Review Article

Journal of Hand Surgery

(European Volume)
Important updates of finger fractures, 2022, Vol. 47(1) 24–30
! The Author(s) 2021
entrapment neuropathies and wide-awake Article reuse guidelines:
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surgery of the upper extremity DOI: 10.1177/17531934211029543
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Donald Lalonde1, Egemen Ayhan2 , Amir Adham Ahmad3

and Steven Koehler4

Abstract
Hand surgery is rapidly changing. The wide-awake approach, minimum dissection surgery and early protected
movement have changed many things. This is an update of some of the important changes regarding early
protected movement with K-wired finger fracture management, simplification of nerve decompression sur-
gery, such as elbow median and ulnar nerve releases, and some new areas in performing surgery with wide-
awake local anaesthesia without tourniquet.

Keywords
Wide awake, local anaesthesia, finger fracture, nerve entrapment, early active motion

Date received: 11th June 2021; revised: 13th June 2021; accepted: 14th June 2021

inserting and bending K-wires, and then placing

Introduction
There are important changes in early protected
movement with K-wired finger fracture management,
simplification of nerve decompression surgery, such
as elbow median and ulnar nerve releases, and some
new areas in performing surgery with wide-awake
local anaesthesia no tourniquet (WALANT).
Traditional hand surgery in a main operating room
with a tourniquet, sedation and extensive dissection
are evolving. This article is a snapshot of the front
edge of the new wave in technical evolution and sum-
marizes changes in the field of fracture treatment in
the hand, entrapment neuropathies and application
of WALANT in hand surgery.
Finger fractures
Most finger fractures can be treated with
WALANT K-wire fixation, field sterility, and
early protected movement
K-wire fracture fixation is not as rigid as plates and
screws. However, closed K-wire fixation require no
soft tissue dissection. Dynamic traction is particularly
useful for intra-articular fractures of finger joints, par-
ticularly the proximal interphalangeal joint, to allow
finger motion while maintaining reduction of intra-
articular fracture fragments. This traction can also
be constructed under WALANT setting though
rubber bands to the bent K-wires for traction. Open
reduction is required only sometimes before fixation,
but most can be reliably treated with closed K-wire
fixation. We found plate fixation is almost not neces-
sary and plate fixation interferes tendon motion.
Surgically created dead space between bone and peri-
osteum fills with blood clot that becomes callus and
scar, which can lead to stiffness after plate and screw
fixation, even with early protected movement.
Dissection is limited with transarticular screw fixation
(Gueffier et al., 2021), but this is still more dissection
than percutaneous K-wire fixation.
WALANT finger-fracture fixation permits surgeons
to see the stability of the K-wire fixation fluoroscopi-
cally when they ask the patient to take the involved
finger through a full active range of motion during
surgery. Seeing very little movement of the K-wired
1
2
Plastic Surgery, Dalhousie University, Saint John, NB, Canada
Orthopaedics and Traumatology, University of Health Sciences
Turkey, Ankara, Turkey
3
Department of Orthopaedics, Prince Court Medical Centre, Kuala
Lumpur, Malaysia
4
Department of Orthopaedic Surgery and Rehabilitation Medicine,
State University of New York, Brooklyn, NY, USA
Corresponding Author:
Donald Lalonde, Plastic Surgery, Dalhousie University, Saint John,
NB, Canada.
Email: dlalonde@drlalonde.ca
Lalonde et al.
Figure 1. Motion of the distal interphalangeal joint start-
ing 3–5 days after surgery of K-wire fixation of a proximal
phalangeal fracture with splint protection.
Figure 2. K-wiring Bennett’s fracture thumb base with
field sterility as many Canadians routinely do.
fractures with full flexion and extension at surgery
gives the surgeon confidence to start early protected
movement of up to half a fist after 3–5 days of ele-
vation and immobilization to relieve oedema and pain
(Gregory et al., 2014; Hyatt and Rhee, 2019; Lalonde,
2021, 2016) (Figure 1). This keeps the tendons and
ligaments gliding and precludes adhesions to the
fractured bones.
Elimination of sedation in WALANT surgery per-
mits moving K-wire fixation procedures out of the
main operating room, thereby decreasing cost
(Gillis and Williams, 2017; Steve et al., 2019) and
increasing surgery availability (Behar et al., 2019;
Holoyda et al., 2020) without raising risk of infection
using minor procedure room field sterility (Figure 2)
(Avoricani et al., 2021; Dua et al., 2019; Garon et al.,
2018; Jagodzinski et al., 2017; Kurtzman et al., 2021;
Starker and Eaton, 1995; Yu et al., 2019).
25
Figure 3. The operative setting for carpal tunnel release.
The picture shows closing the carpal tunnel incision with
field sterility (drapes on the operated part, gloves and
masks for surgeons). The field sterility is performed for
more than 90% of patients with carpal tunnel release in
Canada.
K-wires can be removed from finger
fractures as early as 2 weeks after surgery if
there is good clinical healing
Finger fractures are frequently reported as not
healed with radiologist-interpreted plain radio-
graphs. Radiographic healing time for finger frac-
tures is often longer than clinical healing. Fractures
are often quite solidly healed clinically 2–3 weeks
after injury in spite of no apparent healing seen in
radiographs. If you press firmly on the finger fracture
at 2–3 weeks after injury and elicit very little pain, the
fracture will be difficult to take apart at surgery for
malunion. The absence of fracture line tenderness
implies good clinical healing. Clinical healing (no
pain on firm pressure on the fracture with the exam-
iner thumb and index finger) is our best guide to when
the K-wires can be removed (Gregory et al., 2014;
Hyatt and Rhee, 2019; Lalonde, 2021). If there are
nerve injuries causing numbness at the fracture
site, clinical healing is obviously no longer a valid
measure. In addition, early K-wire removal will not
be wise in fractures with reduced blood supply, such
as in cases with periosteal stripping that occurred
during open reduction.
Entrapment neuropathies
Nerve release surgery can be performed
with WALANT and field sterility in minor
procedure rooms
Many surgeons are now performing carpal, cubital
and lacertus tunnel releases with field sterility and
26 Journal of Hand Surgery (Eur) 47(1)

WALANT in minor procedure rooms instead of use of

a main operating room, tourniquet and sedation. This
decreases cost and medical waste without increasing
risk of infection (Figure 3) (Avoricani et al., 2021;
Foster et al., 2017; Hagert and Lalonde, 2016; Kang
et al., 2019; Kazmers et al., 2018; Ki Lee et al., 2020;
Lalonde and Phillips, 2016; Leblanc et al., 2007; Rhee
et al., 2017).

Lacertus syndrome is more frequent than

many surgeons think: how to diagnose
and treat median nerve compression at
the elbow
Surgeons do not commonly release the median
nerve at the elbow for two main reasons. The
first is that the traditional ‘pronator release’ oper-
ation extends several centimetres above and below
the elbow crease and carries risk of noteworthy
morbidity and scarring. Extensive dissection is not
necessary, and simple division of the lacertus fibro-
sus in a 3 cm elbow crease incision relieves symp-
toms in most cases (Hagert, 2013; Hagert and
Lalonde, 2016). The second reason is that many
surgeons do not examine for motor weakness of
flexor carpi radialis (FCR), flexor pollicis longus
(FPL), and flexor digitorum profundus (FDP)2
when they are looking for median nerve compres-
sion at the elbow.
Symptoms of median nerve compression at the
Figure 4. (a) Injection of 60 ml of 0.5% lidocaine with
elbow (lacertus syndrome) may include: (1) weak-
1:200,000 epinephrine in the medial anterior elbow crease
ness of thumb and index interphalangeal joint flexion, and proximal forearm for lacertus release. (b) Scissors
(2) numbness/paraesthesia/pain in the area inner- under the leading edge of lacertus fibrosus as seen from
vated by the palmar cutaneous branch of the anterior to the elbow with release of the median nerve.
median nerve, (3) aching proximally in the volar fore-
arm to where the lacertus crosses the median nerve
Cubital tunnel syndrome
and (4) median nerve paraesthesia in the hand fol-
lowing median nerve compression. Like many surgeons, we have moved away from long
Signs of lacertus syndrome may include M4 (as incisions and nerve transposition toward simple
opposed to M5) decreased power of FCR, FPL and decompression of Osborne’s ligament (cubital
FDP2, and tenderness of the median nerve just prox- tunnel) and the proximal forearm fascia over the
imal and deep to the lacertus fibrosus edge, which is flexor carpi ulnaris with a short incision. This can
frequently thickened. also be easily accomplished with WALANT with the
Treatment of lacertus syndrome is similar to shoulder abducted, the elbow flexed and the forearm
carpal tunnel release in its simplicity. A short incision supinated at the level of the head for better visibility
is confined to the elbow crease, medial to the biceps of the ulnar nerve. This is easier than using a tour-
tendon and centralized over the brachial artery/ niquet with the limb on an arm board (Figure 5). This
median nerve neurovascular bundle (Figure 4). In procedure is also easily done with the patient prone
addition to all the other advantages of WALANT, or on their side when they are wide awake. Patients
patients and surgeons can see immediate return of with sore shoulders can more easily find a comfort-
power of FPL and FDP2 during the surgery in many able position when they are awake.
cases (Hagert and Lalonde, 2016). The procedure has One of the authors (SK) routinely performs cubital
minimal morbidity, and many patients can return to tunnel decompression with WALANT reverse end-to-
work within a week. side anterior interosseous nerve to ulnar motor
Lalonde et al.
Figure 5. (a) Comfortable position for the patient and the
surgeon for cubital tunnel release after injection of 60 ml of
0.5% lidocaine with 1:200,000 epinephrine in the elbow and
20 ml in the carpal tunnel for simultaneous carpal tunnel
release. (b) Injection of 60 ml of 0.3% lidocaine with
1:300,000 epinephrine in each area of lacertus and cubital
tunnels (total 120 ml) for simultaneous releases of median
and ulnar nerves at the elbow.
nerve transfers (Kurtzman et al., 2021). The con-
straints of the epidemic in 2020 have inspired his
group to considerably expand the number of proced-
ures performed under WALANT. These include
median and ulnar nerve cabled sural nerve graft
reconstructions.
Wide-awake surgery of hand and upper
extremity
Minimal pain injection of large volumes of
tumescent local anaesthesia to eliminate
the need for sedation
Properly injected tumescent local anaesthesia
should not hurt patients any more than a tiny injec-
tion with a fine 30 - or 27-gauge needle
(Farhangkhoee et al., 2012; Lalonde et al., 2016;
Strazar et al., 2013). This even applies to major pro-
cedures that require up to 200 ml of tumescent local
anaesthesia, such as for tendon transfers or fracture
fixation in the forearm.
27
Figure 6. Periosteal injection given circumferentially to
give good anaesthesia coverage for fracture fixation.
Figure 7. Plating a fractured distal radius under WALANT.
For videos on injecting large volumes of local
anaesthesia nearly pain free, see videos at http://
www.mediafire.com/file/9uz6krlly19h1q2/
20200714_The_5th_ICTEC_On-Line_Updates_
in_Hand_Surgery.mp4/file) (accessed 13 June 2021)
and https://www.youtube.com/watch?v¼IcSizvzD6LM
(accessed 13 June 2021).
Periosteal bathing with tumescent local
anaesthesia for fracture fixation
The use of WALANT beyond the hand has been suc-
cessful with using circumferential periosteal injec-
tions. Large volumes of tumescent anaesthesia can
be injected circumferentially around long bones such
as the radius to allow for painless manipulation and
plating (Figure 6) (Ahmad et al., 2018, 2020, 2021;
Huang et al., 2018; Orbach et al., 2018; Tahir et al.,
2020).
28
Surgeons are applying WALANT to volar plate and/
or fragment specific fixation of distal radius, both
bone forearm, olecranon and clavicle fractures and
radioscapholunate arthrodesis (Figure 7) (Online
Supplementary Figure S1) (Ahmad et al., 2018,
2020, 2021; Huang et al., 2018; Kurtzman et al.,
2021; Orbach et al., 2018; Tahir et al., 2020). One of
the authors (SK) routinely performs distal radius
fracture fixation under WALANT using field sterility
(Kurtzman et al., 2021).
Expanding scope of application
WALANT stands as a paradigm shift for hand and
upper extremity surgery. WALANT scope expansion
depends on the particular surgeon’s perspectives
and preferences as well as on the motivation of
patients for awake surgery. Both the surgeon and
the patient must be willing and feel confident about
cooperating for a successful pain-free awake proced-
ure. Some surgeons are using WALANT for long bone
fractures, as we will discuss below (Ahmad et al.,
2018, 2020, 2021; Kurtzman et al., 2021). Moreover,
the scope of WALANT surgery could be affected by
the departmental settings and the contemporary
working conditions (Das De et al., 2020; Kurtzman
et al., 2021; Tang et al., 2019b). The pandemic in
2020 has expanded the scope of WALANT surgery to
limit exposure of both patients and health care work-
ers to viral infections (Das De et al., 2020; Kurtzman
et al., 2021). In many countries, including Canada,
China, Singapore, Turkey, Indonesia, United
Kingdom and Egypt, WALANT is a popular setting for
hand surgery (Tang et al., 2019b). Not only are clinical
outcomes comparable or better with WALANT, but
patients have less postoperative pain than with trad-
itional anaesthesia (Kurtzman et al., 2021).
WALANT has been widely adopted for many minor
and small upper extremity procedures, such as carpal
tunnel release and percutaneous K-wire placement.
However, surgeons are regularly adopting new pro-
cedures to WALANT, such as arthroscopic wrist sur-
gery, first dorsal compartment release and local hand
flaps (Kurtzman et al., 2021; Liu et al., 2019; Tang
et al., 2019a; Xing and Tang, 2019). Use of WALANT
for development of local hand flaps permits the
immediate assessment of perfusion and facilitates
pedicle and perforator identification. We routinely
employ WALANT for flaps like Louvre and Qaba
flaps, so that patients can comfortably position their
shoulder, elbow and hand.
Additionally, we have used WALANT to perform
regional flaps, such as lower extremity propeller
flaps around the ankle and reverse radial forearm
Journal of Hand Surgery (Eur) 47(1)
fasciocutaneous flaps (Online Supplementary Figure
S2). This permits complex wound coverage to be per-
formed in an office setting and nullifies many of the
traditional barriers to performing surgery in the main
operating room: availability, medical clearance and
optimization, and anaesthesia. WALANT has also
been used for microvascular procedures, such as
finger replantation (Wong et al., 2017).
WALANT has improved results in routine flexor
tendon repair because gaps seen with active move-
ment are corrected to prevent rupture, and incremen-
tal pulley venting can preserve motion and avoid
tenolysis (Higgins et al., 2010). WALANT has also
been beneficial in delayed flexor tendon reconstruc-
tion (Ayhan et al., 2021). Although some of these cases
can be treated primarily even after a few months,
some might need tendon grafting or secondary
flexor tendon reconstruction (Ayhan et al., 2021;
Tang, 2019). Either treatment can be performed
according to the intraoperative active movement of
the particular finger when WALANT is used. If primary
repair is possible, the intraoperative active extension–
flexion test guides the appropriate treatment.
After primary flexor tendon repair, mild (<30 )
flexion contracture of the fingers can benefit from
supervised rehabilitation (Ayhan et al., 2021; Tang,
2007, 2013, 2018). Moderate (<50 ) contractures of
index and long fingers can be minimized after imme-
diate WALANT fractional lengthening of the particu-
lar muscle in the distal forearm (Ayhan et al., 2021;
Le Viet, 1986; Tang, 2013). The surgical methods are
shown in videos of Ayhan et al (2021).
When the primary repair is not possible because of
marked muscle contracture, one-stage grafting or
two-stage flexor tendon reconstruction can be per-
formed with WALANT (Ayhan et al., 2021). Surgical
settings and methods can be found in videos of
Ayhan et al (2021). WALANT allows for accurate
tendon graft tensioning, thus preventing the compli-
cations of quadriga and lumbrical plus finger.
Moreover, it can reveal symptomatic bowstringing
and permit the surgeon to recognize when primary
pulley reconstruction is necessary. For tenolysis,
WALANT not only limits the amount of dissection,
but sometimes reveals the true extent of tenolysis
necessary to regain full, active motion.
Benefits of WALANT in regions with
limited medical resources
Particularly in developing countries, the costs of sed-
ation and main operating-room sterility often strain
available resources. WALANT and evidence-based
sterility (Yu et al., 2019) have permitted moving a
Lalonde et al.
lot of hand surgery out of the main operating room
and into minor procedure rooms (Behar et al., 2019;
Holoyda et al., 2020; Steve et al., 2019).
Declaration of conflicting interests We declare no
potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
Funding We received no financial support for the
research, authorship, and/or publication of this article.
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Supplemental material Supplemental material for this
article is available online.
ORCID iD Egemen Ayhan https://orcid.org/0000-0002-
0324-3126
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