at their thumb to get it to move, since they can-
not eel the numbed thumb. Although most patients do not mind
looking at the wound, you can cover the wound with a towel as they
move the thumb i this seems appropriate.
•
Consider per orming this operation standing instead o sitting so you
can easily walk around the table and ensure that the used or recon-
structed thumb looks good f exing and extending rom all positions.
Clip 28-2 Thumb
MCP fusion in the
same patient in
Clip 28-1.
Clip 28-3 Thumb
UCL repair.

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