Wide Awake Hand Surgery

(Trang không có chữ)

227
t e n D o n t r A n S f e r S
Ch a P t e r 3 9
Ten d o n Tr an sf er s
Donald H. Lalonde, Robert M. Szabo, Mark E. Baratz
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN TEN D ON TRAN SFERS
•
The biggest advantage o using the wide awake approach or tendon
trans er is getting the correct tension on the trans er. It is easy to
make a tendon trans er too tight or too loose. You can see that your
tendon trans er tension is correct by watching the patient take the
thumb or nger through a ull range o motion be ore you close the
skin.1 You can tighten or loosen the trans er and have the com ort-
able, pain- ree patient retest the tension. Both you and your patient
know the tension is right be ore you close the skin.
•
In Clip 39-2 Dr. Robert Szabo per orms a wide awake EI to EPL trans er
with intraoperative testing to make sure the tendon trans er is right.
•
You can explain to your patient how to activate the trans er during
the surgery. Some patients need to think that they are li ting their
index nger to get their thumb to move with extensor indicis (EI) to
extensor pollicis longus (EPL) tendon trans er. Most patients are able
to extend the thumb without initially thinking about li ting the index
nger.
•
Patients are able to see that their trans er is working during surgery.
They are motivated to achieve the result they know they will get i
they work at it a ter surgery.
•
In Clip 39-3 Dr. Mark Baratz demonstrates a patient watching hersel
extend her thumb in the procedure room.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
Clip 39-1 EI to EPL:
getting the transfer
tension right; clinical
experience.
Clip 39-2 Dr. Robert
Szabo performs a
wide awake EI to EPL
transfer.
Clip 39-3 Dr. Mark
Baratz demonstrates
a patient watching
herself extend her
thumb.

Sec t io n H ° Ten d o n Tr an sf er s
228
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC
FOR EI TO EPL TRAN SFER
Inject 30 to 40 ml of 1% lidocaine with 1:100,000 epinephrine buffered with 3 to 4 ml of
8.4% bicarbonate (1 ml of sodium bicarbonate for each 10 ml of 1% lidocaine with
1:100,000 epinephrine). The dotted red lines are the possible incisions.
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC
FOR FLEXOR D IGITORUM SUPERFICIALIS 3 OR
(FD S3 OR FD S4 ) TO TH E FLEXOR POLLICIS
LON GUS (FPL) TRAN SFER
Inject 50 to 100 ml of 0.5% lidocaine with 1:200,000 epinephrine buffered with 10:1 8.4% sodium
bicarbonate. Add 10 ml 0.5% bupivacaine with 1:200,000 epinephrine to the total injectate in cases
anticipated to last more than 21⁄2 hours, in case the effects of the lidocaine begin to wear off.
•
See Chapter 1, Atlas, or more illustrations o the anatomy o di usion
o tumescent local anesthetic in the orearm, wrist, and hand.

Ch apt er 39 ° Ten d o n Tr an sf er s
229
SPECIFICS OF IN JECTIN G MIN IMALLY PAIN FUL LOCAL
AN ESTH ETIC FOR TEN D ON TRAN SFERS
•
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.2,3
•
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 27-gauge needle (not a
25-gauge) into the most proximal injection point (red dot). This point
is marked at least 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 insert the needle to add the sensory
“noise” o pressure to decrease the pain. You can also pinch loose
orearm skin lightly and push the skin into the needle to decrease
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.
•
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 arther distally into clearly vasoconstricted white
skin that has unctioning lidocaine and epinephrine so the needle re-
insertion is pain ree.
•
The goal o the injection is to bathe local anesthetic 2 cm beyond
wherever you think you even have a small chance o dissecting.
•
We keep the total dose o in ltration less than 7 mg/kg. I you need
less than 50 ml to produce tumescent local anesthesia (see Chapter 4),
use bu ered 1% lidocaine with 1:100,000 epinephrine. I you want
50 to 100 ml o volume to inject, dilute with saline solution to a con-
centration o 0.5% lidocaine with 1:200,000 epinephrine. I you need
100 to 200 ml o volume or larger orearm trans ers, dilute bu ered
50 ml o commercially available 1% lidocaine with 1:100,000 epineph-
rine with 150 ml o saline solution to produce 200 ml o 0.25% lido-
caine with 1:400,000 epinephrine, which is clinically very e ective both
or local anesthesia and or vasoconstriction.
•
You can inject large areas with blunt-tipped cannulas aster but still
pain ree. See Chapter 5 or a video clip o cannula injection o tumes-
cent local anesthetic or synovectomy and EI to EPL tendon trans er.
Clip 39-4 How
to inject local
anesthetic for EI to
EPL transfer.

Sec t io n H ° Ten d o n Tr an sf er s
230
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 D ON
TRAN SFERS WITH TH E WID E AWAKE APPROACH
•
What you see on the table with intraoperative trans er tension testing
is what you will get as a result. I the trans er looks too loose, it will be
too loose postoperatively. I it looks too tight, it will be too tight post-
operatively.
•
Do not be a raid to test ull f exion and ull extension. Your sutures
should be strong enough to take it. I they are not, you need to rein-
orce them.
•
Patients may need to look at their ngers or thumb when you ask
them to test the trans er, since they may not eel the numbed digits.
Although most patients do not mind looking at the wound, you can
cover the wound with a towel as they watch their ngers and thumb
move.
•
Many patients are interested in looking at the tendon to understand
the nature o their problem. You can mask them, show them the ten-
don, and have them watch it move. It will help greatly that they see
the trans er move, because they know that it will work a ter they
overcome the pain and sti ness.
•
I you want the thumb EPL to relax, ask the patient to f ex the thumb
IP joint. The spinal cord ref ex will orce the EPL to relax.4
•
I you are going to remove a radius racture volar plate at the same
time you are per orming an FDS to FPL tendon trans er, you will
need more local anesthetic. In the case shown in Clip 39-7, we used
125 ml o 0.25% lidocaine with 1:400,000 epinephrine and added
10 ml 0.5% bupivacaine with 1:200,000 epinephrine, because we knew
the case might take longer than 21⁄2 hours. We injected the local anes-
thetic down onto the plate and the bone di usely on both sides o the
radius where the plate was located.
•
We have patients relieve themselves in the restroom a ter we inject
the local anesthetic and just be ore we start the surgery to avoid un-
necessary surgical interruptions or these longer cases. Patients do not
receive an intravenous f uid that increases the urge to void. I we give
preoperative antibiotics, we give them by mouth.
Clip 39-5 EI to
EPL surgery with
intraoperative testing
of thumb flexion and
extension.
Clip 39-6 Another
video of EI to
EPL surgery with
intraoperative testing
of thumb flexion and
extension.
Clip 39-7 FDS4 to
FPL transfer with
radius plate removal.

Ch apt er 39 ° Ten d o n Tr an sf er s
231
•
For older patients with cardiac comorbidities, you can decrease the
concentration o epinephrine and per orm the WALANT procedure in
the hospital main operating room with monitoring.
•
In Clip 39-8, an 84-year-old man with cardiac issues was given a low-
ered epinephrine concentration in the hospital and was monitored
during WALANT surgery or EI to EPL tendon trans er.
References
1. Lalonde D. Wide-awake extensor indicis proprius to extensor pollicis longus tendon trans-
fer. J Hand Surg 39:2297, 2014.
2. Lalonde DH, Wong A. Dosage of local anesthesia in wide awake hand surgery. J Hand
Surg Am 38:2025, 2013.
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. Bezuhly M, Sparkes GL, Higgins A, Neumeister M, Lalonde DH. Immediate thumb exten-
sion following extensor indicis proprius to extensor pollicis longus tendon transfer using
the wide-awake approach. Plast Reconstr Surg 119:1507, 2007.
Clip 39-8 84-year-old
man with cardiac
issues was given a
lowered epinephrine
concentration.

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233
LA c e r At e D n e r v e S
Ch a P t e r 4 0
Lac er at ed N er ves
Donald H. Lalonde
AD VAN TAGES OF WALAN T VERSUS SED ATION AN D
TOURN IQUET IN REPAIR OF LACERATED N ERVES
•
You are able to see how much tension there is on your nerve repair
with the patient’s active movement be ore you close the skin. You may
decide to let the patient go back to work 3 to 7 days postoperatively
with a relative motion f exion splint (see the relative motion f exion
splint in Clip 40-1 and other videos in Chapters 35 and 36).
•
During surgery you will have the unhurried time to explain to the
patient all o the problems o a nerve laceration. You can explain in
simple terms what to expect over the next ew months, including his
or her ability to return to work and the best way to take pain medica-
tions a ter surgery. Your patient can remember and absorb all o this
in a pain- ree, unsedated state.
•
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 REPAIR
OF D IGITAL N ERVE LACERATION S
The orange line in the illustration is the laceration and the dotted red lines are the possible inci-
sions. Inject 8 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.
Clip 40-1 Relative
motion flexion splint.

Sec t io n I ° Lac er at ed N er ves
234
SPECIFICS OF MIN IMALLY PAIN FUL IN JECTION OF
LOCAL AN ESTH ETIC FOR REPAIR OF LACERATED N ERVES
•
Inject the anesthetic solution a minimum o 30 minutes be ore surgery
to allow the lidocaine and epinephrine to take optimal e ect and pro-
vide an adequately dry working eld, as outlined in Chapters 3, 4, and
14. Inject the patient in the waiting area outside the procedure room
so no time is wasted.
•
We inject supine patients lying down on stretchers to decrease the risk
o their ainting (Chapter 6).
•
To minimize the pain o injection, inject 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 your patient tells you that all the needle pain is gone.
Inject the rest o the rst 4 ml slowly (over 2 minutes) without moving
the needle.
•
Inject the rst 4 ml o 1% lidocaine with 1:100,000 epinephrine bu -
ered 10:1 with 8.4% sodium bicarbonate in the most proximal injec-
tion point in the distal palm.
•
Ideally, wait 30 minutes to let the digital nerves get numb so the next
injections will be pain ree. Then inject 2 ml subcutaneously in each o
the injection points in the subcutaneous at in the center o the proxi-
mal and middle phalanges.
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC FOR REPAIR
OF A MED IAN N ERVE LACERATION IN TH E FOREARM
Inject 30 to 50 ml of 1% lidocaine with 1:100,000 epinephrine (buffered with 10 ml lido/epi:1 ml of
8.4% sodium bicarbonate).

Ch apt er 4 0 ° Lac er at ed N er ves
235
•
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 IN JECTIN G TH E LOCAL AN ESTH ETIC
FOR REPAIR OF A MED IAN N ERVE LACERATION
IN TH E FOREARM
•
Inject patients be ore they come into the procedure room, as outlined
in Chapters 3, 4, 5, and 14, to give the local anesthetic at least 45 to
60 minutes to work or major nerve lacerations such as the median
nerve.
•
Always start by injecting well proximal to the laceration where the
nerve is “live” to anesthetize the nerve. You can inject distal to the lac-
eration a ter the entire area proximal to the laceration is completely
numb.
•
Inject 25 ml o 1% lidocaine with 1:100,000 epinephrine bu ered
10:1 with 8.4% sodium bicarbonate 2 to 3 cm proximal to the lacera-
tion. The rst 15 ml is injected just under the skin and the remaining
10 ml is placed sub ascially.
•
Gradually advance the needle as you inject the 25 ml, as described in
Chapter 5, or minimal pain injection. The ascia is 3 to 5 mm under
the skin, depending on the patient’s size. It is best to have extra local
anesthetic at hand, because some o it may well come out through the
laceration.
•
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.
•
Consider adding 10 ml o 0.5% bupivacaine with 1:200,000 epineph-
rine or liposomal bupivacaine to produce longer pain relie or major
nerve lacerations.
•
Inject another 10 to 15 ml o local anesthetic to tumesce the skin distal
to the laceration.
•
Be sure to have at least 5 cm o visible palpable local anesthetic proxi-
mal to the laceration along the path o the nerve.
TIPS AN D TRICKS FOR REPAIRIN G LACERATED N ERVES
WITH TH E WID E AWAKE APPROACH
•
We have per ormed a level I evidence study (still to be published) that
shows that large nerve blocks such as in the median nerve increase in
intensity over 90 minutes a ter injection. We there ore inject patients
and have them wait an hour or more i possible or the nerve to be-
come completely numb while we see other patients or operate in the

Sec t io n I ° Lac er at ed N er ves
236
clinic. In this way, no time is wasted and the patient with lacerated
nerves experiences no pain during the repair.
•
I you cannot wait or 60 minutes or a median or ulnar nerve to get
numb, you can approach the “live nerve” very care ully at surgery.
Expose it above the laceration. Inject the loose areolar tissue outside
the healthy proximal part o the nerve with a 30-gauge needle with
the bevel parallel to the nerve. This will balloon the outside covering
o the nerve to accelerate nerve in ltration by the lidocaine. Do not
inject inside the nerve perineurium or elicit paresthesias, because you
may damage axons.
•
For digital nerve injuries, you can simulate relative motion f exion
splinting or early protected movement to begin 3 to 5 days a ter sur-
gery. Repair the nerve and insert a tongue depressor, as in Clip 40-1.
•
I the nerve stays together with no tension with active f exion and ex-
tension, you can prescribe a relative motion f exion splint to be worn
postoperatively. I the nerve comes apart with tongue depressor simu-
lation, then clearly you would treat this patient with standard immobi-
lization a ter surgery.
•
We per orm these nerve repairs in the clinic with eld sterility (see
Chapter 10) and loupe magni cation.

237
f r A c t u r e S
Ch a P t e r 41
Fin g er Fr ac t u r es
Donald H. Lalonde
AD VAN TAGES OF WALAN T VERSUS SED ATION AN D
TOURN IQUET FOR FIN GER FRACTURE RED UCTION
•
When you see ull f exion and extension o the nger you have
K-wired at surgery and see that your reduction is stable with f uoros-
copy, you will eel a lot more com ortable about starting early pro-
tected movement or these ngers, just as in f exor tendon injuries.1,2
•
A ter you reduce the ractures, you can watch the patient, who is com-
orable and tourniquet ree, move the reconstructed bone to see how
stable the xation is. You can add more K-wires i you eel greater sta-
bility is needed to support early protected movement.
•
You can see whether the K-wires are interrupting active nger move-
ment by impinging on ligaments or tendons in their current location.
You have the opportunity to change the K-wire location to optimize
postoperative early active movement be ore the end o the operation.
•
A major advantage o eliminating sedation or nger ractures is that
you do not need to per orm the reduction in the main operating room
(see Chapters 10 and 16). I patients need internal xation, you can
per orm closed reduction and K-wire insertion in minor procedure
rooms in the clinic outside the main operating room Monday to Friday,
9 AM to 5 PM (see Clip 41-3). You no longer need to do these at night
to suit the main operating room and anesthesiologist’s schedules. You
are more likely to do better surgery with a clear head at 1 PM than
when you are tired at 1 AM. You no longer have to admit patients to
the hospital because o their medical comorbidities; these issues are
only a problem when you use sedation.
•
Because you can per orm these operations in the clinic, your hand
therapists can see how much active nger movement is possible dur-
ing the surgery. You can discuss the sa e early protected movement
plan with therapists during and a ter the surgery (see Chapter 15).
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.
Clip 41-1 Early
protected movement
3 days after K-wiring
middle phalanx
fracture.
Clip 41-2 Two finger
fractures: numbing,
intraoperative testing
of functionally stable
fixation of K-wire
reduction, early
protected movement
demonstration, and
final result.
Clip 41-3 Augmented
field sterility setup
for inserting K-wires
in a minor procedure
room.

Sec t io n J ° Fr ac t u r es
238
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC
FOR FIN GER FRACTURE RED UCTION
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 each of
the palmar proximal and middle phalanges in the subcutaneous fat. Dorsal 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) 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 each of the dorsal proximal and middle pha-
langes 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.
Clip 41-4 Real-time
minimal pain local
injection for proximal
phalanx fracture.

Ch apt er 4 1 ° Fin g er Fr ac t u r es
239
SPECIFICS OF MIN IMALLY PAIN FUL IN JECTION
OF LOCAL AN ESTH ETIC FOR FIN GER FRACTURE
RED UCTION
•
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,3 as outlined in Chapters 4 and 14.
•
Inject patients in a waiting area be ore they come into the procedure
room to give the local anesthetic time to work.
•
We inject supine patients lying down on stretchers to decrease the risk
o their ainting (see Chapter 6).
•
To minimize the pain o injection, inject 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. (See Chapter 5 or other
hints on how to decrease the pain o local injection.)
•
Start with the rst 4 ml in the proximal palmar red injection point.
Then inject 4 ml just under the skin on the dorsal side’s most proximal
red dot injection point.
•
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 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 1 to 2 minutes) without moving
the needle.
•
There is no need to move the needle, since the local anesthetic will di -
use through the at, unless there is previous scarring.
•
I convenient, wait 15 to 30 minutes be ore injecting distally on the
palmar side and dorsal sides so the next two digital palmar and dorsal
injections will not be pain ul. This waiting period can be used produc-
tively to see other patients.
•
Follow with the next pain- ree injections. Inject 2 ml just under the
skin on the palmar side in the red injection points o the proximal and
middle phalanges. Then inject 2 ml just under the skin on the dorsal
side in the red injection points o the proximal and middle phalanges.
•
It is worth injecting into the middle phalanx i you are operating on
a proximal phalanx racture, because the epinephrine will help with
hemostasis and decrease internal bleeding, which would occupy space
and be replaced with inf ammatory tissue.
•
There is no need to inject into the distal phalanx dorsum, since bleed-
ing will be minimal i you have injected in the dorsal middle phalanx.

Sec t io n J ° Fr ac t u r es
240
•
I you are only using K-wires or a percutaneous reduction and not
cutting through the skin, it is still worth having epinephrine in the so t
tissue around the bone you are K-wiring, even i that tissue is numb
rom proximal blocks. Epinephrine will provide less internal bleeding
in the periosteal tissue, which means less callus and less scar or the pa-
tient to work through later.
TIPS AN D TRICKS FOR PERFORMIN G FIN GER FRACTURE
RED UCTION WITH TH E WID E AWAKE APPROACH
•
Patients may need to look at their ngers or thumb to help them
move the digit a ter you reduce the racture, since they cannot eel
the numbed digit move. Although most patients do not mind looking
at the wound, you can cover it with a towel as they f ex and extend
the tip o the nger or thumb.
•
Take advantage o the act that the patient is not sedated to give him
or her clear instructions on postoperative activity. You can get better
patient cooperation or postoperative hand elevation and care be-
cause the patient is able to listen and remember your advice right at
the end o surgery. This can decrease your complication risk.
•
Clip 41-5 shows advice to an awake patient at the end o nger rac-
ture reduction surgery. (See Chapter 8 or other videos on intraopera-
tive advice or patients.)
•
An experienced surgeon can insert a K-wire quickly and sa ely with
eld sterility. I the K-wiring will take a long time because it is di -
cult, or i we may need to open the skin to reduce the racture, we
import gowns and hal sheets to the clinic or augmented eld sterility
(see Clip 41-3). There is no rule that says that an added gown and hal
sheet sterility are restricted to the main operating room.
•
You can test the stability o your dorsal blocking K-wire when using
this technique or dorsal racture dislocations o the PIP joint or early
protected movement (see Clip 41-6).
•
You can test the stability o your internal xation and the active mo-
bility o the tendons and joints intraoperatively in complex malunion
reduction cases (see Clip 41-7).
Clip 41-5 Advice to
an awake patient
at the end of finger
fracture reduction
surgery.
Clip 41-6 Testing
stability of dorsal
blocking K-wire
for dorsal fracture
dislocation of PIP
joint.
Clip 41-7 Wide
awake operative
reduction of
a 4-week-old
scissoring malunion
of the proximal
phalanx.

Ch apt er 4 1 ° Fin g er Fr ac t u r es
241
•
For comminuted intraarticular PIP and MP ractures that require dis-
traction splinting, consider inserting K-wires or distraction splinting in
the clinic. We have the therapists apply a banjo distraction splint while
the patient’s hand is still numb. You can then assess the joint in the
splint with f uoroscopy while the patient is still numb, as in Clip 41-8.
You can change the K-wire while the patient’s hand is still numb i
necessary.
•
Some nger ractures don’t need surgery (see Clip 41-9).
References
1. Gregory S, Lalonde DH, Leung LT. Minimally invasive finger fracture management, wide-
awake closed reduction, K-wire fixation, and early protective movement. In Curtin C,
Chung KC, eds. Hand Clinics: Minimally Invasive Hand Surgery. London: Elsevier, 2014.
2. Jones NF, Jupiter JB, Lalonde DH. Common fractures and dislocations of the hand. Plast
Reconstr Surg 130:722e, 2012.
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 41-8
Distraction splint for
comminuted PIP and
MP fractures.
Clip 41-9 Fracture
boutonniere treated
with a relative
motion flexion splint
only.
Clip 41-10 Mallet
fractures involving
50% to 60% of
the joint but with
congruous or parallel
joint surfaces (not
subluxated) can be
treated with mallet
splinting only.

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243
Ch a P t e r 4 2
Red u c t io n an d In t er n al Fixat io n
o f Met ac ar pal Fr ac t u r es
Shu Guo Xing, Jin Bo Tang, Donald H. Lalonde
AD VAN TAGES OF WALAN T VERSUS SED ATION
AN D TOURN IQ UET IN RED UCTION AN D IN TERN AL
FIXATION OF METACARPAL FRACTURES
•
You can see that you have solved the scissoring problem by watching
your patient take the ngers through a ull range o active motion be-
ore you close the skin.
•
Patients see the reduction o their bone on f uoroscopy. They watch
themselves achieve a ull range o f exion and extension o their n-
gers during the surgery. They remember this and know that this will
be achievable i they stick with therapy and exercise a ter the surgery.
•
You and your hand therapist can educate wide awake patients during
the operation to instill the importance o postoperative therapy into
patients’ consciousness.
•
Patients can practice postoperative movement in a pain- ree state dur-
ing surgery.
•
You can check the stability o the bone xation with ull f exion and
extension during the surgery. This helps you to decide whether or not
to allow early protected movement a ter surgery.
•
All o the general advantages listed in Chapter 2 apply to both the sur-
geon and the patient.

Sec t io n J ° Fr ac t u r es
244
WH ERE TO IN JECT TH E LOCAL AN ESTH ETIC
FOR RED UCTION AN D IN TERN AL FIXATION
OF METACARPAL FRACTURES
Inject a total of 30 to 40 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 illustrations o the anatomy o di usion o tu-
mescent local anesthetic in the orearm, wrist, and hand.
•
Local anesthesia or a Bennett racture is the same as or a trapeziec-
tomy (see Chapter 27). You f ood the radial side o the hand with
40 ml o bu ered lidocaine with epinephrine, as shown in Clip 42-1.
•
The local anesthetic or racture dislocations o the ourth and th
metacarpal bases is 40 ml o bu ered lidocaine and epinephrine f ood-
ing the ulnar side o the distal wrist and base o the hand, as shown in
Clip 42-2.
Clip 42-1 Fracture
dislocation at the
base of the thumb
metacarpal (Bennett
fracture).
Clip 42-2 Fracture
dislocation at the
base of the fifth
metacarpal.

Ch apt er 4 2 ° Red u c t io n an d In t er n al Fixat io n o f Met ac ar pal Fr ac t u r es
245
SPECIFICS OF MIN IMALLY PAIN FUL IN JECTION
OF LOCAL AN ESTH ETIC IN RED UCTION AN D
IN TERN AL FIXATION OF METACARPAL FRACTURES
•
To minimize the pain o injection, inject with a 27-gauge needle (not a
25-gauge).
•
The rst 10 ml goes into the most proximal location that you will dis-
sect.
•
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
the needle pain is gone. Inject the rest o the rst 10 ml slowly (over
2 to 3 minutes) without moving the needle (see Chapter 5).
•
You may inject an additional 10 ml between the median and ulnar
nerves under the orearm ascia at the volar wrist i you would like to
block those nerves with tumescent local anesthetic.
•
Inject the second 10 ml o local anesthetic in the center o the incision
site with the needle inserted into clearly vasoconstricted white skin
that has unctioning lidocaine and epinephrine so that needle inser-
tion is pain ree. You should have tumescent local anesthetic (Chapter
4) di used at least 2 cm on either side o the incision.
•
Inject the third 10 ml in the distal third o the incision.
•
The goal o the injection is to bathe local anesthetic all around the
metacarpal where dissection or internal xation will occur, including
the palmar side and between the metacarpals. You may want to add
additional local anesthetic in the lateral and volar aspects o the meta-
carpal with a ourth 10 ml syringe.
•
Inject the anesthetic solution in a waiting area a minimum o 30 min-
utes be ore surgery to allow the epinephrine to take optimal e ect
and provide an adequately dry working eld. This waiting period can
be used productively to see other patients.
•
We inject supine patients lying down on stretchers to decrease the risk
o their ainting (see Chapter 6).
•
For articular ractures, add 2 to 4 ml into the joint cavity and in the
so t tissues around the joint.
•
For plate removal, bathe the entire surgical dissection area with am-
ple local anesthetic rom proximal to distal on both sides o the surgi-
cal scar. Let the local anesthetic di use into the scar on its own. You
should have 2 cm o local anesthetic all around the planned dissection
area (see Clip 42-4).
Clip 42-3 Local
anesthesia for fourth
and fifth metacarpal
operative reduction.
Clip 42-4 Local
anesthetic injection
for WALANT
metacarpal plate
removal.

Sec t io n J ° Fr ac t u r es
246
TIPS AN D TRICKS FOR PERFORMIN G RED UCTION
AN D IN TERN AL FIXATION OF METACARPAL FRACTURES
WITH TH E WID E AWAKE APPROACH
•
A ter you have provisional reduction, ask the patient to make a st
and extend the ngers to test the stability o your internal xation.
You will see whether there is enough stability in the xation to sup-
port early protected movement or whether you need to insert addi-
tional xation.
•
You can correct any malrotation that the patient demonstrates with
intraoperative active f exion and extension be ore you close the skin.
•
A dynamic compression bone clamp provides enough temporary rigid
xation in transverse metacarpal ractures that you can test ull f ex-
ion and ull extension o the clamp-held reduced ractures to make
sure there is no malrotation be ore you drill screw holes.
Clip 42-5 Operative
reduction of fourth
and fifth metacarpal
fractures in the
patient injected with
local anesthetic seen
in Clip 42-3.
Clip 42-6 Early
protected movement
3 days after K-wire
fixation of a
metacarpal fracture.
Clip 42-7 A 3-month-
old malunion of a
metacarpal with
intraoperative testing
of full flexion and
extension after
reduction and
plating.
Clip 42-8 Checking
scissoring
after dynamic
compression bone
clamp metacarpal
fracture reduction.

Co mpl ex Rec o n s t r u c t io n s
Part IV

(Trang không có chữ)

249
Ch a P t e r 4 3
Co mpl ex Rec o n s t r u c t io n s
in H an d Su r g er y
Donald H. Lalonde, Jason Wong, Alistair Phillips, Nik Jagodzinski
Many complex reconstructions are undertaken when movement a ter
trauma or surgery does not produce ideal unction. The goal is usually to
restore use ul movement o the wrist, thumb, and ngers. Patients with
sedation, a motor block, or a tourniquet are not able to move recon-
structed parts during surgery in com ort. WALANT permits them to do just
that. Furthermore, the surgeon can adjust the reconstruction to make it
work i the preoperative plan is success ul when patients move recon-
structed ngers or thumbs during the surgery. The more complex the
reconstruction, the more help ul WALANT can be. We present a video
series o cases to illustrate this point.
•
Clip 43-1 shows a repair o a 51⁄2-week-old f exor pollicis longus (FPL)
laceration. We did not know which operation would be possible or
best—primary repair, primary palmaris longus tendon gra t, or tendon
trans er o the long nger f exor digitorum super cialis (FDS). We
injected local anesthetic or all three possibilities and made our deci-
sion based on active movement by the patient during the surgery.
•
Clip 43-2 demonstrates a change in thumb tip pinch a ter adult pollici-
zation. This patient had an adult pollicization o the index nger a ter
a ailed thumb replantation. Years later, he requested better thumb
tip pinch and was able to participate in selecting the per ect angle
during the surgery.
•
Clip 43-3 describes cleaning a severely contaminated hand wound in
the emergency department. This illustrates how we wash very contam-
inated wounds with tap water a ter adequate local anesthetic is ad-
ministered in the emergency department.
Clip 43-1 Repair of
a 51⁄2-week-old FPL
laceration.
Clip 43-2 Change
thumb tip pinch after
adult pollicization.
Clip 43-3 Cleaning
a severely
contaminated
hand wound in
the emergency
department.

Par t IV ° Co mpl ex Rec o n st r u c t io n s
250
•
Clip 43-4 shows a complex secondary reconstruction with extensor
tendon gra ting where intraoperative active movement demonstrated
that the preoperative plan o simple tendon gra t insertion ailed be-
cause it did not extend the proximal phalanx adequately. We added
gra t suturing to the proximal extensor hood o the proximal phalanx
to the preoperative plan because o intraoperative active extension
observation and were ultimately success ul.
•
Clip 43-5 is o a complex extensor tendon trans er case. The patient
had had polio 50 years earlier, which resulted in muscle dys unction
o the entire upper limb and shoulder usion. She subsequently rac-
tured her humerus and acquired a postplating radial nerve palsy. We
planned a f exor carpi radialis (FCR) and f exor carpi ulnaris (FCU)
trans er procedure. We saw the true active excursion o the polio a -
ected muscles at surgery that altered the preoperative plan with ulti-
mate success.
•
Clip 43-6 shows a nger revascularization with wrist vein gra ts by Dr.
Jason Wong. The patient had sustained a severe crush injury to all our
digits o the le t hand, with delayed presentation that rendered the
index and middle ngers nonsalvageable. The ring and little ngers
were salvaged using the WALANT technique.
•
In Clip 43-7 a homodigital island f ap was per ormed by Dr. Jason
Wong. This was a case o ngertip reconstruction with a local pedicled
island f ap with WALANT anesthesia. Active movement during surgery
shows correct tension o the inserted pedicle.
•
In Clip 43-8 thumb extension was restored a ter a subtotal amputa-
tion. This subtotal amputation o a thumb ended up without extensor
pollicis longus (EPL) unction. We injected enough local anesthetic to
allow extensor indicis proprius (EIP) tendon trans er i the EPL muscle
had been too short to permit simple tendon repair.
Clip 43-4 Extensor
tendon graft of the
dorsum of the hand.
Clip 43-5 FCR and
FCU transfer in a
polio case.
Clip 43-6 Finger
revascularization
with wrist vein grafts
by Dr. Jason Wong.
Clip 43-7
Homodigital island
flap by Dr. Jason
Wong.
Clip 43-8 Restoration
of thumb extension
after subtotal
amputation.

Ch apt er 4 3 ° Co mpl ex Rec o n st r u c t io n s in H an d Su r g er y
251
•
Clip 43-9 shows a WALANT FPL repair under the motor branch in the
carpal tunnel. The patient ruptured the repair. We also show the sec-
ondary repair with WALANT 8 days a ter the initial repair. Postopera-
tive management o both operations is explained.
•
Clip 43-10 shows a swan neck f exor digitorum super cialis (FDS) trans-
er. We sutured the proximal FDS o the small nger to the proximal
phalanx with a bone anchor to correct a swan neck de ormity. Active
movement during the surgery shows the correct selection o tension.
•
In Clip 43-11 a woman in her late sixties presented with rupture o the
ourth and th extensors o her le t hand. We harvested a palmaris
longus tendon gra t and hooked it up to proximal tendon stump mo-
tors that still had good active excursion. We strengthened the repair
with a trans er to the long nger extensor and per ormed a tenodesis
o the extensor digiti minimi, all decisions based on active movement
at the time o surgery.
CON CLUSION
We have ound that secondary reconstructions o the hand and ngers
in awake pain- ree patients have the great bene t o adding voluntary
active movement during the surgery. We have o ten been pleasantly sur-
prised, as we have been in the cases presented here, that outcomes have
been improved because o intraoperative adjustments on reconstructed
parts based on what we see with patients moving. It has become our
method o choice where the goal o the operation is to improve active
unction.
Clip 43-9 Ruptured
FPL repair under the
motor branch in the
carpal tunnel.
Clip 43-10 Swan
neck FDS transfer.
Clip 43-11 Palmaris
longus tendon graft
for rupture of fourth
and fifth extensors.

(Trang không có chữ)

253
A
Abductor pollicis longus, ligament recon-
struction and tendon interposi-
tion with, 167
Accountable Care Act (ACA), 96
Accountable care organizations (ACOs),
96
Administrators, 79-80, 91, 112
Airway, 89
Amadio, Peter, 92-94
American Association or Accreditation
o Ambulatory Surgery Facilities
(AAASF), 76, 118
Amputation
nger; see Finger amputation
ray; see Ray amputation
thumb, extension restoration a ter,
250
Anesthesia; see General anesthesia; Local
anesthesia; Local anesthetics
Anesthesiologists
barriers to WALANT by, 88-89
carpal tunnel decompression/release
participation by, 135
description o , 31
extensor tendon repair participation
by
nger, 211
orearm, 219
hand, 215
f exor tendon repair participation by
nger, 192
orearm, 207
hand, 202
median nerve release at elbow
participation by, 143
open triangular brocartilage
complex repair participation by,
185
proximal interphalangeal joint
procedures
arthroplasty, 163
usion, 176
tendon trans er participation by, 230
tenolysis participation by, 224
thumb metacarpophalangeal joint
usion participation by, 173
trapeziectomy participation by, 168
ulnar collateral ligament repair
participation by, 173
WALANT buy-in by, 79-81
working with, 104
wrist arthroscopy participation by, 182
Anticoagulants, 19-20, 94
Anxious patients, 52, 55
Arthroscopy, wrist; see Wrist arthroscopy
B
Baratz, Mark, 227
Barriers
anesthesiologist-perceived, 88-89
general types o , 82-84
nurse-perceived, 85-86
patient-perceived, 84-85
surgeon-perceived, 86-88
Bennett racture, 244
Blunt cannulas, or local anesthetic injec-
tion, 45-46, 218, 229
Bone reconstruction, 56
Boutonniere surgery, 209
Brachial artery, 144
Brazil, 33
Bu ering o lidocaine with 1:100,000 epi-
nephrine, with 10:1 8.4% so-
dium bicarbonate, 37-38, 138
Bupivacaine, 32, 50-51, 100, 230, 235
Buy-in
rom administrators, 79-80
rom anesthesiologists, 79-81
rom nurses, 79-81
rom payers, 79-82
C
Canadian Association or Accreditation
o Ambulatory Surgical Facilities
(CAAASF), 76, 117
Cannulas, blunt, 45-46, 218
i n d e x

In d e x
254
Dermis, injection o 0.5 ml with perpen-
dicular needle just under, 40-41
Dermo asciectomy, 153-154
Desmarres retractors, 119, 148
Di cult surgeries, 87
Digital extension-f exion test, 195
Digital nerve laceration, 233
Dorsal block augmentation, nger block
with, 12
Dorsal thumb proximal phalanx block, 13
Draping, 85
Driving, 58
Dupuytren’s contracture
local anesthetic injection or, 152-153
recurrent, 151, 153
tips or, 153-154
WALANT advantages or, 151
Dynamic compression bone clamp, 246
E
Education
o patients, 59-60
o trainees, 61
Egypt, 33
Emergency department consultations,
109
Endoscopy
carpal tunnel decompression/release
local anesthetic injection or, 133
tips or, 136
cubital tunnel decompression, 139
Epinephrine; see also Lidocaine with epi-
nephrine
1:1000
accidental injection o , in nger, 27
illustration o , 33
vasoconstriction duration with, 32
1:10,000, 32
1:100,000
de nition o , 33
lidocaine with; see Lidocaine (1% )
with 1:100,000 epinephrine
vasoconstriction with, 30, 32
1:200,000
de nition o , 33
lidocaine (0.5% ) with, 132, 138,
228, 230
1:400,000, 121
1:1,000,000
clinical uses o , 33
hemostasis with, 105
adverse reactions to, 50-51
author’s reasons or using, 24
Carpal tunnel decompression/release
anesthesiologist involvement in, 135
cubital tunnel decompression and, 140
endoscopic
local anesthetic injection or, 133
tips or, 136
eld sterility versus ull sterility or,
69-71, 134
local anesthetic injections or, 43, 130-
133
open
local anesthetic injection or, 130-
132
tips or, 134-135
patient education about, 62-63
patient positioning or, 132
surgical instrument or, 119
WALANT bene ts or, 21, 129-130
wound care a ter, 62
Caseload, 107-108, 129
Catech-O-methyl trans erase, 51
Cautery, 105
Cautery machine, 120
Children, 65-67
Comminuted ractures, 241
Complex reconstruction, 249-250
Consultation
rom emergency department, 109
talking with patient during, 55-57
rom trauma surgery, 109
Cost reductions
or governments, 78
or hospitals, 77-78
or insurance companies, 78
or operating acility, 77-78
or patients, 75-76
or payers, 78
or surgeons, 76, 96
Creases, skin, 34, 44
Cubital tunnel decompression
carpal tunnel decompression/release
and, 140
description o , 17
eld sterility or, 140
local anesthetic injection or, 138-139
patient positioning or, 137, 139-140
tips or, 139-140
WALANT advantages or, 137
D
Dalhousie Project experimental phase, 26
De Quervain release, 149-150
Denkler, Keith, 24

In d e x
255
F
Facilities, local anesthetic injections in,
83-84
Fainting, 51-52, 57
Field sterility
bene ts o , 77
or carpal tunnel decompression/
release, 134
components o , 95
or cubital tunnel decompression, 140
de nition o , 69
or extensor tendon repair o hand,
216
ull sterility versus, 69-72, 77
in minor procedure rooms, 119
outcomes with, 71
Fielding, John, 23
Fi teen cases per day, scheduling o , 107-
108, 129
Finger
extensor tendon repair o ; see
Extensor tendon repair, o nger
f exor tendon repair o ; see Flexor
tendon repair, o nger
in arction o , 27
revascularization o , with wrist vein
gra ts, 250
Finger amputation
local anesthetic injection or, 125-128
tips and tricks or, 128
WALANT advantages or, 125
Finger block
with dorsal block augmentation, 12
subcutaneous midline proximal
phalanx, 11
Finger racture reduction
comminuted ractures, 241
hand therapy a ter, 114-115
K-wire xation a ter; see K-wire nger
racture repair
local anesthetic injection or, 238-239
tips or, 240-241
WALANT advantages or, 237
Fingertip
numbness in, 195
white, 27
Flexor carpi radialis
ligament reconstruction and tendon
interposition with, 167
tendon trans er involving, 250
Flexor carpi ulnaris, 250
Flexor digitorum pro undus, 193
cardiac responses to, 83, 231
concentrations o , 33
in ngers, 23-24, 83
hal -li e o , 51
hemostasis uses o , 20, 23-24, 50, 105
history o , 23-24
in hypertensive patients, 50
myths regarding, 24-25
phentolamine reversal o , 24-27, 50,
83
“rush” caused by, 51
sa ety o , 17, 49-50, 83
vasoconstriction rom, 32, 108, 128
Europe, 33
Evidence-based medicine, 78
Extension-f exion test
a ter extensor tendon repair o hand,
215
a ter f exor tendon repair
o nger, 195
o hand, 202
Extensor indicis to extensor pollicis lon-
gus tendon trans er, 227-228
Extensor tendon gra ting, 250
Extensor tendon repair
o nger
anesthesiologist participation in,
211
local anesthetic injection or, 210-
211
patient education during, 212
tips or, 211-212
WALANT advantages or, 209
o orearm
anesthesiologist participation in,
219
incisions or, 217
local anesthetic injection or, 217-
218
tips or, 219
WALANT advantages or, 217
o hand
anesthesiologist participation in,
215
extension-f exion testing a ter,
215
eld sterility or, 216
local anesthetic injection or, 214-
215
tips or, 215-216
WALANT advantages or, 213
hand therapy in, 114
percutaneous, 211

In d e x
256
local anesthetic injection or, 217-
218
tips or, 219
WALANT advantages or, 217
f exor tendon repair o
anesthesiologist participation in, 207
local anesthetic injection or, 207
tips or, 208
WALANT advantages or, 205
radial, 5
ulnar, 5
volar, 4
Forearm ascia, 132
Full sterility
de nition o , 69
eld sterility versus, 69-72
G
General anesthesia
in children, 67
WALANT and, 100
Germann, Günter, 102
Governments, 78
H
Hand
f exor tendon repair o ; see Flexor
tendon repair, o hand
palmaris longus tendon gra t or
rupture o ourth and th
extensor o , 251
wound to, cleaning o , 249
Hand surgery, complex reconstructions
in, 249-250
Hand therapists, 111-115
Hemostasis, epinephrine or, 20, 23-24,
50, 105
Homodigital island f ap, 250
Hong Kong, 33
Hospitals
cost reductions or, 77-78
pro tability or, 77-78
I
Incision
bleeding rom, 136
a ter injections, 104
pain caused by, 62
redness around, 63
In ants, 65-67
In ection
hands, 34
wound, 63, 70-72
Flexor digitorum super cialis
description o , 193
to f exor pollicis longus tendon
trans er, 228
swan neck trans er o , 251
Flexor pollicis longus
f exor digitorum super cialis tendon
trans er to, 228
laceration o , 249
repair o , 251
Flexor sheath ganglion surgery, 155-156
Flexor tendon repair
o nger
anesthesiologist participation in,
192
digital extension-f exion test a ter,
195
ull active st testing a ter, 197
intraoperative testing, 187
local anesthetic injection or, 190-
192
patient education during, 188
postoperative regimen or, 196-197
rectangular f ap incisions in, 191
sheathotomy, 194
super cialis repair, 189
tenolysis rates, 187-188
tips or, 193-195
WALANT advantages or, 187-189
o orearm
anesthesiologist participation in,
207
local anesthetic injection or, 207
tips or, 208
WALANT advantages or, 205
o hand
anesthesiologist participation in,
202
extension-f exion test a ter, 202
incisions or, 200
local anesthetic injection or, 200-
202
tips or, 202
WALANT advantages or, 199
hand therapy in, 113-114
talking with patients during, 60
tenolysis rate reduction, 187-188
Forearm
dorsal, 4
extensor tendon repair o
anesthesiologist participation in,
219
incisions or, 217

In d e x
257
thumb metacarpophalangeal joint
usion using, 172
timing o , 83, 108
trapeziectomy using, 166-168
trigger nger surgery using, 146-147
ulnar collateral ligament repair using,
172
vasovagal attack secondary to, 51-52
volume recommendations, 44
wrist arthroscopy using, 180-181
Insulin syringe, 33
Insurance companies
cost reductions or, 78
pro tability or, 78
WALANT buy-in by, 82
Internal xation
o nger racture; see K-wire nger
racture repair
o metacarpal racture
local anesthetic injection or, 244-
245
tips or, 246
WALANT advantages or, 243
Intralipid, 50
Island f ap, homodigital, 250
K
Kerrigan, Carolyn, 91-92, 130
Kleinert rubber bands, 188
K-wire nger racture repair
eld sterility or, 71
hand therapy in, 114-115
local anesthetic injection or, 239
minor procedure rooms or, 120
talking with patients during, 60
tips or, 240
WALANT advantages or, 237
L
Lacerated nerve repair
digital nerve, 233
local anesthetic injection or, 233-235
median nerve, 234-235
tips or, 235-236
WALANT advantages or, 233
Lacertus syndrome
characteristics o , 141
diagnosis o , 141
local anesthetic injection or, 142-143
median nerve release at elbow or,
141-144
tips or, 144
Liability, 86
Injections, local anesthetics
0.5 ml with perpendicular needle just
under dermis, 40-41
or Bennett racture, 244
“blow slow be ore you go” rule or,
41-42
blunt cannulas or, 45-46, 218, 229
carpal tunnel decompression/release
using, 130-133
in children, 65-67
common mistakes in, 43
cubital tunnel decompression using,
138-139
De Quervain release using, 149-150
details o , 44
Dupuytren’s contracture surgery
using, 152-153
extensor tendon repairs using
orearm, 217-218
hand, 214-215
ainting during, 51-52, 57
eedback rom patient about, 43
nger amputation using, 125-128
nger racture reduction using, 238-
239
f exor sheath ganglion surgery using,
155-156
f exor tendon repairs using
nger, 190-192
hand, 200-202
incision a ter, 104
K-wire nger racture repair using,
239
lacerated nerve repair using, 233-235
median nerve release at elbow using,
142-143
metacarpal racture reduction and
internal xation using, 244-245
needle should never get ahead o
local anesthetic, 41-42
pain- ree, rules or, 37-44
patient positioning during, 52
proximal interphalangeal joint
arthroplasty using, 162-163
reinserting needles within 1 cm o
blanched/unblanched border, 43
sensory noise in area o , 38-39, 201
sharp needles or, 44
skin cancer excision using, 158-159
small-bore 27- or 30-gauge needles
or, 38, 126, 191
talking with patients during, 61
tenolysis using, 222-223

In d e x
258
trigger thumb surgery using, 146
ulnar collateral ligament repair using,
172
vasoconstriction duration with, 32
wrist arthroplasty using, 180
Lidocaine with epinephrine; see also Epi-
nephrine
0.5% with 1:200,000 epinephrine, 132,
228, 239
1% with 1:100,000 epinephrine; see
Lidocaine (1% ) with 1:100,000
epinephrine
1% with 1:200,000 epinephrine, 33,
138
adverse reactions to, 50
duration o anesthesia with, 51, 104
maximal dose o , 49
numbness duration with, 104
sa ety o , 49-50, 83
talking with patients during injection
o , 61
Ligament reconstruction and tendon in-
terposition, 165, 167
Lipid emulsion therapy, 50
Lipoma excision, 160
Litigation, 77
Local anesthesia
hospital operating rooms or, 90
perspectives on, 34-35, 92-93
sedation versus, 89
tumescent; see Tumescent local
anesthesia
Local anesthetics
bupivacaine, 50-51
di usion o
in middorsal hand, 9, 126-127
in midline dorsal orearm, 4
in midline dorsal wrist, 6
in midline radial orearm, 5
in midline radial wrist, 7
in midline ulnar orearm, 5
in midline ulnar wrist, 8
in midline volar orearm, 4
in midline volar wrist, 6
in midpalmar hand, 8, 125, 127,
162, 175
natural barriers to, 34
in thumb midmetacarpal dorsal, 10
in thumb midmetacarpal volar, 10
in ulnar hand, 9
injection o
0.5 ml with perpendicular needle
just under dermis, 40-41
Lidocaine
adverse reactions to, 50
anaphylaxis, 49
history o , 49
onset o anesthesia with, 30
sa ety o , 17, 49-50
seizures caused by, 50
Lidocaine (1% ) with 1:100,000 epineph-
rine
bu ering o , with 10:1 8.4% sodium
bicarbonate, 37-38, 138
carpal tunnel release using, 130-131,
133
De Quervain release using, 149
dilution o , 32
dosage o , 31-32
Dupuytren’s contracture surgery
using, 152
extensor tendon repairs using
nger, 210
orearm, 217
hand, 214
nger racture repair using, 238
f exor sheath ganglion surgery using,
155
f exor tendon repairs using
nger, 190-191
orearm, 206
hand, 200-201
in in ants, 66
lacerated nerve repair using, 233-235
lacertus tunnel release using, 142
lipoma excision using, 160
median nerve laceration repair using,
234
metacarpal racture reduction and
internal xation using, 244
open triangular brocartilage
complex repair using, 184-185
pH o , 37
proximal interphalangeal joint
applications o
arthroplasty, 162
usion, 175
proximal phalanx injection o , 27
ray amputation using, 127
skin cancer excision using, 158
tendon trans ers using, 228-229
tenolysis using, 222-223
thumb metacarpophalangeal joint
usion using, 172
trapeziectomy using, 166, 168
trigger nger surgery using, 146

In d e x
259
thumb metacarpophalangeal joint
usion using, 172
timing o , 83, 108
trapeziectomy using, 166-168
trigger nger surgery using, 146-
147
ulnar collateral ligament repair
using, 172
vasovagal attack secondary to, 51-
52
volume recommendations, 44
wrist arthroscopy using, 180-181
lidocaine; see Lidocaine
longer-lasting, 50-51
re rigeration o , 38
ropivacaine, 50
volume recommendations or, 44
Lymphedema, 94
M
MacFarlane, Bobby, 23
Median nerve
anesthetic block o , 129
carpal tunnel decompression o ; see
Carpal tunnel decompression/
release
laceration repair o , local anesthetic
injection or, 234-235
release o , at elbow
anesthesiologist participation in,
143
local anesthetic injection or, 142-
143
tips or, 144
WALANT advantages or, 141-142
Merritt splint, 209, 213
Metacarpal racture reduction and inter-
nal xation
local anesthetic injection or, 244-245
WALANT advantages or, 243
Metaphalangeal ractures, 241
Middorsal hand, local anesthetic di u-
sion pattern in, 9, 126-127
Midline dorsal orearm, local anesthetic
di usion pattern in, 4
Midline dorsal wrist, local anesthetic di -
usion pattern in, 6
Midline radial orearm, local anesthetic
di usion pattern in, 5
Midline radial wrist, local anesthetic di -
usion pattern in, 7
Midline ulnar orearm, local anesthetic
di usion pattern in, 5
Bennett racture surgery using, 244
“blow slow be ore you go” rule or,
41-42
blunt cannulas or, 45-46, 218, 229
carpal tunnel decompression/
release using, 130-133
in children, 65-67
common mistakes in, 43
De Quervain release using, 149-150
details o , 44
Dupuytren’s contracture surgery
using, 152-153
extensor tendon repair o orearm
using, 217-218
extensor tendon repair o hand
using, 214-215
ainting during, 51-52, 57
eedback rom patient about, 43
nger amputation using, 125-128
nger racture reduction using,
238-239
f exor sheath ganglion surgery
using, 155-156
f exor tendon repair o nger
using, 190-192
f exor tendon repair o hand using,
200-202
incision a ter, 104
K-wire nger racture repair using,
239
lacerated nerve repair using, 233-
235
median nerve release at elbow
using, 142-143
metacarpal racture reduction and
internal xation using, 244-245
needle should never get ahead o
local anesthetic, 41-42
or cubital tunnel decompression
using, 138-139
pain- ree, rules or, 37-44
patient positioning during, 52
proximal interphalangeal joint
arthroplasty using, 162-163
reinserting needles within 1 cm o
blanched/unblanched border, 43
sensory noise in area o , 38-39, 201
sharp needles or, 44
skin cancer excision using, 158-159
small-bore 27- or 30-gauge needles
or, 38, 126, 191
talking with patients during, 61
tenolysis using, 222-223

In d e x
260
Open triangular brocartilage complex
repair
anesthesiologist participation in, 185
local anesthetic injection or, 184-185
tips or, 186
WALANT advantages or, 183
Operating rooms
time out in, 84
WALANT procedures in, 72
P
Pain
ear o , 84-85
eeling o , a ter injection, 85
management o , 89
types o , 62
Palmar/dorsal borders, local anesthetic
di usion a ected by, 34
Palmaris longus tendon gra t, 251
Paresthesia, 29, 44
Patient(s)
anxious, 52, 55
barriers to WALANT by, 84-85
calming o , 86
compliance by, 20
cost decreases or, 75-76
expectations o , 55
ainting by, during injection, 51-52
ears o , 84-85
hand therapists or, 112-113
monitoring o , 121
satis action o , 95, 102
scheduling o , 107-108
talking with; see also Patient
education
during carpal tunnel release, 62-63
during consultation, 55-57
during local anesthetic injection, 61
during surgery, 59-60, 87
on day o surgery, 57-58
WALANT bene ts or, 18-19, 56, 75-76,
100-101
Patient education; see also Patient(s),
talking with
about procedure, 59-60
during f exor tendon repair o nger,
188
during trigger nger surgery, 147-148
intraoperative, 76
Payers
cost reductions or, 78
WALANT buy-in by, 79-82
Pediatrics, 65-67
Midline ulnar wrist, local anesthetic di -
usion pattern in, 8
Midline volar orearm, local anesthetic
di usion pattern in, 4
Midline volar wrist, local anesthetic di u-
sion pattern in, 6
Midpalmar hand, local anesthetic di u-
sion pattern in, 8, 125, 127, 162,
175
Minor procedure rooms
cleaning o , 118
equipment in, 118-120
acilities near, 121
eld sterility in, 119
hand trauma, 120-121
personnel, 118
physical space o , 117-118
procedures not per ormed in, 121
reception area, 117
surgical equipment in, 118-120
Mohs surgery, 70
Monoamine oxidase, 51
Motion extension splint, 209, 213, 219
N
Needles
“blow slow be ore you go” rule or,
41-42
blunt cannulas versus, 45
perpendicular, injection o 0.5 ml just
under dermis using, 40-41
reinserting o , within 1 cm o
blanched/unblanched border, 43
or sedation versus WALANT, 56
20-gauge, 56
27- or 30-gauge, or local anesthetic
injections, 38, 56, 126, 147, 150,
156, 172, 191
Nelson, David L., 100
Nerve, lacerated; see Lacerated nerve
repair
Neurapraxia, ischemic, 27
Nurses, 20
barriers to WALANT by, 85-86
liability concerns o , 86
WALANT buy-in by, 79-81
working with, 91
O
Open carpal tunnel decompression/
release
local anesthetic injection or, 130-132
tips or, 134-135

In d e x
261
Sedation
advantages o not using, 129
in anxious patients, 52
costs associated with, 77
culture regarding need or, in surgery,
90
lack o need or, 21
local anesthesia versus, 89
patient satis action and, 90
Seizures, lidocaine-induced, 50
Senn retractors, 103, 118
Sensory noise, 38-39, 201
Sheathotomy, 194
Shoemaker, Pat, 23
Single subcutaneous injection in the
proximal phalanx with lidocaine
and epinephrine (SIMPLE)
with dorsal block augmentation, 12
or nger amputation, 127
illustration o , 11
thumb block, 11
two dorsal injection block versus, 46-
47
Skin
creases in, local anesthetic di usion
a ected by, 34, 44
sensory noise in, 39
Skin cancer excision
local anesthetic injection or, 158-159
patient education during, 157
tips or, 159-160
WALANT advantages or, 157-158
Sodium bicarbonate (10:1 8.4% ), or
bu ering o 1% lidocaine with
1:100,000 epinephrine, 37-38,
138
So t tissue excisions
lipomas, 160
skin cancer, 157-160
“Space-suit” operating room sterility, 71
“Spaghetti wrist” injury, 205
Stakeholders, 79-80
Sterility; see Field sterility; Full sterility
Students, 87-88
Surgeons
anesthesiologist and, 86
barriers to WALANT by, 86-88
case studies o , 91-97
cost bene ts or, 76-78
reimbursement concerns o , 87, 92
revenue or, 76, 87
wide awake hand surgery bene ts or,
20-21
Phentolamine, 24-27, 50, 83
Pilot study, 80
Postoperative period
a ter carpal tunnel release, 62-63
a ter f exor tendon repair o nger,
196-197
WALANT bene ts, 18, 57
Preoperative testing, 76
Procaine, 25
Pro tability, 77-78
Propo ol, 31, 81, 86, 88, 104, 135, 143,
163, 168, 173, 176, 182, 185, 192,
202, 207, 211, 215, 219, 224, 230
Proximal interphalangeal joint (PIP)
arthroplasty o
anesthesiologist participation in,
163
local anesthetic injection or, 162-
163
tips or, 163
WALANT advantages or, 161
comminuted racture o , 241
dorsal racture dislocations o , 240
usion o
anesthesiologist participation in,
176
local anesthetic injection or, 175-
176
tips or, 177
WALANT advantages or, 175
Proximal phalanx
dorsal thumb, anesthetic block o , 13
subcutaneous midline, with lidocaine
and epinephrine, 11
R
Ray amputation
local anesthetic injection or, 125-128
tips and tricks or, 128
WALANT advantages or, 125
Regitine; see Phentolamine
Reimbursement, 87, 92, 96
Residents
education o , 61
WALANT participation by, 87-88
Revenue, or surgeons, 76, 87
Ropivacaine, 50
S
Sa ety checklists, 90
Sauerbier, Michael, 221
Scars, 34, 44
Scheduling o patients, 107-108

In d e x
262
Tourniquet, 19, 75, 102-103
Trainees, 61
Trapeziectomy
anesthesiologist participation in, 168
local anesthetic injection or, 166-168
tips or, 168-169
WALANT advantages or, 165-166
Triangular brocartilage complex repair,
open
anesthesiologist participation in, 185
local anesthetic injection or, 184-185
tips or, 186
WALANT advantages or, 183
Trigger nger surgery
in children, 67
eld sterility or, 70
local anesthetic injection or, 146-147
patient education during, 147-148
tips or, 147-148
WALANT advantages or, 145-146
wide awake hand surgery bene ts
or, 21
Tumescent local anesthesia
characteristics o , 29
de nition o , 29
in general anesthesia patients, 29
injection rules or, 30-31, 44
or skin cancer excision, 157
“top-ups,” 30
volume recommendations, 30
27-gauge needles, or local anesthetic
injection, 38, 56, 126, 147, 150,
156, 172
Two dorsal injection block, single subcu-
taneous injection in the proxi-
mal phalanx with lidocaine and
epinephrine (SIMPLE) block ver-
sus, 46-47
U
Ulnar collateral ligament repair
anesthesiologist participation in, 173
local anesthetic injection or, 172
tips or, 173
WALANT advantages or, 171
Ulnar hand, local anesthetic di usion
pattern in, 9
V
Van Demark, Robert, Jr., 94-97, 100-101
Vasovagal attack, 51-52
Swan neck trans er, o f exor digitorum
super cialis, 251
Syringe, stabilization o , 39
Szabo, Robert, 227
T
Tendon reconstruction, 56
Tendon trans ers
anesthesiologist participation in, 230
extensor indicis to extensor pollicis
longus, 227-228
f exor carpi radialis and f exor carpi
ulnaris, 250
f exor digitorum super cialis to f exor
pollicis longus, 228
local anesthetic injection or, 228-229
tension on, 227
tips or, 230-231
WALANT advantages or, 227
Tenolysis
anesthesiologist participation in, 224
local anesthetic injection or, 222-223
patient education during, 225
postoperative instructions, 224
talking with patient during, 221-222
tips or, 224-225
WALANT advantages or, 221-222
30-gauge needles, or local anesthetic in-
jection, 38
Thumb
anesthetic block o , single
subcutaneous injection in the
proximal phalanx with lidocaine
and epinephrine or, 12
basal joint arthritis o , trapeziectomy
or; see Trapeziectomy
extension restoration in, a ter subtotal
amputation, 250
extensor pollicis longus tendon o , 230
midmetacarpal dorsal, 10
midmetacarpal volar, 10
trigger; see Trigger nger surgery
Thumb metacarpophalangeal joint u-
sion
anesthesiologist participation in, 173
local anesthetic injection or, 172
tips or, 173
WALANT advantages or, 171
Thumb tip pinch, a ter adult polliciza-
tion, 249
“Top-ups,” 30, 44

In d e x
263
Wound
care o , a ter carpal tunnel release, 62
cleaning o , 249
in ection o , 63, 70-72
Wrist, local anesthetic di usion patterns
in
dorsal, 6
radial, 7
ulnar, 8
volar, 6
Wrist arthroscopy
anesthesiologist participation in, 182
dry, 179
local anesthetic injection or, 180-181
tips or, 181-182
WALANT advantages or, 179
Wrist injections
concerns about, 35
or wrist arthroscopy, 180-181
Wrist vein gra ts, or nger revasculariza-
tion, 250
W
WALANT
advantages o , 18-21, 101; see also
specif c procedure, WALANT
advantages or
contraindications or, 103
description o , 17
duration o , 57
general anesthesia and, 100
getting started, 99-101
indications or, 93-94, 102-103
patient bene ts rom, 18-19
postoperative recovery rom, 18, 57
sa ety o , 19, 56, 95
surgeon bene ts rom, 20-21
talking with patients, 55-60
Weilby suspension, 169
White ngertip, 27
Wong, Jason, 102-103, 221, 250

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