Wide Awake Hand Surgery

Sec t io n E ° Ar t h r it is Su r g er y
176
•
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 FUSION
•
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.
•
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 a stretcher in a waiting area
be ore they come into the operating room, as outlined in Chapter 6,
to decrease the risk o their ainting.
•
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 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 4 ml slowly (over 2 minutes) without moving the
needle.
•
In this operation, inject the 4 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 provide a little more time or the distal injec-
tion points in the phalanges 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 anes-
thetic. The anesthesiologist can then wake the patient up 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.

Ch apt er 29 ° Pr o ximal In t er ph al an g eal Jo in t Fu sio n
177
TIPS AN D TRICKS FOR PERFORMIN G PIP JOIN T FUSION
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 temporary K-wire stabilization, have the patient test his or her
active range o motion be ore nal usion. This will let you and the
patient see that this is the best movement that he or she can achieve
with the PIP joint in this position. (See the video o thumb MP joint u-
sion in Chapter 28, which illustrates this point.)
•
Patients need to look at their ngers to get them to move, since they
cannot eel the numbed nger. Although most patients do not mind
looking at the wound, you can cover it with a gauze as they f ex all
the ngers together while looking at them.
•
I you have patients participate in selecting the nal angle o usion,
they may be more likely to be satis ed with the result. You can ask or
their opinion a ter inserting temporary K-wires and having them see
their resulting movement.
•
Consider per orming this operation standing so you can easily walk
around the table and ensure that the used nger looks good f exing
and extending rom all positions.

(Trang không có chữ)

179
W r i S t S u r g e r y
Ch a P t e r 3 0
Wr is t Ar t h r o s c o py
Elisabet Hagert, Donald H. Lalonde
AD VAN TAGES OF WALAN T VERSUS SED ATION AN D
TOURN IQUET IN WRIST ARTH ROSCOPY
•
Watching an awake patient move the wrist during WALANT wrist
arthroscopy provides in ormation not available rom MRIs or rom a
sedated patient. It can be more use ul as both a diagnostic and a ther-
apeutic tool.
•
Intraoperative active motion o the wrist can give you better in orma-
tion about the degree o ligament injury in situations such as a scaph-
olunate or lunotriquetral injury. A cooperative, pain- ree patient pro-
vides an “active” Geissler evaluation.1
•
By per orming dry or wet wrist arthroscopy using WALANT, patients
can participate in the diagnosis and decision-making. This enhances
their ability to take an active part in their treatment.
•
You do not in use water into the joint in dry wrist arthroscopy. This
has advantages that make it valuable in diagnostic arthroscopy.2
WALANT works well or this technique. The advantage with WALANT
in dry arthroscopy is that detailed imaging o the wrist may be ob-
tained to both diagnose and educate the patient during surgery.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.

Sec t io n F ° Wr is t Su r g er y
180
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC FOR WRIST
ARTH ROSCOPY
Inject at least 20 to 30 ml of 1% lidocaine
with 1:100,000 (available in North America) or
1:200,000 (available in Sweden) epinephrine
(buffered with 10 ml lido/epi:1 ml of 8.4% sodium
bicarbonate). Note that the higher concentration of
epinephrine will increase the hemostatic effect and
prolong the duration of anesthesia (see Chapter 4).
•
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 WRIST ARTH ROSCOPY
•
It is important to block the nerve branches innervating the dorsal wrist
capsule so you can access pain- ree portals.
•
We inject patients lying down on stretchers in a waiting area be ore
they come into the operating room to decrease the risk o their aint-
ing (see Chapter 6).
•
Slowly in ltrate at least 20 to 30 ml o bu ered lidocaine with epi-
nephrine to the dorsal aspect o the wrist to block the sensory
branches o the radial, ulnar, and posterior interosseous nerves.1 The
in ltration should cover the area rom the level o Lister’s tubercle to
the carpometacarpal joints.
•
The goal o the injection is to bathe local anesthetic 2 cm beyond
wherever you think you have even a small chance o dissecting in the
wrist or orearm.

Ch apt er 30 ° Wr ist Ar t h r o sc o py
181
•
To minimize the pain o injection, start with a 27-gauge needle (not a
25-gauge) in the most proximal red dot injection point.
•
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 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 minutes) without mov-
ing the needle.
•
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
local anesthetic with minimal pain.)
•
Following the subcutaneous in ltration, inject at least 2 ml o lido-
caine-epinephrine into the radiocarpal joint to ensure anesthesia o
the volar wrist capsule i shaving manipulation o the joint proves nec-
essary.
•
A technique using portal site anesthesia alone has been described, in
which each portal is marked and injected with an average o 5 to 6 ml
o local anesthetic.3 Blocking the entire dorsal aspect o the wrist en-
sures a pain- ree procedure and retains the option to convert rom ar-
throscopic to open surgery with good anesthesia and hemostasis.
•
We seldom use volar wrist portals. I you plan to use these, you must
in ltrate subcutaneous volar anesthetic as well.4
•
I you are going to manipulate the palmar structures as well, you
should inject an additional 10 ml under the orearm ascia between
the median and ulnar nerves on the palmar side 1 cm proximal to the
wrist crease.
TIPS AN D TRICKS FOR PERFORMIN G WRIST
ARTH ROSCOPY WITH TH E WID E AWAKE APPROACH
•
Patients will still have sensation in their ngers. We recommend plastic
nger traps or wrist traction, because the metal traps may be uncom-
ortable.
•
Finger traction is not pain ul in itsel ; however, the patient will eel as
though the ngers are cold and a little numb toward the end o the
surgery. This will resolve as soon as the nger traps are removed.
Clip 30-1 Wrist
arthroscopy.

Sec t io n F ° Wr is t Su r g er y
182
•
When arthroscopic shaving is done, the patient will eel the vibrations
but not eel pain. Explain this to your patient be ore you start shaving
to reduce the patient’s stress that may be caused by the sensation o
vibrations.
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) and ully
cooperative pain- ree movement. This will give the epinephrine a little
time to become more e ective. Suggest that the anesthesia provider
avoid administering opiates and amnestics to prevent nausea and per-
mit the patient to remember your intraoperative advice and discus-
sions.
References
1. Hagert E, Lalonde D. Wide-awake wrist arthroscopy and open TFCC Repair. J Wrist Surg
1:55, 2012.
2. del Pinal F. Dry arthroscopy and its applications. Hand Clin 27:335, 2011.
3. Ong MT, Ho PC, Wong CW, Cheng SH, Tse WL. Wrist arthroscopy under portal site local
anesthesia (PSLA) without tourniquet. J Wrist Surg 1:149, 2012.
4. Slutsky DJ, Nagle DJ. Wrist arthroscopy: current concepts. J Hand Surg Am 33:1228,
2008.

183
AD VAN TAGES OF WALAN T VERSUS SED ATION AN D
TOURN IQUET IN OPEN TRIAN GULAR FIBROCARTILAGE
COMPLEX (TFCC) REPAIR
•
A diagnostic wrist arthroscopy (see Chapter 30) o ten precedes this
surgery to veri y the need to per orm a TFCC repair as a result o o-
veal detachment o the dorsal and/or volar radioulnar ligaments
(DRUL/VRUL).
•
Because the patient is awake, you can discuss the need to continue
with an open repair. Thus the unsedated patient can actively partici-
pate in this decision.
•
When per orming the reattachment o the DRUL/VRUL to the ovea
with either osteosutures or a bone anchor, you can test the tension in
the ligaments with the patient’s active movement.
•
I you reattach the ligaments too loosely, you will see instability with
the distal radioulnar joint (DRUJ) shi t test.
•
I you reattach the ligaments too tightly, the patient will not have ull
range o active pronation and supination.
•
Because awake patients can see their hand move through a ull range
o pronation and supination a ter the reconstruction, they know that
they can achieve it again a ter they go through postoperative immobi-
lization and subsequent rehabilitation.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
Ch a P t e r 3 1
Open Tr ian g u l ar Fibr o c ar t il ag e
Co mpl ex Repair
Elisabet Hagert, Donald H. Lalonde

Sec t io n F ° Wr is t Su r g er y
184
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC FOR OPEN
TFCC REPAIR
Inject 40 ml of 1% lidocaine with 1:100,000 (available in North America) or 1:200,000 (available in
Sweden) (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 ESIA IN OPEN TFCC REPAIR
•
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 in a waiting area to
decrease the risk o their ainting (see Chapter 6).
•
The tumescent local anesthetic will block the dorsal cutaneous branch
o the ulnar nerve and the terminal branch o the posterior interosse-
ous nerve to ensure a pain- ree procedure.1
•
Begin the injection 5 to 7 cm proximal to the DRUJ, along the ulnar
border o the orearm. Slowly inject 20 ml along the ulnar border and
dorsal distal ulna. Inject about 10 ml along the dorsal wrist, making
sure to add 2 ml in the area o the PIN at the level o Lister’s tubercle.
Finally, inject the remaining 5 to 10 ml in the ulnocarpal region, with a
ew milliliters into the ulnocarpal joint or maximum e ect.
•
The goal o the injection is to bathe local anesthetic 2 cm beyond
wherever you think you have even a small chance o dissecting.
•
To minimize the pain o injection, use a 27-gauge needle (not a
25-gauge).

Ch apt er 31 ° Open Tr ian g u l ar Fibr o c ar t il ag e Co mpl ex Repair
185
•
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 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) without
moving the needle.
•
Reinsert the needle arther distally within 1 cm o clearly vasocon-
stricted blanched skin that has unctioning lidocaine and epinephrine
so the needle reinsertion is pain ree.
•
Continue injecting rom proximal to distal, blowing the local anesthe-
sia slowly ahead o the needle so there is always at least 1 cm o vis-
ible 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 lo-
cal anesthesia with minimal pain.)
•
We keep the total dose o in ltrated anesthetic to less than 7 mg/kg.
I less than 50 ml will be required to produce tumescent local anesthe-
sia, we use premixed 1% lidocaine with 1:100,000 epinephrine. I 50 to
100 ml is required, we dilute 50 ml o lidocaine and epinephrine with
50 ml o saline solution to a concentration o 0.5% lidocaine with
1:200,000 epinephrine.
•
I you have access to blunt-tipped injection cannulas,2 you can inject
the local anesthetic more quickly than you can with a sharp needle tip
in a minimally pain ul ashion (see Chapter 5).
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 coop-
erative pain- ree movement.
•
This will give the epinephrine a little time to become more e ective.
Suggest that the anesthesia provider avoid administering opiates and
amnestics to prevent nausea and permit patients to remember your in-
traoperative advice. Patients will also remember the range o motion
they can achieve.

Sec t io n F ° Wr is t Su r g er y
186
TIPS AN D TRICKS FOR PERFORMIN G OPEN TFCC
REPAIR WITH TH E WID E AWAKE APPROACH
•
Make sure to use enough volume o local anesthetic to keep the pa-
tient pain ree during surgery. Too much local anesthetic is always bet-
ter than not enough—i you stay within a sa e dosage range.
•
Patients will still have sensation in their ngers unless you block the
median and ulnar nerves on the volar aspect o the hand. You may
want to use plastic nger traps or wrist traction, because metal traps
may be uncom ortable.
•
Finger traction is not pain ul in itsel ; however, the patient will eel as
though the ngers are cold and a little numb toward the end o the
surgery. This will resolve as soon as the nger traps are removed.
•
When you drill the canals or the osteosutures or the bone anchor, the
patient will eel the vibration in the distal ulna, but no pain. Explain
this to the patient be ore you start drilling to reduce the stress that
may be caused by the sensation o vibrations.
References
1. Hagert E, Lalonde D. Wide-awake wrist arthroscopy and open TFCC repair. J Wrist Surg
1:55, 2012.
2. Lalonde D, Wong A. Local anesthetics: what’s new in minimal pain injection and best evi-
dence in pain control. Plast Reconstr Surg 134(4 Suppl 2):40S, 2014.
Clip 31-1 Wide
awake TFCC.

187
Ch a P t e r 3 2
Fl exo r Ten d o n Repair o f t h e Fin g er
Jin Bo Tang, Shu Guo Xing, Jason Wong, Jeffrey Yao,
Donald H. Lalonde
LA c e r At e D t e n D o n S A n D t e n o Ly S i S
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN FLEXOR TEN D ON REPAIR
OF TH E FIN GER
in t r Ao per At iv e t eSt in g o f A r epAir
•
Intraoperative testing o a repair with WALANT (such as asking the
patient to actively extend and f ex the operated nger ully) can re-
veal gapping o a weak repair and decrease rupture rates.
•
I you see the repair gapping a ter you ask the patient to make a ull
st and completely straighten the ngers, you can repair the gap with
more sutures, retest the repair to con rm that it is reliable with intra-
operative f exion testing, and then close the skin. This is like testing
blood f ow through a microvascular anastomosis to avoid ailure.
•
You are less likely to have to per orm a secondary surgery or rupture
repair i you test the repair intraoperatively by having the patient take
the ngers through a ull range o f exion and extension be ore skin
closure.1,2
•
Clip 32-2 contains other use ul tips on avoiding rupture during and
a ter surgery.
WALAn t c An Dec r eASe t en o Ly SiS r At eS
•
You are less likely to have to come back or tenolysis i you see the
patient take the ngers through a ull range o motion be ore you
close the skin. You know the repair will t through the pulleys. You
only need to vent (divide) the parts o the pulleys that are required to
obtain a ull range o intraoperative active movement o the nger,
including all o A4 or one hal to two thirds o the distal A2 pulley.
(See Clip 32-12 o A4 pulley venting with no bowstringing in the Tips
and Tricks section o this chapter.)
•
Seeing the patient make a ull st and completely straighten out the
ngers without gapping at surgery gives the surgeon ull con dence
to allow up to hal a st o true active movement 3 to 5 days later.
Clip 32-1 How
WALANT has
improved flexor
tendon repair
results.
Clip 32-2 Decreasing
the rupture rate
with intraoperative
testing.
Clip 32-3 Tenolysis
rate decreased by
ensuring the repair
fits through all
pulleys.

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
188
•
We have abandoned the use o Kleinert rubber bands as well as
“place-and-hold” active extension and passive f exion in avor o
true active movement in our postoperative regimen. We eel that up
to hal a st o true active nger f exion and ull nger phalangeal
joint extension has improved the results o our repair. We allow ull
wrist extension, up to hal a st o active f exion (45 degrees o active
metacarpophalangeal [MP] extension, and up to 45 degrees o active
proximal interphalangeal [PIP] and distal interphalangeal [DIP] f ex-
ion). Hal a st o f exion translates to 1 cm o active f exor digitorum
pro undus (FDP) tendon glide. (See Clip 32-16 on 1 cm o tendon glide
with hal a st in the Tips and Tricks section o this chapter.)
in t r Ao per At iv e pAt ien t e Du c At io n
•
The ability to educate the patient intraoperatively during a WALANT
f exor tendon repair decreases rupture and tenolysis rates because the
patient sees it all and remembers the consequences o moving versus
using the hand a ter surgery.
•
WALANT allows you and the hand therapist (see Chapter 15) to assess
patients and educate them or up to 60 uninterrupted minutes during
the surgery. We think this has been very important in improving our
results.
•
You are able to talk to unsedated patients, who usually become very
interested in learning about the procedure during the operation. Pa-
tients have the greatest stake in the result, and this propels them to
be more e ective members o the rehabilitation team. When patients
leave the operating room, they know exactly what they need to do to
get a good result. What is more important, they know what they must
not do. They know they can m ove the ngers, but that they cannot
use the ngers or they will lose the good result.
•
The therapist can also participate with the surgeon in intraoperative
patient evaluation and education i invited into the operating room,
as we do at our hospital (see Chapter 15).
•
For a clip on a surgeon and therapist explaining the Saint John postop-
erative f exor tendon repair protocol to a patient during surgery, see
Clip 15-3 in Chapter 15.
•
Patients get to see that the repaired tendon works as they watch
themselves moving the ngers through a ull range o motion be ore
the skin is closed. They know that their nger will unction well once
they get past the postoperative discom ort and sti ness i they put the
e ort into therapy.
•
You and the hand therapist can get to know patients during the sur-
gery and decide whether you can trust them with early protected
movement.
Clip 32-4 Half a
fist of true active
movement.
Clip 32-5
Intraoperative patient
education decreases
rupture and tenolysis
rates.

Ch apt er 32 ° Fl exo r Ten d o n Repair o f t h e Fin g er
189
WALAn t ALLo WS y o u t o Det er min e Wh et h er
Su per f ic iALiS r epAir iS Appr o pr iAt e
•
In a wide awake procedure you are able to have the patient move the
hand through a ull range o active movement.
•
Based on this, you can repair the super cialis and see how this a ects
the ull range o active movement during the surgery. I super cialis
repair downgrades the movement, you can resect one o the slips or
take down the whole super cialis repair to get the best possible active
movement be ore you end the operation.
•
For the ull-length video o the repair o the 6-year-old patient shown
in Clip 32-6, see Chapter 9, Clip 9-1. Also see Chapter 9, Clip 9-2, o a
f exor tendon repair in a 10-year-old patient.
o t h er ADvAn t Ag eS o f WALAn t v er Su S SeDAt io n
An D t o u r n iq u et
•
A major advantage o eliminating sedation and the tourniquet or
f exor tendon repair is that you do not need to per orm the procedure
in the main operating room. Some o us (authors) do all tendon re-
pairs in minor procedure rooms in the clinic outside the main operat-
ing room Monday to Friday, 8 AM to 4 PM (see Chapter 16). Others o
us still pre er to per orm f exor tendon repair in the main operating
room.
•
We no longer need to per orm such procedures at night. We know
that we do better tendon repairs at 2 PM when we are resh and
awake than at 2 AM, when we are tired and sleepy.
•
We no longer have to admit patients because o their medical comor-
bidities, which are only a problem when we sedate them.
•
We per orm the surgery with eld sterility or add gowns and drapes
or augmented eld sterility (see Chapter 10).
•
Working outside the main operating room also allows our hand thera-
pists to be there to teach patients during the surgery and see the re-
pair (see Chapter 15).
•
You can suture the tendon inside the f exor sheath through sheathoto-
mies to get a 1 cm bite without having to cut long segments o sheath
when patients are wide awake (see the Tips and Tricks section). You
can do this because you then test active f exion to prove that you have
not caught your needle and suture inside the sheath.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
Clip 32-6
Determining
whether to repair the
superficialis.

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
190
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC
FOR FLEXOR TEN D ON REPAIR OF TH E FIN GER
Inject 10 ml of 1% lidocaine with 1:100,000 epinephrine buffered with sodium bicarbonate (1 ml of
8.4% bicarbonate for each 10 ml of 1% lidocaine with 1:100,000 epinephrine) in the most proximal
injection point. The first few milliliters go under the skin, and the rest is injected under the superfi-
cial palmar fascia without moving the needle. Wait 30 minutes for the local anesthesia to numb the
common digital nerves, and then inject the distal palm (3 ml at each finger base) and fingers for the
epinephrine effect. (From Lalonde DH, Kozin S. Tendon disorders of the hand. Plast Reconstr Surg
128:1e, 2011.)

Inject 2 ml in the fat just below the skin between the two digital nerves in each of the proximal and
middle phalanges. Inject one milliliter of the same solution in the subcutaneous fat in the middle
of the distal phalanx just past the crease if you feel you will need to dissect in the distal phalanx.
(From Lalonde DH, Kozin S. Tendon disorders of the hand. Plast Reconstr Surg 128:1e, 2011.)

Ch apt er 32 ° Fl exo r Ten d o n Repair o f t h e Fin g er
191
Alternative rectangular flap incisions are shown, which cover the tendon more effectively if the
wounds dehisce. Some surgeons prefer to use only parts of the possible incisions illustrated.
•
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 TEN D ON REPAIR
OF TH E FIN GER
•
Inject local anesthetic into the hand in the waiting area 30 or more
minutes be ore surgery, as outlined in Chapters 4, 5, and 14. This al-
lows the epinephrine to take e ect and provides an adequately dry
working eld.3
•
We inject patients while they are lying down to decrease the risk o
their ainting (see Chapter 6).
•
Use nonre rigerated 1% lidocaine with 1:100,000 epinephrine bu -
ered with 10 ml:1 ml o 8.4% sodium bicarbonate or all injections.
•
During the injection, encourage the patient to look away. Create sen-
sory “noise” to decrease pain by using pressure, touch, or pinch just
proximal to the injection site. In the rst injection, insert the needle
perpendicular to the skin into the subcutaneous at. Have your thumb
ready on the plunger. Immobilize the syringe with ngers propped on
the skin to avoid pain ul needle movement until the needle penetra-
tion site is numb.
•
Start by injecting with a 27-gauge needle into the most proximal loca-
tion that you are likely to nd the proximal tendon stumps. For nger
tendon lacerations, this usually means the proximal palm at the level
at which the median nerve begins branching. I the injury disrupted
the vincula and the proximal tendon f ips proximally with great orce
out o the sheath and into the palm, you can retrieve it easily rom the
numbed palm.
Clip 32-7 How
to inject local
anesthetic for flexor
tendon repair.

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
192
•
Inject the rst 0.5 ml until it is visible below the skin, then pause. The
rst bleb must be visible or palpable under the skin to properly numb
the needle insertion site. Wait 15 to 45 seconds until the patient tells
you that the sting is gone. Then inject the rest o the 10 ml in ltration
very slowly (over 2 to 3 minutes) without moving the needle.
•
There is no need to move the needle distally as you inject. I you keep
your needle in one place and continue to inject slowly, you will see
and palpate the local anesthetic going everywhere in the palm. You
want the area you will dissect to become a little rm with visible and
palpable local anesthetic. You will not cause a palmar compartment
syndrome. As soon as you incise the skin, the pressure will come down
as the local anesthetic leaks out.
•
I you inject 10 to 20 ml into the palm, where is it going to go? Every-
where! It is like an extravascular Bier block, but only where you need
it.
•
The goal o the injection is to bathe visible and palpable local anes-
thetic 2 cm beyond wherever you think you have even a small chance
o dissecting.
•
Wait 30 or more minutes i possible to let the palm’s common digital
nerves become completely numb. Then inject the distal palm with 3 ml
at the base o each nger. A ter this, inject each proximal and middle
phalanx with only 2 ml o bu ered lidocaine and epinephrine in the
subcutaneous at between both digital nerves. The distal phalanges
only get 1 ml between the digital nerves i dissection will be needed
there. These nger injections are or the epinephrine 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-
esthesia. 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 coop-
erative pain- ree movement. This will give the epinephrine a little time
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. Patients will also re-
member the range o motion they can achieve.

Ch apt er 32 ° Fl exo r Ten d o n Repair o f t h e Fin g er
193
TIPS AN D TRICKS FOR PERFORMIN G FLEXOR TEN D ON
REPAIR OF TH E FIN GER WITH TH E WID E AWAKE
APPROACH
•
When you are pulling the proximal tendon stump distally, an awake
patient may nd it hard to relax and may pull the tendon away rom
you. Ask the patient to extend the ngers while you f ex the wrist and
MP joints. Active extension o the ngers causes a spinal ref ex relax-
ation o the nger f exors to help you deliver the tendon without ex-
tra incisions.
•
Patients need to look at their ngers to know whether they are mov-
ing because they cannot eel them. However, i patients look, they can
move just as they wish. Although most patients do not mind looking
at the wound, you can cover it with a towel as they f ex their ngers.
•
Consider accessing the tendon through a proximal sheathotomy where
you can see it through the sheath. Leave the tendon in the sheath and
push it with two Adson orceps. Thus you avoid having the orceps
crush the severed tendon ends you are trying to heal. Alternatively (as
pre erred by Jin Bo Tang), the incision made to expose the tendon cut
site can be quite short, and a separate small incision is made at the
distal palm to nd the retracted tendon, which is delivered through
the intact sheath distally.
•
You are more likely to keep the FDP between the two slips o the
f exor digitorum super cialis (FDS) i you push it rom proximal to dis-
tal than i you pass a red rubber catheter proximally and blindly down
the sheath rom the laceration site. However, even when you push the
tendon rom a proximal sheathotomy, it may not end up between the
super cialis slips. Be sure you have restored that anatomy be ore you
suture the tendon.
•
Clip 32-10 shows an entire FDP repair with a our-strand locking Kes-
sler repair and an epitenon suture (which is illustrated in Clip 32-11).
•
You can suture the tendon inside the f exor sheath through sheathoto-
mies to get a 1 cm bite without having to cut long segments o sheath
when the patient is wide awake (see the tips on pp. 194 and 195). You
can do this because you can then test active f exion to prove that you
have not caught your needle and suture inside the sheath. Use 3-0 or
4-0 sutures or core suture repair and 6-0 or peripheral suturing.
Clip 32-8 Dr. Jeffrey
Yao has the patient
see the fingers flex
and extend.
Clip 32-9 Retrieving
the tendon from
the proximal flexor
sheath.
Clip 32-10 Delivering
a misdirected FDP
proximal stump
between both slips
of FDS.
Clip 32-11 Suturing
tendon inside flexor
tendon sheath.

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
194
Retrieve the proximal tendon by performing a sheathotomy where you can see it through the
sheath. Do not grab and crush the tendon ends you are going to ask to heal. Push the tendon
forward in small increments by grabbing the tendon on the sides with two Adson forceps. Repair
the tendon through the sheathotomies. Verify that you have not caught your needle with active
flexion and extension. Repair the sheathotomies with an absorbable suture. These images show a
four-strand locking Kessler with an epitenon repair. You can also use a six-strand M-shaped Jin Bo
Tang repair using looped sutures or other repair with a simple running epitenon repair, not repair-
ing the incised sheath.4
•
Some o the authors o this chapter pre er less invasive exposure o
the f exor sheath in the nger. They would rather make a separate in-
cision in the palm and possibly advance the tendon rom there using a
pediatric eeding tube.5
•
A ter the repair, ask the patient to make a ull st and extend the
ngers completely. This is an important test to veri y that the repair

Ch apt er 32 ° Fl exo r Ten d o n Repair o f t h e Fin g er
195
is strong and can tolerate early active motion. The three parts o the
digital extension-f exion test are:
1. Full active extension to veri y no gapping between the tendon
ends
2. Smooth active f exion to veri y smooth gliding o the repair site
3. Total active f exion to veri y that none o the pulleys prevents
tendon gliding
• I the extension-f exion test creates a visible gap between the two
tendon ends during nger extension, the suture is usually not tight
enough and needs repair with additional tighter sutures with proper
tension to avoid rupture. You can remove, tighten, or leave the previ-
ously loose suture, as appropriate. Slightly tensioning the repair is very
important to prevent gapping.
• Do not be a raid to test ull st f exion and ull extension. Your sutures
need to be strong enough to take it. I they are not, you need to rein-
orce them. Repeated evaluation o total active movement is impor-
tant to veri y that the repair is strong and pulley release is su cient.
• I active f exion indicates that the annular pulleys prevent the tendon
rom ample gliding, you can incrementally vent the pulleys until the
patient achieves a ull range o active motion be ore you close the
skin. You can vent one hal to two thirds o the distal part o the
A2 pulley, and you can cut the entire A4 pulley and not get clinically
signi cant bowstringing i adjacent pulleys are intact.
• Clip 32-12 shows total A4 pulley venting with no bowstringing with
intraoperative total movement examination, and no bowstringing
6 months postoperatively. (See also Clip 15-1 in Chapter 15 o
a tendon repair on a 10-year-old patient with venting o A3 and
A4 pulleys and no bowstringing.)
• We do not worry about minor bleeding when we cut the skin, be-
cause most little bleeders will stop spontaneously by the time we sew
the f aps to the dorsal skin or exposure. We no longer use cautery or
most cases but occasionally use a hemostat on bigger veins or a ew
minutes.
• We always test f exor pollicis longus repairs as well as nger repairs to
make certain there is no gapping and that the repair ts through the
pulleys.
• To avoid numbness in the ngertip a ter dissection in zone 1 f exor
tendon injuries, remember that 90% o the digital nerve goes to the
ngertip. You want to make incisions midline in the volar pulp o the
ngertip only as ar as the center o the whorl o the ngerprint.
Spread with scissors proximal to distal to the center o the whorl to
avoid damaging the “leaves o the tree” o the digital nerves.
Clip 32-12 Total A4
pulley venting with
no bowstringing.
Clip 32-13 Testing
flexor pollicis
longus repair during
surgery.
Clip 32-14 Where
and how to dissect
in pulp of distal
phalanx to avoid
numbness.

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
196
TH E POSTOPERATIVE REGIMEN
•
For more important details o the postoperative regimen or f exor
tendon repair, see the ollowing three videos: (1) Clip 32-4, in which
the surgeon gets the con dence to allow the hand therapist to teach
the patient up to hal a st o true active movement postoperatively,
(2) Clip 32-5, in which intraoperative patient education decreases rup-
ture and tenolysis rates, and (3) Clip 15-3 in Chapter 15 on the Saint
John postoperative movement protocol or lacerated nger f exor ten-
dons.
•
The hand is elevated and not moved or the rst 2 to 5 days to al-
low internal bleeding to stop. Moving the hand on the day o surgery
causes internal bleeding, which results in edema and inf ammation to
remove the clot. The clot then turns to scar. There is no collagen or-
mation in the rst 3 days, so there is no need to move the ngers dur-
ing that time. Elevation and immobilization or a ew days will also
allow any swelling to decrease and there ore decrease the work and
riction o f exion, which decreases the risk o rupture.
•
We want our patients o all pain medication when they start early
protected movement so they know what hurts. We tell them to stop
moving when they eel pain and listen to their body.
•
We move the ngers passively be ore we move them actively to de-
crease joint riction and work o movement.
•
All o the authors o this chapter use a similar orm o postoperative
early protected true active movement. They know that the patient was
able to make a ull st and ully extend the ngers on the operating
table without gapping. Good common sense tells us that up to hal a
st o true active movement 3 days later will not cause a gap or rup-
ture.
•
Hal a st o early active movement makes the pro undus glide 1 cm.
•
Do not ask a patient to make a ull st with “place-and-hold” or true
active movement therapy a ter surgery, because this can cause the
repair to catch on the proximal edge o a hard pulley at 90 degrees,
which can cause a gap in the repair. Instead, allow up to hal a st
(45 degrees o f exion o the MP, PIP, and DIP joints) with early pro-
tected movement. You just want to keep the repair moving a little so
it does not get stuck.
Clip 32-15 Passive
and active finger
movement up to half
a fist after surgery.
Clip 32-16
Profundus glides
1 cm of tendon when
patient makes half
a fist.

Ch apt er 32 ° Fl exo r Ten d o n Repair o f t h e Fin g er
197
Intraoperative full active fist testing reveals a gap caused by the tendon repair caught on the proxi-
mal edge of the hard entry point of the A4 pulley. This is a reason to avoid full-fist place-and-hold
in postoperative therapy, which would have gone on to rupture. Other reasons are the highest work
of flexion and highest friction with a full fist. Up to half a fist in postoperative active flexion is safer.
When you see this gap with full fist testing at surgery, simply add sutures to the repair and vent the
A4 pulley until you get full fist flexion with no gap.
•
Clip 32-17 shows a tendon repair that caught on the proximal edge o
the A4 pulley, causing a gap with ull st f exion. The gap was re-
vealed and repaired during surgery. The A4 pulley was divided and the
gap repaired be ore skin closure to avoid rupture.
References
1. Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rup-
ture with intraoperative total active movement examination. Plast Reconstr Surg 126:941,
2010.
2. Lalonde DH, Kozin S. Tendon disorders of the hand. Plast Reconstr Surg 128:1e, 2011.
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.
4. Tang JB. Wide-awake primary flexor tendon repair, tenolysis, and tendon transfer. Clin
Orthop Surg 7:275, 2015.
5. Wong J, McGrouther DA. Minimizing trauma over ‘no man’s land’ with flexor tendon re-
trieval. J Hand Surg Eur 39:1004, 2014.
Clip 32-17 Tendon
repair caught on
proximal edge of
A4 pulley.
Clip 32-18 Fiona
Peck Manchester
short splint and
Gwen van Strien
scratch movement
for true active
movement after
flexor tendon repair.

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199
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN FLEXOR TEN D ON REPAIR
OF TH E H AN D
•
The surgeon is less likely to have to per orm secondary surgery or
rupture repair i he or she tests the repair by having the patient take
the ngers through a ull range o motion be ore skin closure. I the
surgeon sees gapping with the stress o ull active movement, this can
be repaired, with retesting o the repair to con rm that it is solid, and
then the skin can be closed.1 This is like testing and ensuring good pa-
tency and blood f ow through a microvascular anastomosis be ore skin
closure.
•
See Chapter 32 or relevant videos, illustrations, and discussion o n-
ger f exor tendon repairs.
•
A major advantage o eliminating sedation or f exor tendon repair is
that you do not need to per orm the procedure in the main operating
room. We do all o our tendon repairs in minor procedure rooms in
the clinic outside the main operating room Monday to Friday, 8 AM to
4 PM. We know that we do better surgery at 2 PM than at 2 AM. In ad-
dition, our hand therapists can teach patients during the surgery and
see the repair (see Chapter 15).
•
You get to educate unsedated patients or the 90 or so minutes o the
procedure without interruption. You can tell them that they can move
their ngers but not use them, as the therapist will instruct. The pa-
tients will remember what you say and be even more motivated to ol-
low hand therapy advice.
•
Patients get to see that the repaired tendon works as they watch
themselves moving their ngers through a ull range o motion be ore
skin closure. They know that their ngers will unction well once they
get past the postoperative discom ort and sti ness i they put the nec-
essary e ort into therapy.
•
All o the general advantages listed in Chapters 2 and 32 apply to both
the surgeon and the patient.
Ch a P t e r 3 3
Fl exo r Ten d o n Repair o f t h e H an d
Donald H. Lalonde

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
200
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC
FOR FLEXOR TEN D ON REPAIR OF TH E H AN D
The orange lines represent the laceration and the dotted red lines are the possible incisions.
This operation may benefit from a median/ulnar nerve block of 10 ml of 1% lidocaine with
1:100,000 epinephrine and 1 ml of 8.4% sodium bicarbonate under the skin and under the distal
forearm fascia in the proximal red injection point. Up to 20 ml of the same solution would go in
the palm, starting with 10 ml over the carpal tunnel, then 10 ml in the distal palm, and 2 ml in the
proximal phalanx just under the skin. If the middle phalanx also needs exposure, you can inject
another 2 ml there. The flexor pollicis longus (FPL) laceration shown in the carpal tunnel in the
lower illustration above may benefit from a median nerve block of 10 ml of 1% lidocaine with
1:100,000 epinephrine and 1 ml of 8.4% sodium bicarbonate under the skin and under the distal
forearm fascia in the proximal red injection point. Up to 20 ml of the same solution would go in the
palm, starting with 10 ml over the carpal tunnel, then 10 ml over the thenar eminence and 2 ml in
the thumb proximal phalanx injection point just under the skin. (Clip 43-9 in Chapter 43 shows this
case.)
•
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 TEN D ON
REPAIR OF TH E H AN D
•
Inject local anesthetic into the patient’s hand in the waiting area
30 minutes be ore surgery. This allows the epinephrine to take e ect
and provides an adequately dry working eld.2

Ch apt er 33 ° Fl exo r Ten d o n Repair o f t h e H an d
201
•
We inject patients while they are lying down on a stretcher to de-
crease the risk o their ainting (see Chapter 6).
•
Use nonre rigerated 1% lidocaine with 1:100,000 epinephrine bu -
ered with 10:1 8.4% sodium bicarbonate or all injections. Keep the
total dose o in ltration less than 7 mg/kg. I less than 50 ml will be
required or tumescent local anesthesia (see Chapter 4), use premixed
1% lidocaine with 1:100,000 epinephrine. I 50 to 100 ml is required,
dilute 50 ml o lidocaine and epinephrine with 50 ml o saline solution
to produce a concentration o 0.5% lidocaine with 1:200,000 epineph-
rine.
•
Flexor tendon lacerations o the hand requently bene t rom wrist
median/ulnar nerve blocks. Start by injecting with a ne 27-gauge
needle (not a 25-gauge) into the most proximal red injection point.
Slowly inject 2 ml under the skin and then 8 ml under the orearm as-
cia to block the nerves.
•
During the injection, encourage the patient to look away. Create sen-
sory “noise” to decrease pain by using pressure, touch, or pinch near
the injection site. In the rst injection, insert the needle perpendicular
to the skin into the subcutaneous at. Immobilize the syringe with n-
gers propped on the skin to avoid the pain o needle wobble until
the needle penetration site is numb. Inject the rst 0.5 ml bleb slowly
(5 seconds) and then pause. Wait 15 to 45 seconds until the patient
tells you that all the sting is gone. Then inject the rest o the in ltrate
very slowly (2 to 3 minutes) without moving the needle.
•
There is no need to move the needle distally as you inject, only rom
super cial to below the wrist/ orearm ascia. You will not cause a pal-
mar compartment syndrome. As soon as you incise the skin, the pres-
sure will come down as the local anesthetic leaks out.
•
When per orming major nerve blocks such as o the median or ulnar
nerves, do not elicit paresthesias. Let the tumescent local anesthetic
nd and bathe the nerve so you do not damage it with the sharp nee-
dle tip.
•
A ter the initial wrist median/ulnar nerve block, inject an additional
10 ml over the carpal tunnel super cial palmar ascia.
•
Inject 10 ml under the skin o the thenar eminence. It will bathe the
whole thenar pad, as shown in the thumb midmetacarpal volar illus-
tration in Chapter 1.
•
The goal o the injection is to bathe visible and palpable local anes-
thetic 2 cm beyond wherever you think you have even a small chance
o dissecting in the wrist and hand.
•
I you inject 20 ml into the palm, where will it go? Everywhere! Per-
ect! This is like an extravascular Bier block, but only where you need
it.
•
The metacarpal phalangeal crease o the thumb has sheath/cutaneous
ligaments that are a natural barrier to the di usion o local anesthetic
into the proximal phalanx. Inject into the thenar eminence rst to
anesthetize the digital nerves o the proximal phalanx so the patient
does not eel pain when you insert the needle into the thumb. Inject a

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
202
urther 2 ml into the subcutaneous at in the proximal phalanx or the
epinephrine e ect in case the distal end o FPL or FDP is there.
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. This will give the epinephrine a little time to become more
e ective. 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 per-
mit the patient to remember your intraoperative advice. Patients will
also remember the range o motion they can achieve.
TIPS AN D TRICKS FOR D OIN G FLEXOR TEN D ON REPAIR
OF TH E H AN D WITH TH E WID E AWAKE APPROACH
•
Do not worry about minor bleeding rom cut skin edges, because most
little bleeders will stop spontaneously by the time you nish tacking
the skin f aps back or exposure. We no longer use cautery or f exor
tendon repairs but occasionally use a hemostat on bigger vessels or a
ew minutes.
•
When you are delivering the proximal tendon into the wound, it is
help ul to ask the patient to try to relax the f exors. It is even more
help ul to ask the patient to extend the ngers while you f ex the
wrist and MP joints. Active extension o the ngers causes a spinal re-
f ex relaxation o the nger f exors to help you deliver them into the
wound without extra incisions.
•
Patients need to look at their ngers to get them to move. They can-
not eel their numbed nger move, because it has lost its propriocep-
tive sense. However, i patients look, they can move the nger just
as they wish. Although many patients do not mind looking at the
wound, you can cover the wound with a towel as they f ex the ngers
or thumb while looking at them.
•
Do not be a raid to test ull f exion and ull extension. Your sutures
need to be strong enough to take f exion and extension. I they are
not, you need to rein orce them.
•
See Clip 43-9 in Chapter 43 o an original repair and subsequent rup-
tured FPL repair under the motor branch in the carpal tunnel.
•
See the many additional tips and tricks o f exor tendon repair in
Chapter 32.

Ch apt er 33 ° Fl exo r Ten d o n Repair o f t h e H an d
203
References
1. Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rup-
ture with intraoperative total active movement examination. Plast Reconstr Surg 126:941,
2010.
2. 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.

(Trang không có chữ)

205
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN FLEXOR TEN D ON REPAIR
OF TH E FOREARM
•
Many o these injuries happen at night and on weekends—not an
ideal time to per orm a repair. WALANT permits the elective schedul-
ing o these operations in minor procedure rooms outside the main
operating room Monday through Friday, 8 AM to 4 PM, a ter the
wound is washed and the skin is closed in the emergency department.
This permits patients to be sober so they can understand their injury
and learn how to look a ter it with intraoperative teaching they can
remember.
•
We all do better surgery at 11 AM than at 11 PM.
•
It is o ten di cult to tell which proximal tendon stumps belong to
which distal tendons in a “spaghetti wrist” injury. This can be even
more di cult with ragged cuts such as might happen with a table saw
accident. I you ask the patient to f ex the long nger, the proximal
long nger pro undus and super cialis tendon stumps move the most.
This helps you in tendon identi cation and correct matching o proxi-
mal to distal structures (see Clip 34-1).
•
You can ask the patient to move each nger, and you will see which
proximal tendons belong to which distal tendons, because com ort-
able tourniquet- ree patients can control the movement o the proxi-
mal stumps.
•
You can educate your patients during the case about how important
it is that they keep their hand elevated and “on strike,” doing abso-
lutely nothing with it or the next week while the tendons heal. At
the end o the procedure, they sit up and elevate their hand with total
understanding o what to do. I they had been asleep, they might not
understand as well what they should do a ter surgery. They may keep
their hand dependent and are more likely to try to use their ngers
and hand.
•
All o the general advantages listed in Chapters 2 and 32 apply to both
the surgeon and the patient.
Clip 34-1 “Spaghetti
wrist.” Active
movement in
proximal forearm
identifies which
proximal tendons
belong to which
distal tendon ends.
Ch a P t e r 3 4
Fl exo r Ten d o n Repair o f t h e Fo r ear m
Donald H. Lalonde

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
206
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC FOR
FLEXOR TEN D ON REPAIR OF TH E FOREARM
The orange line in the illustration is the laceration and the dotted red lines are the possible inci-
sions. Inject up to 100 ml of 0.5% lidocaine with 1:200,000 (buffered with 10 ml of 1% lidocaine
with 1:100,000 epinephrine:1 ml of 8.4% sodium bicarbonate). Add 10 ml 0.5% bupivacaine with
1:200,000 epinephrine to the injectate if you think the procedure will take more than 21⁄2 hours.
•
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 FLEXOR TEN D ON REPAIR OF TH E
FOREARM
•
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,1 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).
•
Use nonre rigerated 1% lidocaine with 1:100,000 epinephrine bu -
ered with 10:1 8.4% bicarbonate or all injections. Keep the total
dose o in ltration less than 7 mg/kg. I less than 50 ml will be re-
quired, use premixed 1% lidocaine with 1:100,000 epinephrine. I
50 to 100 ml is required, dilute with saline solution to a concentration
o 0.5% lidocaine with 1:200,000 epinephrine. I 100 to 200 ml o solu-
tion is required to produce tumescent local anesthesia (see Chapter 4),
dilute with saline solution to a concentration o 0.25% lidocaine with
1:400,000 epinephrine.
•
To minimize the pain o injection, start to inject with a ne 27-gauge
needle (not a 25-gauge) 2 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

Ch apt er 34 ° Fl exo r Ten d o n Repair o f t h e Fo r ear m
207
“noise” o pressure to decrease the pain. The skin o the volar orearm
is loose, so you can pinch it gently and push the skin into the needle as
another technique to reduce needle insertion 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,
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 minutes) without moving the needle.
•
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 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 the local anesthesia 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 in the
orearm.
•
Most o the injection is in the subcutaneous plane. A ter the skin f aps
are elevated and you identi y the plane between super cialis and pro-
undus, an additional 20 ml o local in this plane will numb the me-
dian nerve indirectly. Alternatively, you can elevate the super cialis
muscle, identi y the median and/or ulnar nerves, and slowly inject
5 ml o local anesthetic into the loose areolar tissue around the nerve
or nerves. Do not inject directly into the nerves, as you will lacerate
ascicles and damage axons.
•
The more volume that you inject, the greater are the odds that the
patient will eel no pain a ter you begin dissection. Try to avoid “top-
ups” o local anesthetic that give patients unnecessary bad memories.
•
I you have access to blunt-tipped injection cannulas such as those
used to inject dermal llers, you can inject the local anesthetic pain-
lessly more quickly than with a sharp needle tip 2 (see Chapter 5).
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-
esthesia. This will give the epinephrine a little time to become more
e ective. 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 per-
mit patients to remember your intraoperative advice. Patients will also
remember the range o motion they can achieve.

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
208
TIPS AN D TRICKS FOR PERFORMIN G FLEXOR TEN D ON
REPAIR OF TH E FOREARM WITH TH E WID E AWAKE
APPROACH
•
See the many additional tips and tricks or f exor tendon repair in
Chapter 32.
•
We do not worry about minor bleeding rom cut skin edges, because
most little bleeders will stop spontaneously by the time we sew the
skin f aps back or exposure. We no longer use cautery but occasion-
ally use a hemostat on larger veins or a ew minutes, or we tie them
o .
•
We use augmented eld sterility in our minor procedure rooms or
longer cases such as these by importing ull drapes and gowns rom
the main operating room (see Chapter 10).
•
We wait or at least 30 minutes between local anesthetic injection in
the patient waiting area and bringing the patient into the minor pro-
cedure room to allow the epinephrine to reach maximal vasoconstric-
tion. We per orm a couple o carpal tunnels or see patients or hand
consultations rom the emergency department while waiting so our
time is used productively.
•
We ask patients to go to the restroom to relieve themselves a ter we
inject the local anesthetic and just be ore we start the surgery to avoid
unnecessary surgical interruptions or these longer cases. The patient
has no intravenous in usion that would increase the urge to void. I
we give preoperative antibiotics, they are administered by mouth.
•
When you are trying retrieve or to sew the tendons together, the pa-
tient may pull the proximal tendons away rom you. I you ask him or
her to extend the ngers, the f exor muscles ref exly relax and the pa-
tient will stop pulling as much. In addition, you can keep the wrist and
ngers passively f exed, which will also help to decrease the tension
on the repair.
References
1. 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.
2. Lalonde D, Wong A, Local anesthetics: What’s new in minimal pain injection and best evi-
dence in pain control. Plast Reconstr Surg 134(4 Suppl 2):40S, 2014.

209
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN EXTEN SOR TEN D ON REPAIR
OF TH E FIN GER
•
You can simulate the relative motion extension splint during WALANT
surgery with a sterile tongue depressor.1-3 This will help you decide
whether you need to add a wrist component to the Merritt splint.
Wyndell Merritt’s relative motion extension splint has revolutionized
management o lacerations at the proximal phalanx and dorsal hand
levels (see Chapter 37) in the last ew years. Patients can return to
work with these very unctional splints as early as a ew days a ter
surgery.
•
Clip 35-1 demonstrates that the relative motion extension splint de-
creases excursion in extensor tendon repair in the proximal nger. The
relative motion extension splint keeps the MP joint o the a ected n-
ger more extended than the other MP joints. This takes the tension o
the long extensors, even when ngers are actively f exing. (See also
video clips in Chapter 37.)
•
You can simulate the relative motion f exion splint during WALANT
boutonniere surgery or in clinic consultations with a sterile tongue
depressor. The Merritt relative motion f exion splint has revolutionized
acute and chronic boutonniere management in the last ew years.
Patients can return to work with these very unctional splints.
•
Clip 35-2 shows Merritt relative motion f exion splinting or bouton-
niere de ormity. The relative motion f exion splint keeps the MP joint
o the a ected nger more f exed than the MP joints o the adjacent
ngers. This increased tension on the long extensors pulls the lateral
bands dorsal to the axis o the PIP joint while taking the tension o
the intrinsic volar pull on the same lateral bands.
•
WALANT takes many o the inconveniences o general and motor
block anesthesia out o the management o racture mallet injuries.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
Clip 35-1 Relative
motion extension
splint decreases
excursion in
extensor tendon
repair in the
proximal finger.
Clip 35-2 Merritt
relative motion
flexion splinting
for boutonniere
deformity.
Clip 35-3 WALANT
mallet fracture
management.
Ch a P t e r 3 5
Ext en s o r Ten d o n Repair o f t h e Fin g er
Donald H. Lalonde

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
210
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC FOR
EXTEN SOR TEN D ON REPAIR OF TH E FIN GER
The orange line in the illustration is the laceration and the dotted red lines are the possible inci-
sions. Palmar injections: 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 the most proximal red injection point in the
subcutaneous palmar fat. Perform the most proximal dorsal injection next, and then inject 2 ml in
the middle of the subcutaneous fat of the palmar middle phalanx. Dorsal injections: Inject 2 ml of
1% lidocaine with 1:100,000 epinephrine (buffered with 10 ml lido/epi:1 ml of 8.4% sodium bicar-
bonate) in the proximal red injection dot in the subcutaneous fat of the dorsal proximal phalanx.
Inject the middle phalanx palmar side next and then finally inject 2 ml in the middle of the dorsal
middle phalanx 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 EXTEN SOR TEN D ON
REPAIR OF TH E FIN GER
•
Inject just under the skin. There is no need to inject into the sheath;
this would only add unnecessary pain.
•
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,4 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, use 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.
•
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 o needle wobble until the skin needle site

Ch apt er 35 ° Ext en so r Ten d o n Repair o f t h e Fin g er
211
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 2 ml slowly (over 1 minute) without moving the
needle.
•
In this operation, inject 2 ml in the palmar proximal phalanx rst, then
inject 2 ml in the dorsal proximal phalanx a ter that. This will give the
local anesthetic time to numb the digital nerves proximally so the pha-
langeal injections will hurt less.
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. This will give the epinephrine a little time to become more
e ective. 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 per-
mit patients to remember your intraoperative advice. Patients will also
remember the range o motion they can achieve.
TIPS AN D TRICKS FOR PERFORMIN G EXTEN SOR
TEN D ON REPAIR OF TH E FIN GER WITH TH E WID E
AWAKE APPROACH
•
Percutaneous extensor tendon repair is use ul because the thin nger
extensor tendon does not hold a suture very well. Nylon sutures
through both skin and tendon hold the suture better. This is especially
true when the skin is rayed, such as rom a table saw accident. The
ends o the extensor tendon are close enough that the splinting will
allow unctional healing o the tendon with a gap.
•
You can see that your sutures are tight enough with WALANT, because
the nger stays in ull extension when you let it go and stop holding
it up. Avoiding buried permanent sutures also avoids stitch abscesses
later. For the past 10 years, I have mostly used mono lament absorb-
able suture on the extensor side o ngers i I use anything buried
at all.
•
Use the pencil test to simulate relative motion f exion and extension
splints in the clinic when you evaluate patients with hand problems. It
will help you solve many problems such as boutonniere de ormity,
extensor lag, f exor lag, interosseous muscle tear, and sagittal band
rupture.
•
Patients may need to look at their ngers to get them to extend to
test the repair, since they may not eel the numbed ngers. Although
most patients do not mind looking at the wound, you can cover the
wound with a towel as they watch their ngers move.
Clip 35-4
Percutaneous
extensor tendon
repair.
Clip 35-5 Pencil test
for relative motion
splinting.

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
212
•
In contrast to f exor tendon repairs, we do not make patients test ex-
tensor tendon repairs over the proximal phalanx with a ull st o f ex-
ion. The sutures will generally not hold well enough in the thin exten-
sor tendons. Flexor tendon repairs are stronger and withstand ull st
f exion testing easily. In addition, nger extensor repairs can tolerate a
gap, as we all witness with most mallet injuries. Flexor tendon lacera-
tions do not tolerate a gap.
•
Many patients are interested in looking at the tendon to understand
the nature o their problem. You can put a mask on the patient, show
him the tendon and have him watch it move. Many patients love this
type o thing. Some patients will tell others it is something they need
to put on their bucket list!
•
You can per orm these operations with eld sterility to increase e -
ciency (see Chapter 10).
References
1. Howell JW, Merritt WH, Robinson SJ. Immediate controlled active motion following zone
4-7 extensor tendon repair. J Hand Ther 18:182, 2005.
2. Merritt WH. Relative motion splint: active motion after extensor tendon injury and repair.
J Hand Surg Am 39:1187, 2014.
3. Burns MC, Derby B, Neumeister MW. Wyndell Merritt immediate controlled active motion
(ICAM) protocol following extensor tendon repairs in zone IV-VII: review of literature, or-
thosis design, and case study—a multimedia article. Hand (N Y) 8:17, 2013.
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.

213
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN EXTEN SOR TEN D ON REPAIR
OF TH E H AN D
•
You can see that that your repair is solid enough by watching the pa-
tient take the ngers through a ull range o motion be ore you close
the skin.
•
You can simulate the relative motion extension splint during WALANT
surgery with a sterile tongue depressor,1-3 This will help you decide
whether you need to add a wrist component to the Merritt splint.
Wyndell Merritt’s relative motion extension splint has revolutionized
extensor tendon laceration o the proximal phalanx (see Clip 35-1 in
Chapter 35) and dorsal hand management in the last ew years. Pa-
tients can go back to work with these very unctional splints as early as
a ew days a ter surgery, as shown in Clip 36-1.
•
The relative motion extension splint keeps the MP joint o the a ected
nger more extended than the other MP joints. This takes the tension
o the repaired long extensor, even when ngers are actively f exing.
•
Patients get to see their nger movement restored during the surgery.
They will remember this light at the end o the tunnel when they are
working through the pain and sti ness o postoperative healing and
therapy.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
Clip 36-1 Hand
extensor repair
revolutionized by
Merritt relative
motion extension
splinting.
Ch a P t e r 3 6
Ext en s o r Ten d o n Repair o f t h e H an d
Donald H. Lalonde, Geoff Cook

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
214
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC
FOR EXTEN SOR TEN D ON REPAIR OF TH E H AN D
Inject 20 ml of 1% lidocaine with
1:100,000 epinephrine buffered with 2 ml
of 8.4% sodium bicarbonate. The orange
line in the illustration is the laceration
and the dotted red lines are the possible
incisions.
•
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 EXTEN SOR TEN D ON
REPAIR OF TH E H AN D
•
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,4 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, use 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. The skin o the dorsal hand
is loose. You can there ore pinch it gently and push the skin into the
needle as another technique to reduce needle insertion 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
the needle pain is gone. Inject the rest o the rst 10 ml slowly (over
2 minutes) without moving the needle.
•
Reinsert the needle arther distally within 1 cm o clearly vasocon-
stricted white skin that has unctioning lidocaine and epinephrine so
the 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

Ch apt er 36 ° Ext en so r Ten d o n Repair o f t h e H an d
215
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.)
•
The goal o the injection is to get visible and palpable local anesthetic
under the skin at least 2 cm outside any area you are likely to dissect.
•
Keep the total dose o in ltration less than 7 mg/kg. I less than 50 ml
will be required to produce tumescent local anesthesia (see Chapter
4), we use premixed 1% lidocaine with 1:100,000 epinephrine. I 50 to
100 ml is required, we dilute with saline solution to a concentration o
0.5% lidocaine with 1:200,000 epinephrine.
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. This will give the epinephrine a little time to become more
e ective. 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 per-
mit the patient to remember your intraoperative advice. Patients will
also remember the range o motion they can achieve.
TIPS AN D TRICKS FOR PERFORMIN G EXTEN SOR
TEN D ON REPAIR OF TH E H AN D WITH TH E WID E
AWAKE APPROACH
•
To get the extensors to relax, ask the patient to f ex the nger. There is
a ref ex arc in the spinal cord that causes the extensors to relax.
•
Test ull st f exion and ull extension a ter every extensor tendon
repair over the hand with the protection o a tongue depressor that
simulates a relative motion extension splint, as shown in Clip 36-1. You
can then have your therapists build a splint or the patient and begin
early protected movement a ew days a ter surgery in reliable pa-
tients.
•
Patients may need to look at their ngers to get them to extend to
test the repair, since they may not eel the numbed ngers. Although
most patients do not mind looking at the wound, you can cover the
wound with a towel as they watch their ngers move.
•
Many patients are interested in looking at the tendon to understand
their problem. You can mask patients, show them the tendon, and
have them watch it move. Many patients love this. Some patients will
tell others it is something they need to put on their bucket list!
Clip 36-2 Extensors
reflexively relax
when patient is
asked to actively flex
the finger.

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
216
•
You can per orm this brie operation with eld sterility to increase e -
ciency (Chapter 10). Alternatively, you may choose to bring drapes
and gowns into the clinic or augmented eld sterility.
References
1. Howell JW, Merritt WH, Robinson SJ. Immediate controlled active motion following zone
4-7 extensor tendon repair. J Hand Ther 18:182, 2005.
2. Merritt WH. Relative motion splint: active motion after extensor tendon injury and repair.
J Hand Surg Am 39:1187, 2014.
3. Burns MC, Derby B, Neumeister MW. Wyndell Merritt immediate controlled active motion
(ICAM) protocol following extensor tendon repairs in zone IV-VII: review of literature, or-
thosis design, and case study—a multimedia article. Hand (N Y) 8:17, 2013.
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.

217
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN EXTEN SOR TEN D ON REPAIR
OF TH E FOREARM
•
You can test the strength o your orearm extensor tendon repairs by
asking patients to make a st and extend their ngers and wrist. I
you see gapping, you can strengthen your repairs with more sutures to
avoid rupture postoperatively.
•
You can allow nger movement while patients recover rom the ten-
don repair based on what you see with active movement during the
surgery. You may put them into relative motion extension splinting,
which you can simulate with a tongue depressor during the surgery
(see Chapters 35 and 36).
•
Patients can see that they can once again move their ngers without
pain during the surgery. They know that they can get their movement
back a ter they work through the pain and sti ness o the surgery.
•
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
EXTEN SOR TEN D ON REPAIR OF TH E FOREARM
The orange line in the illustration is the laceration and the dotted red lines are the possible
incisions. Inject up to 100 ml of 0.5% lidocaine with 1:200,000 epinephrine (buffered with
10 ml of 1% lidocaine with 1:100,000 epinephrine:1 ml of 8.4% sodium bicarbonate). Add
10 ml 0.5% bupivacaine with 1:200,000 epinephrine to the injectate if you think the procedure
will take more than 21⁄2 hours.
Ch a P t e r 3 7
Ext en s o r Ten d o n Repair o f t h e Fo r ear m
Donald H. Lalonde

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
218
•
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 EXTEN SOR TEN D ON
REPAIR OF TH E FOREARM
•
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,1 as outlined in Chapters 4, 5, 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, use a small 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. The skin o the dorsal ore-
arm is loose. You can there ore pinch it gently and push the skin into
the needle as another technique to reduce needle insertion 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 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) without
moving the needle.
•
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.)
•
Reinsert the needle within 1 cm o clearly vasoconstricted white skin
that has unctioning lidocaine and epinephrine so the needle reinser-
tion is pain ree.
•
The goal o the injection is to bathe local anesthetic at least 2 cm out-
side o wherever you think you have even a small chance o dissecting
in the orearm.
•
I you have access to blunt-tipped injection cannulas,2 you can inject
the local anesthetic with minimal pain and quicker than with a sharp
needle tip (see Chapter 5).

Ch apt er 37 ° Ext en s o r Ten d o n Repair o f t h e Fo r ear m
219
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. This will give the epinephrine a little time to become more
e ective. 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 per-
mit the patient to remember your intraoperative advice. Patients will
also remember the range o motion they can achieve.
TIPS AN D TRICKS FOR PERFORMIN G EXTEN SOR
TEN D ON REPAIR OF TH E FOREARM WITH TH E WID E
AWAKE APPROACH
•
Clip 37-1 provides three di erent extensor tendon repairs o the ore-
arm, including a case o primary tendon gra t to EPL a ter rupture
rom a distal radius racture.
•
Do not worry about minor bleeding rom cut skin edges, because most
little bleeders will stop spontaneously by the time you sew the skin
f aps back or exposure. We no longer use cautery or most cases but
occasionally use a hemostat on bigger vessels or a ew minutes, or tie
them o .
•
Patients may need to look at their ngers to get them to extend to
test the repair, since they may not eel the numbed ngers. Although
most patients do not mind looking at the wound, you can cover the
wound with a towel as they watch their ngers move.
•
It is worth placing a tongue depressor under the involved nger or n-
gers to per orm the repair and to simulate a relative motion extension
splint intraoperatively. This may allow you to let the patient have early
protected movement o the ngers at 3 to 5 days a ter surgery3,4 (see
Chapters 35 and 36).
References
1. 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.
2. Lalonde D, Wong A. Local anesthetics: what’s new in minimal pain injection and best evi-
dence in pain control. Plast Reconstr Surg 134(4 Suppl 2):40S, 2014.
3. Howell JW, Merritt WH, Robinson SJ. Immediate controlled active motion following zone
4-7 extensor tendon repair. J Hand Ther 18:182, 2005.
4. Merritt WH. Relative motion splint: active motion after extensor tendon injury and repair.
J Hand Surg Am 39:1187, 2014.
Clip 37-1 Three
different extensor
tendon repairs of the
forearm.

(Trang không có chữ)

221
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN TEN OLYSIS
•
There is no rush when per orming tenolysis, because there is no tour-
niquet.
•
Your patients can help you, because they are com ortable and coop-
erative; they can rupture their own adhesions by actively f exing their
muscles a ter you release some o the adhesions.
•
Patients can show you where their tendon is stuck with active move-
ment; sometimes the tendon stuck in a place that may surprise you.
•
In Clip 38-1, Dr. Jason Wong per orms tenolysis a ter a nger amputa-
tion. The patient, pain- ree and cooperative, helps the surgeon rup-
ture the last o the adhesions.
•
You will know that you nished the surgery when you see a ull range
o active nger movement while the patient is on the operating table.
This is like testing and ensuring good patency and blood f ow through
a microvascular anastomosis be ore you close the skin.
•
At the end o the surgery, you can show your patients exercises they
can per orm. They can do their rst exercises on the table in a totally
pain- ree manner instead o a ter surgery, when they will be sore.
They will remember the exercises and the range o motion they can
achieve because they are sedation ree.
•
You and the patient will both know how much active movement the
nger achieved at the end o the operation. This avoids unrealistic ex-
pectations or you and the patient.
•
In Clip 38-2, Dr. Michael Sauerbier per orms tenolysis with the wide
awake approach. Thus the patient can remember the movement he
was able to experience on the operating table.
•
Patients watch themselves moving the ngers through a ull range o
motion be ore the skin is closed. They know that their nger will unc-
tion well once they get past the postoperative discom ort and sti ness
i they put e ort into their therapy.
•
You are able to talk to unsedated patients or the 90 or so minutes
that local anesthesia and the tenolysis take to accomplish. You can
educate and warn them about what to do and not do a ter surgery.
We know that the tendon is weaker and has less blood supply a ter
Clip 38-1 Dr. Jason
Wong performs
tenolysis after finger
amputation.
Clip 38-2 Dr. Michael
Sauerbier performs
tenolysis.
Ch a P t e r 3 8
Ten o l ysis
Jason Wong, Michael Sauerbier, Peter C. Amadio, Donald H. Lalonde

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
222
tenolysis. There ore, to avoid rupture we warn patients to avoid jerk-
type movements and heavy li ting or 2 to 3 weeks until the tendon
gets stronger.
•
You can get to know your patients better during the surgery and nd
out what will motivate them. The patient in Clip 38-3 wanted to suc-
ceed in an Olympic sport. Seeing her nger move at surgery motivated
her to maintain the movement a ter surgery.
•
The hand therapist can also participate in intraoperative patient evalu-
ation and education i the surgeon allows the therapist into the oper-
ating room, as we do (see Chapter 15).
•
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 TEN OLYSIS
The orange line represents the patient’s original
scarring from 60 years before (see Clip 38-4).
For a tenolysis such as this, inject up to 30 ml
of 1% lidocaine with 1:100,000 epinephrine and
up to 3 ml of 8.4% sodium bicarbonate (1 ml of
bicarbonate for each 10 ml of 1% lidocaine with
1:100,000 epinephrine).
•
A 63-year-old woman was unable to f ex her long and ring ngers
since a tendon repair at age 3 (see the gure above and Clip 38-4). The
clip shows injection o local anesthetic, the tenolysis, and the nal re-
stored range o motion in the long and ring ngers a ter 60 years o
inability to f ex.
•
See Chapter 1, Atlas, or more illustrations o the anatomy o di usion
o tumescent local anesthetic in the orearm, wrist, and hand.
Clip 38-3 Tenolysis
after finger fracture.

Ch apt er 38 ° Ten o l ysis
223
SPECIFICS OF MIN IMALLY PAIN FUL IN JECTION
OF LOCAL AN ESTH ETIC IN TEN OLYSIS
•
Inject the rst 10 ml into the most proximal red dot injection point,
which is the most proximal incision you are likely to use to dissect the
proximal tendon. In this case, we actually injected starting at the wrist
crease as we opened the carpal tunnel to make certain it would not be
too tight a ter surgery.
•
The rst ew milliliters o local anesthetic go under the skin, and the
rest is injected under the super cial palmar ascia.
•
A ter the common digital nerves o the palm are totally numb (30 min-
utes is ideal), you can make all o the arther distal epinephrine e ect
injections in a pain- ree manner. Alternatively, you can continue in-
jecting slowly in an antegrade ashion so there is always 1 cm o local
anesthetic ahead o the needle, as described in Chapter 5 or minimal
pain injection.
•
Inject the distal palm with 3 ml in each o the red dots just proximal to
the preexisting scar.
•
Inject another 2 ml in the subcutaneous at in each o the three most
distal red dots in the palm, which are distal to the scar.
•
Note that preexisting scar in the hand creates a natural barrier or di -
usion o the local anesthetic. You should start proximally, then inject
all around a scar, because the local anesthetic will not traverse it easily,
and it is hard to inject into scar.
•
Inject another 2 ml in the a ected proximal phalanges just under the
skin.
•
Slowly inject until the whole area you will dissect gets a little rm,
with visible and palpable local anesthetic swelling. The goal o the
injection is to bathe local anesthetic 2 cm beyond wherever you think
you even have a small chance o dissecting. You will not cause a palm
compartment syndrome. As soon as you incise the skin, the pressure
will come down as the local anesthetic leaks out.
•
I you inject 20 ml into the palm, where will it go? Everywhere! Per-
ect! It is like an extravascular Bier block, but only where you need it,
and without a tourniquet.
•
We keep the total dose o in ltration less than 7 mg/kg. I less than
50 ml will be required to produce tumescent local anesthesia (see
Chapter 4), we use premixed 1% lidocaine with 1:100,000 epinephrine.
I 50 to 100 ml is required, we dilute with saline solution to a concen-
tration o 0.5% lidocaine with 1:200,000 epinephrine.
•
Inject patients be ore they come into the operating room, as described
in Chapters 3, 4, 5, and 14, to give the lidocaine and epinephrine at
least 30 minutes to work.
Clip 38-4 Tenolysis
in a 63-year-old
woman who had
been unable to
flex her long and
ring fingers since
a tendon repair at
age 3.

Sec t io n G ° Lac er at ed Ten d o n s an d Ten o l ysis
224
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. This will give the epinephrine a little time to become more
e ective. 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 per-
mit the patient to remember your intraoperative advice. Patients will
also remember the range o motion they can achieve.
TIPS AN D TRICKS FOR PERFORMIN G TEN OLYSIS
WITH TH E WID E AWAKE APPROACH
•
Keep testing intraoperative active patient f exion until you get a ull
range o active motion on the operating table be ore you close the
skin.
•
Have the patient pull on the tendons (make a st) rom time to time
as you dissect. You will see the patient per orm mini-ruptures o adhe-
sions. The patient’s movement will guide you to where the tendon is
still stuck and where you have to do more dissection to ree it.
•
We explain to patients during the surgery that we have weakened
their tendon by decreasing its blood supply by cutting all o the adhe-
sions. I they use the hand or heavy li ting early a ter surgery, they
could rupture the weakened tendon. They can apply gradual resis-
tance a ter 14 days when the risk o rupture is less. We treat tenolysed
f exor tendons as we treat reshly repaired tendons postoperatively,
with gentle early protected movement a ter passive mobilization o
the joint to take out the riction (see Chapter 32).
•
We also explain to patients during the surgery that we want them to
keep their hand elevated with minimal movement or the rst 2 to
4 days to let internal bleeding stop and to allow riction-causing
edema to settle. Internal bleeding leads to urther internal scarring
as the white cells need to “mop up” the old clot. Collagen ormation
does not start or 3 days. Waiting a ew days also allows the avascular
tendon to recover rom the decrease in blood supply we have caused
by cutting adhesions. There is no downside to a rest period, but there
are many downsides to immediate orce ul movement—especially
rupture.
•
We do not like to use sedation and amnestics, because many patients
may not be able to cooperate as well to pull and rupture their adhe-
sions. They may also not remember the range o active motion they
achieved during surgery.
Clip 38-5 Patient
ruptures her own
adhesions in the
extensor tendons
after wrist fusion.