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Anesthesia, Regional, Digital Block

Author: Dmitry Volfson, DO; Chief Editor: Meda Raghavendra (Raghu), MD

Background

Digital nerve blocks are important tools for the emergency medicine clinician. Injuries or
infections of the digits are extremely common. Adequate analgesia is essential to properly
address the presenting condition and to minimize the patient's discomfort. Digital blocks
are useful in many scenarios in which local infiltration of an anesthetic would require
several injections into the already painful site of injury. Furthermore, local infiltration
around the wound may create increased swelling, making the repair more difficult.
Several techniques are available for performing digital blocks.


Relevant anatomy
Each digit is innervated by 4 digital nerves. In the upper extremity, the digital nerves
arise from the median, ulnar, and radial nerves. The 2 palmar digital nerves innervate the
palmar aspect of the digit and the nail bed, whereas the dorsal nerves innervate the
dorsum of the digit (see images below). The tibial and peroneal nerves branch off into the
digital nerves of the lower extremities, which follow a pattern of distribution analogous to
those of the upper extremity.[1]

Palmar digital nerves. .

the following:   Large irregular lacerations Lacerations involving the nail or the nail bed  Ingrown nails  Felon or paronychia  Trephination of subungual hematoma  Digit dislocations or fractures[2] Contraindications See the list below:   Compromised digit circulation Infected injection site  Known allergy to anesthetic .Dorsal digital nerves. but are not limited to. Indications Digital blocks are indicated for any minor surgery or procedure of the digits. These include.

procaine) and the amide-type agents (eg.to 30gauge needle for injection  Local anesthetic of choice  Anesthesia    Local anesthetic agents have the basic structure of an aromatic and a hydrophilic. Table 1. drapes. another amide anesthetic. injecting slowly. If the patient is known to be allergic to lidocaine. This forms the basis of classification of local anesthetics into 2 groups: the ester-type agents (eg. Limit the patient’s discomfort by using a smaller needle.  Anesthesia of the great toe is more difficult to achieve and requires 3-sided/4-sided ring blocks.Best Practices See the list below:   Avoid epinephrine use in the digits. an ester-type anesthetic. can be substituted. Infiltrative Administration. Equipment The equipment necessary includes the following:   Sterile gloves. such as bupivacaine. separated in the middle by an amino-ester or an amino-amide. with an 18-gauge needle for drawing up the anesthetic and a 25. Lidocaine is the most commonly used anesthetic.  Use of sterile technique is essential to limit the risk of introducing infections (especially with the transthecal block). and gauze pads Povidone-iodine (Betadine) solution  Syringe. Table 1 summarizes the properties of commonly used agents. see Local Anesthetic Agents. such as procaine. Commonly Used Local Anesthetics and Their Properties[4] (Open Table in a new window) Agent Maximum Adult Dose (mg)/Procedure* Lidocaine 300 Procaine 500 Bupivacaine 175 *Administer by small incremental doses.[3] The choice of agent is based on the desired duration of analgesia and the patient’s allergy profile. For more information. If longer anesthesia is required. lidocaine). Onset (min) Duration 2-5 1-2 h 2-5 15-45 min 2-5 4-8 h . can be used. a clamped Penrose drain can be used to limit bleeding. and using small amounts of anesthetics. 5-10 mL.

the 3-sided digital block. Small volumes of anesthetic should be used to minimize local swelling. including the following:[13]   Pain at injection site Infection at injection site. See the Technique section for detailed explanations. Despite studies that have shown epinephrine to be safe in these circumstances. [16]  Inadvertent intravascular injection: This increases the risk of cardiotoxicity and neurotoxicity. [14]  Local injuries: Injuries to nerves and tendons can result in long-term complications such as neuropathies and tendonitis. Although studies have shown that use of local anesthetics does not alter incidence of wound infection. Standard sterile precautions should be followed for all of the described procedures. especially with transthecal block  Wound infection: Local anesthetics have been shown to possess antimicrobial properties. Monitoring & Follow-up Numerous potential complications and local anesthetic toxicities have been described in the literature. [15] another study showed that local anesthetics decrease local inflammatory response. and the 4-sided ring block. especially in cases in which compartment syndrome is being considered.  Wound healing: Several studies have shown that local anesthetics inhibit wound healing by decreasing the tensile strength of wounds. which may lead to ischemia or infarction of local tissues. Positioning  Depending on the technique used. their use may produce false-negative wound cultures. Also. A study by Sonohata et al showed that a single injection (such as in the transthecal block) of 3 mL anesthetic with epinephrine was effective in achieving adequate analgesia. [13]  Allergic reactions  Vasovagal syncope Approach Considerations  Several different techniques can be used to anesthetize the digits: the web-space block. the extremity position varies.[5] epinephrine is traditionally avoided in the digits. the transthecal block. Ischemic injury was not reported. the time to achieving analgesia was shorter and the effects were longer. .  Local anesthetics are to be used without epinephrine in the digits to avoid vasoconstriction of adjacent arteries.[6] The block should be performed cautiously in areas where nerve function is compromised.

Needle position for web-space block.  Slowly inject the anesthetic in the dorsal aspect of the web space.Web-Space Block This method is very effective in achieving adequate anesthesia and is probably the least painful. .   Place the patient’s hand on a sterile field with the palm down. just distal to the metacarpal-phalangeal (MP) joint (see image below). Hold the syringe perpendicular to the digit and insert the needle into the web space.

 The toes (except the great toe) can be effectively anesthetized in the same manner. 9. Locate the flexor tendon sheath by palpating it at the distal palmar crease. Transthecal Block Originally described by Chiu in 1990. this injection is painful because the needle pierces the very sensitive skin of the palm.[8. Slowly advance the needle straight down toward the volar aspect of the web space.  Withdraw the needle and repeat the procedure on the other web space of the involved digit. The needle should not pierce the volar aspect of the web space.[7] this technique is also known as the flexor tendon sheath digital block. . Studies have shown that this type of block is as effective as traditional ring blocks in achieving adequate anesthesia. Although adequate anesthesia is achieved with a single injection. Web-space block technique.  Insert the needle at a 45-degree angle just distal to the distal palmar crease (see image below). 10]   Place the patient’s hand on the sterile field with the palm up. slowly infiltrating the surrounding tissues of the web space (see video below). While treating trigger finger by injecting steroids and lidocaine into the tendon sheath. Chiu noted that anesthesia of the entire digit was achieved.

 Inject the anesthetic. Insert the needle at a 90-degree angle at the metacarpal crease until bone is hit. to direct the flow distally (see image below).  During the injection. . reposition the needle by slowly withdrawing it.  Withdraw the needle slightly and inject the anesthetic. use the nondominant hand to apply pressure just proximal to the injection site.[11]   Position the patient’s hand with the palm facing up. A modified version of this technique can also be used effectively.Needle position for transthecal block. it should flow freely. If resistance is met.

but it can be used for any digit. Insert the needle at a 90-degree angle at the medial aspect of the digit. just distal to the metatarsal-phalangeal joint (see image below). Three-Sided Digital Block This type of digital block is effective in anesthetizing the great toe. .   Place the patient’s extremity volar/plantar side down.Modified transthecal block.

.Medial injection for 3-sided digital block.

 Advance the needle slowly from medial to lateral side while the anesthetic is injected (see image below). with the needle at 90 degrees. without piercing the volar skin. as was done medially (see image below).  Slowly withdraw the needle and redirect it medially. .  Withdraw the needle. Slowly inject the anesthetic as the needle is advanced toward the volar/plantar side.  Make another injection over the already anesthetized skin at the lateral aspect of the digit. advancing it from the dorsal to ventral aspect. Medial to lateral injection for 3-sided digital block.

.

a wing block procedure can be used instead of a digital block. Hold the needle perpendicular to the long axis of the digit and at 45 degrees to the plane of the sterile field. . After the 3-sided block is performed. nail injury). Insert the needle at the lateral aspect of the digit on the volar/plantar side and advance it medially as the anesthetic is slowly injected. Wing block technique. This technique is less favored because of the potential for ischemic complications.   Position the extremity with the volar/plantar side down. a third injection is performed. Four-Sided Ring Block This method is an extension of the 3-sided block. Wing Block Procedure When only the distal part of the digit is involved (eg.Lateral injection for 3-sided digital block.  Insert the needle 3 mm proximal to an imaginary point where a linear extension of the lateral and proximal nail folds would intersect (see image below).

10. Bendall JC. J Emerg Nurs. 1990 May. 4. 1970 Jun. 15(3):471-7. Elsevier Health Sciences. Transthecal digital block: flexor tendon sheath used for anesthetic infusion. Journal of Research in Medical Sciences. 1997 Oct. Hideki Ishii. Parker JC. Rosenkranz HS. [Medline]. 12. Local anesthetic toxicity. Salinas FV. Surgery. . Comparison of transthecal digital block and traditional digital block for anesthesia of the finger. Bauer J. 14. [Medline]. 22(5):582-4. 25(5):604-7. 2nd ed. A Practical Approach to Regional Anesthesia. Schmidt RM. Diagnosis. [Medline]. Denkler K. Clinical Procedures in Emergency Medicine. 4th ed. Hill RG Jr. 10th ed. Middleton PM. 2012 Jul-Sep. Comparison between single injection transthecal and subcutaneous digital blocks. WB Saunders. 2. 2002 Aug. Low YP. 121(6):597-607. 13. Hedges JR. Maher AJ. Salasche SJ. Flarity-Reed K. Chanmugam AS. Mahmoodian A. Roberts JR. Wong HP. Motoki Sonohata. 28(4):351-4. Agur A. 329. [Medline]. [Medline]. 1. [Medline]. 7. Commonly Used Local Anesthetics and Their Properties[4] Agent Maximum Adult Dose (mg)/Procedure* Onset (min) Duration Lidocaine 300 2-5 1-2 h Procaine 500 2-5 15-45 min Bupivacaine 175 2-5 4-8 h *Administer by small incremental doses. Antimicrobial activity of local anesthetics: lidocaine and procaine. Local anesthetics. Chiu DT. Grant's Atlas of Anatomy. 2001 Jul. J Infect Dis. 3. October 2004. 1995 May. Lippincott Williams and Wilkins. eds. Metcalfe SA. Kenji Tsunoda. 4th ed. J Hand Surg [Br]. Ann Emerg Med. Patterson JW. A revisit of transthecal digital block and traditional digital block for anesthesia of the finger. 9.Table 1. Simpson PM. Scher RK. 2012. Surgery In Nails: Treatment. 18:192197. Satomi Nagamine. McDonald SB. Heller MB. 12(6): 11. [Medline]. Lippincott Williams & Wilkins. Paramedic-performed digital nerve block to facilitate field reduction of a dislocated finger. Low CK. 6. et al. 2012:4. 108(1):114-24. Wright E. McCabe B. Nov/Dec 2007. 16(3):415-7. Bernards CM. Parr S. 8. Kazumasa Maeda. A comprehensive review of epinephrine in the finger: to do or not to do. 1997. Dec 2008. Prehosp Emerg Care. The Foot. Plast Reconstr Surg. [Medline]. Daniels CR. J Hand Surg [Am]. Dehghani M. 2003. Subcutaneous Single Injection Digital Block with Epinephrine. Cone DC. 5. Kenji Ogawa. Mulroy MF. May 2008. Methods of digital block. References 1. Anesthesiology Research and Practice.

1977 Dec. 77(1):74-8. Anesthesiology.medscape.com/article/80887-technique#c6 . Tracey J. Eriksson AS. Thomsen P. 64(12):902-3. Br J Surg. Morris T. http://emedicine.15. Lignocaine: its effects on wound healing. Sinclair R. 16. [Medline]. 1992 Jul. Cassuto J. [Medline]. Influence of lidocaine on leukocyte function in the surgical wound.