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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]
Indications
Digital blocks are indicated for any minor surgery or procedure of the digits. These include, but
are not limited to, the following:
Ingrown nails
Felon or paronychia
Contraindications
See the list below:
Best Practices
See the list below:
Avoid epinephrine use in the digits; a clamped Penrose drain can be used to limit
bleeding.
Limit the patients discomfort by using a smaller needle, injecting slowly, and using small
amounts of anesthetics.
Anesthesia of the great toe is more difficult to achieve and requires 3-sided/4-sided ring
blocks.
Use of sterile technique is essential to limit the risk of introducing infections (especially
with the transthecal block).
Equipment
The equipment necessary includes the following:
Syringe, 5-10 mL, with an 18-gauge needle for drawing up the anesthetic and a 25- to 30gauge needle for injection
Anesthesia
Local anesthetic agents have the basic structure of an aromatic and a hydrophilic,
separated in the middle by an amino-ester or an amino-amide. This forms the basis of
classification of local anesthetics into 2 groups: the ester-type agents (eg, procaine) and
the amide-type agents (eg, lidocaine).[3]
The choice of agent is based on the desired duration of analgesia and the patients allergy
profile. Lidocaine is the most commonly used anesthetic. If longer anesthesia is required,
another amide anesthetic, such as bupivacaine, can be used. If the patient is known to be
allergic to lidocaine, an ester-type anesthetic, such as procaine, can be substituted. Table 1
summarizes the properties of commonly used agents. For more information, see Local
Anesthetic Agents, Infiltrative Administration.
Table 1. 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.
Positioning
Depending on the technique used, the extremity position varies. See the Technique
section for detailed explanations.
Wound infection: Local anesthetics have been shown to possess antimicrobial properties.
Although studies have shown that use of local anesthetics does not alter incidence of
wound infection, their use may produce false-negative wound cultures. [14]
Local injuries: Injuries to nerves and tendons can result in long-term complications such
as neuropathies and tendonitis.
Wound healing: Several studies have shown that local anesthetics inhibit wound healing
by decreasing the tensile strength of wounds; [15] another study showed that local
anesthetics decrease local inflammatory response. [16]
Allergic reactions
Vasovagal syncope
Approach Considerations
Several different techniques can be used to anesthetize the digits: the web-space block,
the transthecal block, the 3-sided digital block, and the 4-sided ring block. Standard
sterile precautions should be followed for all of the described procedures.
Web-Space Block
This method is very effective in achieving adequate anesthesia and is probably the least painful.
Place the patients hand on a sterile field with the palm down.
Hold the syringe perpendicular to the digit and insert the needle into the web space, just
distal to the metacarpal-phalangeal (MP) joint (see image below).
Slowly inject the anesthetic in the dorsal aspect of the web space.
Slowly advance the needle straight down toward the volar aspect of the web space, slowly
infiltrating the surrounding tissues of the web space (see video below). The needle should not
pierce the volar aspect of the web space.
Web-space block technique.
Withdraw the needle and repeat the procedure on the other web space of the involved digit.
The toes (except the great toe) can be effectively anesthetized in the same manner.
Transthecal Block
Originally described by Chiu in 1990,[7] this technique is also known as the flexor tendon sheath
digital block. While treating trigger finger by injecting steroids and lidocaine into the tendon
sheath, Chiu noted that anesthesia of the entire digit was achieved. Although adequate anesthesia
is achieved with a single injection, this injection is painful because the needle pierces the very
sensitive skin of the palm. Studies have shown that this type of block is as effective as traditional
ring blocks in achieving adequate anesthesia.[8, 9, 10]
Place the patients hand on the sterile field with the palm up.
Locate the flexor tendon sheath by palpating it at the distal palmar crease.
Insert the needle at a 45-degree angle just distal to the distal palmar crease (see image
below).
Inject the anesthetic, it should flow freely. If resistance is met, reposition the needle by
slowly withdrawing it.
During the injection, use the nondominant hand to apply pressure just proximal to the
injection site, to direct the flow distally (see image below).
Slowly inject the anesthetic as the needle is advanced toward the volar/plantar side, without
piercing the volar skin.
Slowly withdraw the needle and redirect it medially.
Advance the needle slowly from medial to lateral side while the anesthetic is injected (see
image below).
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).
15. Morris T, Tracey J. Lignocaine: its effects on wound healing. Br J Surg. 1977 Dec.
64(12):902-3. [Medline].
16. Eriksson AS, Sinclair R, Cassuto J, Thomsen P. Influence of lidocaine on leukocyte
function in the surgical wound. Anesthesiology. 1992 Jul. 77(1):74-8. [Medline].
http://emedicine.medscape.com/article/80887-technique#c6