Wrist Block

Figure 1: (A) Technique to accomplish a wrist block. (B) Median nerve block. Needle is inserted medial or
lateral to the flexor palmaris longus tendon and carefully advanced to avoid paresthesia. Then 5 mL of
local anesthetic is injected.

Essentials
Indications: surgery on the hand and fingers

Nerves: radial, ulnar, median

Local anesthetic: 5mL for median and ulnar nerve, 10 mL for radial nerve

Never use an epinepherine-containing local anesthetic.

General Considerations:-

A wrist block consists of anesthetizing the terminal branches of the ulnar, median, and radial nerves at
the level of the wrist. It is an infiltration technique that is simple to perform, essentially devoid of
systemic complications, and highly effective for a variety of procedures on the hand and fingers. The
relative simplicity, low risk of complications, and high efficacy of the procedure mandates this block to
be a standard part of the armamentarium of an anesthesiologist. Several different techniques of wrist
blockade and their modifications are in clinical use; in this chapter, however, we describe the one most
commonly used at our institution. Wrist blocks are used often for carpal tunnel and hand and finger
surgery.

Functional Anatomy

Innervation of the hand is shared by the ulnar, median, and radial nerves (Figure 2 and 3). The ulnar
nerve provides sensory innervation to the skin of the fifth digit and the medial half of the fourth digit,
and to the corresponding area of the palm. The same area is covered on the corresponding dorsal side
of the hand. Motor branches innervate the three hypothenar muscles, the medial two lumbrical
muscles, the palmaris brevis muscle, all the interossei, and the adductor pollicis muscle. The median
nerve traverses the carpal tunnel and terminates as digital and recurrent branches. The digital branches
supply the skin of the lateral three and a half digits and the corresponding area of the palm. Motor
branches supply the two lateral lumbricals and the three thenar muscles (recurrent median branch).

Although there is significant variability in the innervation of the ring and middle fingers, the skin on the
anterior surface of the thumb is always supplied by the median nerve and that of the 5th finger by the
ulnar nerve. The palmar digital B branches of the median and ulnar nerves also innervate the nail beds
of the respective digits.

The radial nerve lies on the anterior aspect of the radial side of the forearm. About 7 cm above the wrist,
the nerve deviates from the artery and emerges from the deep fascia, dividing into medial and lateral
branches to supply sensation to the dorsum of the thumb and the dorsum of the hand (the first three
and one-half digits as far as the distal interphalangeal joint).

Distribution of Blockade
Blocking the ulnar, median, and radial nerves results in anesthesia of the entire hand. The nerve
contribution to innervation of the hand varies considerably; Figure 3 shows the most common
arrangement.

Figure 2: (A) Anatomy of the right wrist. (1) median nerve. (2) flexor palmaris longus. (3) flexor carpi
radialis. (4) ulnar artery. (5) Ulnar nerve. (6) radial artery (7) flexor carpi ulnaris. (B) Anatomy of the right
superficial radial nerve. (1) Superficial radial nerve. (2) Radial styloid. (3) flexor carpi radialis tendon. (4)
thumb.

Equipment

A standard regional anesthesia tray is prepared with the following equipment:

1- Sterile towels and gauze packs

2-Two 10-mL syringes containing local anesthetic

3-A 1.5-inch, 25-gauge needle

Figure 3: Cutaneous innervation of the left hand.

Landmarks and Patient Positioning

The patient is positioned supine, with the arm in abduction. The wrist is best kept in slight extension.

Maneuvers to Facilitate Landmark Identification

The superficial branch of the radial nerve emerges from between the tendon of the brachioradialis and
the radius just proximal to the easily palpable styloid process of the radius (circle) (Figure 4). Then it
divides into the medial and lateral branches, which continue subcutaneously on the dorsum of the
thumb and hand. Several of the branches pass superficially over the anatomic "snuffbox." The median
nerve is located between the tendons of the flexor palmaris longus (white arrow) and the flexor carpi
radialis (red arrow) (Figure 5A and B). The flexor palmaris longus tendon is usually the more prominent
of the two, and it can be accentuated by asking the patient to oppose the thumb and 5th finger while
flexing the wrist (Figure 6); the median nerve passes just lateral to it. The ulnar nerve passes between
the ulnar artery and tendon of the fl exor carpi ulnaris (Figure 7) . The tendon of flexor carpi ulnaris is
superficial to the ulnar nerve.
Figure 4: Palpation of the radial styloid. The superficial radial nerve is blocked by an injection just
proximal to the styloid.

A B

Figure 5: A maneuver to accentuate the tendons of the flexors of the wrist. (A) Shown are flexor
palmaris longus (white arrow) and flexor carpi radialis (red arrow) tendons. (B) Outlining flexor
palmaris longus tendon.
Figure 6: The flexor palmaris longus tendon can Figure 7: Outlining flexor carpi ulnaris tendon. 

be accentuated by asking the patient to oppose

the thumb and fifth finger while flexing the wrist.

Technique

The entire surface of the wrist and palm should be disinfected.

Block of the Ulnar Nerve

The ulnar nerve is anesthetized by inserting the needle under the tendon of the flexor carpi ulnaris
muscle close to its distal attachment just above the styloid process of the ulna. The needle is advanced 5
to 10 mm to just past the tendon of the flexor carpi ulnaris (Figure 9A). After negative aspiration, 3 to 5
mL of local anesthetic solution is injected. A subcutaneous injection of 2 to 3 mL of local anesthesia just
above the tendon of the flexor carpi ulnaris is advisable for blocking the cutaneous branches of the ulnar
nerve, which often extend to the hypothenar area.

Block of the Median Nerve

The median nerve is blocked by inserting the needle between the tendons of the flexor palmaris longus
and flexor carpi radialis (Figure 9B). The needle is inserted until it pierces the deep fascia, and 3 to 5 mL
of local anesthetic is injected. Although piercing of the deep fascia has been described to result in a
fascial "click," it is more reliable to simply insert the needle until it contacts the bone. The needle is
withdrawn 2 to 3 mm, and the local anesthetic is injected.
A

C
Block of the Radial NerveFigure 9: A) Ulnar nerve block. The needle is inserted just medial to and
underneath the flexor carpi ulnaris tendon to inject local anesthetic in the immediate proximity of the
ulnar artery. (B) Median nerve block. The needle is inserted medial or lateral to the flexor palmaris
longus tendon and carefully advanced to avoid paresthesia. Then 5 mL of local anesthetic is injected. (C)
Radial nerve block. The superficial branches of the radial nerve are blocked by a subcutaneous injection
of local anesthetic in a circular fashion. The injection is made proximal to the radial styloid head (circle).

The radial nerve block is essentially a "field block" and requires more extensive infiltration because of its
less predictable anatomic location and division into multiple smaller cutaneous branches. Five milliliters
of local anes- thetic should be injected subcutaneously just proximal to the radial styloid, aiming
medially. Then the infiltration is extended laterally, using an additional 5 mL of local anesthetic (Figure
9C).

Highlights

A "fan" technique is recommended to increase the success rate of the median nerve block. After the
initial injection, the needle is withdrawn back to skin level, redirected 30° laterally, and advanced
again to contact the bone. After pulling back the needle 1 to 2 mm from the bone, an additional 2 mL
of local anesthetic is injected. A similar procedure is repeated with medial redirection of the needle.

Paresthesia in the median nerve distribution warrants a 1- to 2-mm withdrawal of the needle, followed
by a slow measured injection of the local anesthetic. If paresthesia worsens or persists, the needle
should be removed and reinserted.

Block Dynamics and Perioperative Management

The wrist block technique is associated with moderate patient discomfort because multiple insertions
and subcutaneous injections are required. Appropriate sedation and analgesia (midazolam 2-4 mg and
alfentanil 250-500 µg) are useful to ensure the patient's comfort. A typical onset time for a wrist block is
10 to 15 minutes, depending on the concentration and volume of local anesthetic used. Sensory
anesthesia of the skin develops faster than the motor block. Placement of an Esmarch bandage or a
tourniquet at the level of the wrist is well tolerated and does not require additional blockade.

Complications and How to Avoid Them

Complications following a wrist block are typically limited to residual paresthesias due to inadvertent
intraneural injection. Systemic toxicity is rare because of the distal location of the blockade and the
relatively small volumes of local anesthetics (Table 1).