Nerve block: digital block: Difference between revisions
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==Background== | |||
[[File:Gray817.png|thumb|Deep palmar nerves]] | |||
*Each digit is innervated by 4 nerves | |||
**2 Dorsal (10 and 2 o'clock positions) | |||
**2 Ventral - palmar or plantar (4 and 8 o'clock positions) | |||
==Indications== | ==Indications== | ||
*Need to anesthetize entire digit (finger or toe) | *Need to anesthetize entire digit (finger or toe) | ||
**[[Laceration repair]] | **[[Laceration repair]] | ||
**Dislocation/fracture reduction | **[[joint dislocations|Dislocation]]/[[fracture]] reduction | ||
**Pain control for traumatic injury | **[[analgesia|Pain control]] for traumatic injury | ||
**[[Paronychia]] | **[[Paronychia]] | ||
**[[Felon]] | **[[Felon]] | ||
**Nail trephination | **[[Nail trephination]] or removal | ||
==Contraindications== | ==Contraindications== | ||
| Line 16: | Line 22: | ||
*Local anesthetic | *Local anesthetic | ||
*27-30ga needle | *27-30ga needle | ||
*Syringe | *5-10 mL Syringe | ||
*Iodine or chlorhexadine prep | *Iodine or chlorhexadine prep | ||
{{Maximum doses of anesthetic agents}} | {{Maximum doses of anesthetic agents}} | ||
===Epinephrine in Digital Block=== | ===[[Epinephrine]] in Digital Block=== | ||
*Previously, "conventional wisdom" argued that it is unsafe to use epinephrine in digital local anesthesia. | *Previously, "conventional wisdom" argued that it is unsafe to use epinephrine in digital local anesthesia. | ||
*However, many studies going back more than a decade have shown that using local anesthetic with epinephrine is safe for use in digits.<ref>Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstr Surg. 2001 Jul;108(1):114-24.</ref><ref>Krunic AL, Wang LC, Soltani K, Weitzul S, Taylor RS. Digital anesthesia with epinephrine: an old myth revisited. J Am Acad Dermatol. 2004 Nov;51(5):755-9.</ref><ref>Chowdhry S, Seidenstricker L, Cooney DS, Hazani R, Wilhelmi BJ. Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plast Reconstr Surg. 2010 Dec;126(6):2031-4</ref> | *However, many studies going back more than a decade have shown that using local anesthetic with epinephrine is safe for use in digits.<ref>Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstr Surg. 2001 Jul;108(1):114-24.</ref><ref>Krunic AL, Wang LC, Soltani K, Weitzul S, Taylor RS. Digital anesthesia with epinephrine: an old myth revisited. J Am Acad Dermatol. 2004 Nov;51(5):755-9.</ref><ref>Chowdhry S, Seidenstricker L, Cooney DS, Hazani R, Wilhelmi BJ. Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plast Reconstr Surg. 2010 Dec;126(6):2031-4</ref> | ||
| Line 27: | Line 33: | ||
==Procedure== | ==Procedure== | ||
* | ===Traditional Technique<ref name="Block1">Harness NG. Digital block anesthesia. J Hand Surg Am. 2009 Jan;34(1):142-5.</ref><ref name="AEM">Hill RG Jr, Patterson JW, Parker JC, et al. Comparison of transthecal digital block and traditional digital block for anesthesia of the finger. Ann Emerg Med. 1995 May;25(5):604-7.</ref>=== | ||
[[File:Digital nerves.png|thumb|Cross sectional anatomy of digit with four nerves (dark circles) shown. Note that palmar nerves are more medial than dorsal nerves. Arrow shows needle trajectory of traditional technique.]] | |||
*Cleanse skin at proximal, dorsal aspect of the digit to be anesthetized, including web space | |||
*Introduce the needle at the base of the digit near the MCP joint, lateral to the midline of the digit. | |||
*Advance the needle around the bone towards the ventral side of the digit - stop if skin tenting is noted | |||
*Inject ~1mL of anesthetic to block ventral digital nerve | |||
*As needle is withdrawn, inject additional ~1mL of anesthetic to block dorsal digital nerve | |||
*Repeat on opposite side of digit | |||
===Transthecal Technique<ref name="TTB">Hart RG, Fernandas FA, Kutz JE. Transthecal digital block: an underutilized technique in the ED. Am J Emerg Med. 2005 May;23(3):340-2.</ref>=== | |||
'''Described for finger blocks - most effective in 2nd-5th digits'''<br> | |||
'''Contraindicated if flexor tendon involvement or infection (e.g. felon, tenosynovitis, etc)''' | |||
*With hand supinated, locate flexor tendon of finger to be anesthetized | |||
*Cleanse skin over the distal palmar crease and proximal digital crease | |||
*Method 1 | |||
**Insert needle 90 degrees to the skin at the proximal digital crease | |||
**Advance until needle hits bone, then withdraw 2-3mm | |||
**Redirect needle 45 degrees to the skin with needle pointing distally (towards finger tip) | |||
**Slowly inject anesthetic - initially no resistance, progressive resistance felt as tendon sheath fills (~1.5-3mL) | |||
*Method 2 | |||
**Insert needle at 45 degrees to the skin just distal to the distal palmar crease | |||
**Advance into flexor tendon sheath | |||
**Slowly inject anesthesic - if resistance to injection felt, withdraw needle slightly | |||
==Complications== | ==Complications== | ||
| Line 36: | Line 65: | ||
==See Also== | ==See Also== | ||
*[[Nerve Blocks (Main)]] | |||
==External Links== | |||
===Videos=== | |||
{{#widget:YouTube|id=i51y6t1YRNQ}} | |||
Latest revision as of 19:27, 28 September 2022
Background
- Each digit is innervated by 4 nerves
- 2 Dorsal (10 and 2 o'clock positions)
- 2 Ventral - palmar or plantar (4 and 8 o'clock positions)
Indications
- Need to anesthetize entire digit (finger or toe)
- Laceration repair
- Dislocation/fracture reduction
- Pain control for traumatic injury
- Paronychia
- Felon
- Nail trephination or removal
Contraindications
- Overlying skin infection
- Distortion of landmarks
Equipment Needed
- PPE
- Local anesthetic
- 27-30ga needle
- 5-10 mL Syringe
- Iodine or chlorhexadine prep
Maximum Doses of Anesthetic Agents
| Agent | Without Epinephrine | With Epinephrine | Duration | Notes |
| Lidocaine | 5 mg/kg (max 300mg) | 7 mg/kg (max 500mg) | 30-90 min |
|
| Mepivicaine | 7 mg/kg | 8 mg/kg | ||
| Bupivicaine | 2.5 mg/kg (max 175mg) | 3 mg/kg (max 225mg) | 6-8 hr |
|
| Ropivacaine | 3 mg/kg | |||
| Prilocaine | 6 mg/kg | |||
| Tetracaine | 1 mg/kg | 1.5 mg/kg | 3hrs (10hrs with epi) | |
| Procaine | 7 mg/kg | 10 mg/kg | 30min (90min with epi) |
Epinephrine in Digital Block
- Previously, "conventional wisdom" argued that it is unsafe to use epinephrine in digital local anesthesia.
- However, many studies going back more than a decade have shown that using local anesthetic with epinephrine is safe for use in digits.[1][2][3]
- A Cochrane Review concurs that no adverse effects have been reported, but notes that the level of evidence is poor and further high quality studies are required.[4]
Procedure
Traditional Technique[5][6]
- Cleanse skin at proximal, dorsal aspect of the digit to be anesthetized, including web space
- Introduce the needle at the base of the digit near the MCP joint, lateral to the midline of the digit.
- Advance the needle around the bone towards the ventral side of the digit - stop if skin tenting is noted
- Inject ~1mL of anesthetic to block ventral digital nerve
- As needle is withdrawn, inject additional ~1mL of anesthetic to block dorsal digital nerve
- Repeat on opposite side of digit
Transthecal Technique[7]
Described for finger blocks - most effective in 2nd-5th digits
Contraindicated if flexor tendon involvement or infection (e.g. felon, tenosynovitis, etc)
- With hand supinated, locate flexor tendon of finger to be anesthetized
- Cleanse skin over the distal palmar crease and proximal digital crease
- Method 1
- Insert needle 90 degrees to the skin at the proximal digital crease
- Advance until needle hits bone, then withdraw 2-3mm
- Redirect needle 45 degrees to the skin with needle pointing distally (towards finger tip)
- Slowly inject anesthetic - initially no resistance, progressive resistance felt as tendon sheath fills (~1.5-3mL)
- Method 2
- Insert needle at 45 degrees to the skin just distal to the distal palmar crease
- Advance into flexor tendon sheath
- Slowly inject anesthesic - if resistance to injection felt, withdraw needle slightly
Complications
- Damage to surrounding structures
- Bleeding
- Infection
- Accidental intravascular injection of anesthetic
See Also
External Links
Videos
{{#widget:YouTube|id=i51y6t1YRNQ}}
References
- ↑ Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstr Surg. 2001 Jul;108(1):114-24.
- ↑ Krunic AL, Wang LC, Soltani K, Weitzul S, Taylor RS. Digital anesthesia with epinephrine: an old myth revisited. J Am Acad Dermatol. 2004 Nov;51(5):755-9.
- ↑ Chowdhry S, Seidenstricker L, Cooney DS, Hazani R, Wilhelmi BJ. Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plast Reconstr Surg. 2010 Dec;126(6):2031-4
- ↑ Prabhakar H, Rath S, Kalaivani M, Bhanderi N. Adrenaline with lidocaine for digital nerve blocks. Cochrane Database Syst Rev. 2015 Mar 19;3
- ↑ Harness NG. Digital block anesthesia. J Hand Surg Am. 2009 Jan;34(1):142-5.
- ↑ Hill RG Jr, Patterson JW, Parker JC, et al. Comparison of transthecal digital block and traditional digital block for anesthesia of the finger. Ann Emerg Med. 1995 May;25(5):604-7.
- ↑ Hart RG, Fernandas FA, Kutz JE. Transthecal digital block: an underutilized technique in the ED. Am J Emerg Med. 2005 May;23(3):340-2.