Arch Hand Microsurg.  2018 Mar;23(1):1-11. 10.12790/ahm.2018.23.1.1.

Wide-Awake Hand Surgery

• Kang SW
• Kim YW
• Park JK

• KMID: 2412485
• DOI: http://doi.org/10.12790/ahm.2018.23.1.1

Abstract

Wide-awake hand surgery is a surgical procedure that does not use a tourniquet and sedation through lidocaine and epinephrine injections and does not perform regional anesthesia or general anesthesia. Therefore, systemic risk by general anesthesia can be avoided, and more accurate surgeries can be performed through active joint motion during surgery without discomfort due to tourniquet used during local anesthesia. Also, the time and cost associated with anesthesia can be reduced and the hospital day can be reduced by performing the day surgery. The authors will introduce the concept of the wide-awake hand surgery and discuss the indications, drug usage, and injection methods.

Keyword

Anesthesia; Local; Lidocaine; Epinephrine; Tourniquet

MeSH Terms

Ambulatory Surgical Procedures
Anesthesia
Anesthesia, Conduction
Anesthesia, General
Anesthesia, Local
Epinephrine
Hand*
Joints
Lidocaine
Tourniquets
Epinephrine
Lidocaine

Figure

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  Fig. 1 Phentolamine Mesylate (Reyon Pharm., Seoul, Korea) is an alpha-adrenergic blocking agent that rescue for epinephrine vasoconstriction in the finger.

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  Fig. 2 Illustration for the reduction of injection-associated pain. Adapted from the article of Strazar et al.16 (Plast Reconstr Surg. 2013;132:675–84) with original copyright holder's permission.

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  Fig. 3 A simple technique to decrease movement during injection is to stabilize the syringe holding hand with fingers, and too much local anesthetic is better than not enough.

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  Fig. 4 Wide-awake local anesthesia for a case with a complete zone 2 flexor tendon cut in the middle finger. Inject 2 mL of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 mL of lidocaine/epinephrine to 1 mL of 8.4% sodium bicarbonate) in subcutaneous fat in the red injection point just under the skin.

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  Fig. 5 Wide-awake local anesthesia for a case with a complete zone 5 extensor tendon cut in the hand. Inject 20 mL of 1% lidocaine with 1:100,000 epinephrine buffered with 2 mL of 8.4% sodium bicarbonate in subcutaneous fat in the red injection point just under the skin.

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  Fig. 6 Wide-awake local anesthesia for a case with a spontaneous ruptured both flexors of the small finger. The small profundus was reconstructed with a tendon transfer to the ring finger superficialis tendon.

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  Fig. 7 Extensor indicis proprius to extensor pollicis longus tendon transfer with the wide awake approach. (A) Inject 20 mL of 1% lidocaine with 1:100,000 epinephrine buffered with 2 mL of 8.4% bicarbonate, starting 3 cm proximal to the Lister's tubercle. (B) Exposure of the ruptured EPL tendon (C) after the tendon transfer, (D, E) intraoperative testing of thumb flexion and extension. (F, G) At three months postoperatively, the range of motion of the thumb was fully recovered.

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  Fig. 8 Tendon transfer for rupture of the extensors to the long, ring and small finger with the wide awake approach.

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  Fig. 9 A 23-year-old man who had a stiff finger by prior metacarpal fracture surgery. (A, B) The metacarpophalangeal (MCP) extension contracture. (C-F) The patient can regain functional motion of the MCP joint after wide-awake surgical release.

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  Fig. 10 Tenolysis and pulley reconstruction in a 58-year-old woman who had been unable to flex her long finger.

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  Fig. 11 A 55-year-old man underwent plate fixation for an open metacarpal fracture. Inject a total of 30 to 40 mL of 1% lidocaine with 1:100,000 epinephrine (buffered with 10 mL lidocaine/epinephrine:1 mL of 8.4% sodium bicarbonate).

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  Fig. 12 The rotation was assessed from an active range of motion of the metacarpophalangeal joints during the surgery.

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  Fig. 13 (A, B) A 34-year-old man who sustained scissoring of the small finger after minimally displaced metacarpal fracture. (C, D) The malrotation was corrected with the wide awake approach.

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  Fig. 14 For carpal tunnel release, inject 10 mL of buffered 1% lidocaine with 1:100,000 epinephrine just ulnar to the palmaris longus at the proximal injection point. After the initial 10 mL, come back to the subcutaneous plane with the needle tip and slowly infiltrate 10 mL from proximal to distal in an antegrade direction down the palm between the skin and the superficial palmar fascia.

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  Fig. 15 The wide-awake approach to Dupuytren's contracture. (A, B) Inject to 14 mL of 1% lidocaine with 1:100,000 epinephrine. (C-F) Verifying active extension with active movement after cord resection. (G, H) At 3 years follow-up, the patient achieved optimal functional outcomes with a good range of motion.

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