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Wide Awake Open Reduction of Irreducible Metacarpal Phalangeal Joint Dislocations

Article

Wide Awake Open Reduction of Irreducible Metacarpal Phalangeal Joint Dislocations

Abstract

Supplemental Digital Content is available in the text.
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
www.PRSGlobalOpen.com 1
VIDEO
Operative Technique
Many Canadian surgeons now surgically treat
most hand trauma during the day in minor pro-
cedure rooms using local anesthetic, instead of
in the middle of the night in the main operating room.
Surgeons and nurses are more likely to be able to per-
form better surgery when they are rested during daytime
hours than while tired at night. Most patients undergo-
ing wide awake hand surgery for traumatic hand injuries
do not require hospital admission as they do not need to
wait in line to obtain or recover from sedation. Little to
no preoperative workup is required for pure local anes-
thesia. This is much less expensive and more convenient
for patients who have traveled long distances for care.1
We can operate on patients with multiple medical prob-
lems safely because we do not use sedation.
LOCAL ANESTHETIC INJECTION
With the patient supine, we inject 30 ml of 1% lido-
caine with 1:100,000 epinephrine buffered with 3 ml
of 8.4% sodium bicarbonate with a 27 gauge needle.
We inject the local subcutaneously from proximal to
distal both volarly and dorsally from the midmetacar-
pal distally (see video, Supplemental Digital Content 1,
which shows how to perform minimal pain local anes-
thesia injections for traumatic hand injuries involving
the metacarpophalangeal joint. This video is available
in the Related Videos section of the Full-Text article
on PRSGlobalOpen.com. http://links.lww.com/PRSGO/
A470). We use minimally painful local anesthesia injec-
tion technique to avoid the need for sedation.2 After
injection, we wait a minimum of 30 minutes for the lo-
cal anesthetic to fully numb the area and achieve the
maximal epinephrine effect.3 No tourniquet is required
when epinephrine is given adequate time to work. Elim-
inating the tourniquet and painful local anesthetic in-
jections removes the need for sedation.4
OPEN REDUCTION OF IRREDUCIBLE
TRAUMATIC METACARPOPHALANGEAL
JOINT DORSAL DISLOCATIONS
This video clearly shows the anatomy of the disloca-
tion and its reduction (see video, Supplemental Digital
Content 2, which shows open reduction of a irreducible
traumatic metacarpophalangeal joint dorsal disloca-
tions using wide awake local anesthetic no tourniquet
hand surgery. This video is available in the Related Vid-
eos section of the Full-Text article on PRSGlobalOpen.
com. http://links.lww.com/PRSGO/A471).5 The flexor
tendons and the lumbrical form the ulnar side of the
noose around the metacarpal neck. The first dorsal
interosseous muscle and the radial lateral band of the
extensor hood form the radial side of the noose. The
radial digital nerve is tented over the metacarpal head,
which is trapped volarly in the noose. This video also
shows the Wide Awake Local Anesthesia No Tourniquet
release of the A1 pulley, which allows the surgeon to
relocate the flexor tendons and the lumbrical radially
so they can shoe horn the metacarpal head back into
its dorsal position in the joint with a Freer elevator. We
confirm the reduction by asking the patient to extend
and fully flex the finger before we close the skin, there-
by showing congruity of the joint surfaces with active
movement. This also helps us decide the degree of early
protective movement safely allowed after surgery. We
elevate and immobilize the hand for 3 days until the
patient is off all pain killers. Then, we allow pain-guided
full flexion and up to minus 30 degrees of MP extension
blocked with a splint.
Postoperative course (see video, Supplemental Digi-
tal Content 3, which shows the patient’s perspective in
follow-up, after undergoing wide awake surgical correc-
tion of his traumatic hand injury. This video is available
in the Related Videos section of the Full-Text article
on PRSGlobalOpen.com. http://links.lww.com/PRSGO/
A472).
Unsedated patients remember getting a full range of
flexion and extension of their fingers during the surgery.
From the Division of Plastic Surgery, Dalhousie University, Saint
John, NB, Canada.
Received for publication February 19, 2017; accepted May 5, 2017.
This study conformed to the Declaration of Helsinki and hospital
review board guidelines.
xxx
10.1097/GOX.0000000000001394
6
Sudharshini
2017
5
Video
22March2017
19February2017
© 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society
of Plastic Surgeons. All rights reserved.
Wide Awake Open Reduction of Irreducible
Metacarpal Phalangeal Joint Dislocations
Daniel Mckee, MD; Donald Lalonde, MD
Disclosure: The authors have no financial interest to
declare in relation to the content of this article. The Article
Processing Charge was paid for by the authors.
Copyright © 2017 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This is
an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
Plast Reconstr Surg Glob Open 2017;5:e1394; doi: 10.1097/
GOX.0000000000001394; Published online 5 July 2016.
Supplemental digital content is available for this
article. Clickable URL citations appear in the text.
2017
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
PRS Global Open 2017
2
They know what they can achieve if they stick with thera-
py after surgery. Intraoperative advice from the surgeon
helps ensure postoperative patient compliance.
Daniel Mckee, MD
Dalhousie University
Suite C204
600 Main Street
Saint John
NB E2K 1J5 Canada
E-mail: Daniel.mckee@medportal.ca
PATIENT CONSENT
The patient provided written consent for the use of his
image.
REFERENCES
1. Lalonde D, Martin A. Tumescent local anesthesia for hand sur-
gery: improved results, cost effectiveness, and wide-awake patient
satisfaction. Arch Plast Surg. 2014;41:312–316.
2. Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local
anesthesia injection. Plast Reconstr Surg. 2013;132:675–684.
3. McKee DE, Lalonde DH, Thoma A, et al. Optimal time delay be-
tween epinephrine injection and incision to minimize bleeding.
Plast Reconstr Surg. 2013;131:811–814.
4. Lalonde D, Wong A. Local anesthetics: what’s new in minimal
pain injection and best evidence in pain control. Plast Reconstr
Surg. 2014;134:40S–49S.
5. Glickel S, Barron O, Catalano L. Chapter 9 dislocations and liga-
ment injuries in the digits. In: Green DP, Hotchkiss RN, Pederson
WC, Wolfe SW, eds. 5th ed. Green’s Operative Hand Surgery. Phila-
delphia Pa.: Elsevier Churchill Livingstone; 2005:360–363.
Video Graphic 3. See Supplemental Digital Content 3, which shows
the patient’s perspective in follow-up, after undergoing wide awake
surgical correction of his traumatic hand injury. This video is avail-
able in the Related Videos section of the Full-Text article on PRSGlo-
balOpen.com or available at http://links.lww.com/PRSGO/A472.
Video Graphic 1. See Supplemental Digital Content 1, which
shows how to perform minimal pain local anesthesia injections for
traumatic hand injuries involving the metacarpophalangeal joint.
This video is available in the Related Videos section of the Full-Text
article on PRSGlobalOpen.com or available at http://links.lww.
com/PRSGO/A470.
Video Graphic 2. See Supplemental Digital Content 2, which shows
open reduction of a irreducible traumatic metacarpophalangeal
joint dorsal dislocations using wide awake local anesthetic no tour-
niquet hand surgery. This video is available in the Related Videos
section of the Full-Text article on PRSGlobalOpen.com or available
at http://links.lww.com/PRSGO/A471.
... Nonetheless, there are only very few data about its short-term effects on tissue perfusion and oxygen supply after administering epinephrine [5,[18][19][20]29]. Hence, this study's aim was to investigate these by means of microlightguide spectrophotometry and laser Doppler flowmetry. ...
... Regarding the short-term effects of the WALANT technique on tissue perfusion and oxygen levels, there are very few data in scientific literature [5,[18][19][20]29]. Therefore, it was examined tissue blood flow, capillary-venous oxygen saturation (sO 2 ), and hemoglobin volume (rHb) in this study. ...
... Based on these data, however, no conclusions can be drawn as to how long one should wait after an injection, before starting the operation. McKee et al. found that after a subcutaneous infiltration of 5 ml lidocaine 1% with 1:100,000 epinephrine (0.01 mg/ml) into one arm, versus the same amount of lidocaine 1% without epinephrine into the other arm, the vasoconstrictive effect of lidocaine with epinephrine occurred after only 25 min (95% AI, 25.9 ± 5.1 min) [20]. In this study, a vasoconstrictive effect can be measured within a period of 10-20 min after injection, but normalizing within 30 min. ...
Article
Full-text available
Introduction Although the WALANT technique’s long-term safeness has been demonstrated in many studies, there are only few data investigating its short-term effects on tissue perfusion and oxygen levels. It was hypothesized that, temporarily, critical levels of tissue perfusion may occur. Methods Seventeen patients, who were scheduled for different procedures in WALANT technique, were injected with 5–7 ml of 1% Articain containing 1:200,000 epinephrine at the finger base. Capillary-venous oxygen saturation, hemoglobin volume in the capillaries, and relative blood flow in the fingertips were recorded once per second by white light spectrometry and laser Doppler flowmetry before, during and after injection for an average of 32 min. Results Clinically, no persistent tissue malperfusion was observed, and there were no postoperative complications. Capillary-venous oxygen saturation was reduced by ≥ 30% in seven patients. Critical levels of oxygen saturation were detected in four patients during 13 intervals, each lasting for 132.5 s on average. Oxygen saturation returned to noncritical values in all patients by the end of the observation period. Blood flow in the fingertips was reduced by more than 30% in nine patients, but no critical levels were observed, as with the hemoglobin. Three patients demonstrated a reactive increase in blood flow of more than 30% after injection. Conclusions Injection of tumescent local anesthesia containing epinephrine into finger base may temporarily cause a substantial reduction in blood flow and lead to critical levels of oxygen saturation in the fingertips. However, this was fully reversible within minutes and does not cause long-term complications.
Article
Full-text available
This is a review article of the wide-awake approach to hand surgery. More than 95% of all hand surgery can now be performed without a tourniquet. Epinephrine is injected with lidocaine for hemostasis and anesthesia instead of a tourniquet and sedation. This is sedation-free surgery, much like a visit to a dental office. The myth of danger of using epinephrine in the finger is reviewed. The wide awake technique is greatly improving results in tendon repair, tenolysis, and tendon transfer. Here, we will explain its advantages.
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Local anesthesia in plastic surgery is undergoing a revolution. In the last 10 years, significant improvements in technique have permitted surgeons to do more and more under pure local anesthesia to increase patient safety and convenience while maintaining total patient comfort during the injection of the local anesthesia and while the procedure is accomplished. Many procedures which used to require sedation are now being performed without it. This article explores some of the new advances in local anesthesia such as painless blunt-tipped cannula local anesthetic infiltration, decreased pain with sharp needle tip injection, and long-lasting local anesthetics with delayed release from liposomal encapsulation. This article also examines the best evidence of the last 10 years of advances of pain control with local anesthesia.
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Local anesthetic injection is often cited in literature as the most painful part of minor procedures. It is also very possible for all doctors to get better at giving local anesthesia with less pain for patients. The purpose of this article is to illustrate and simplify how to inject local anesthesia in an almost pain-free manner. The information was obtained from reviewing the best evidence, from an extensive review of the literature (from 1950 to August of 2012) and from the experience gained by asking over 500 patients to score injectors by reporting the number of times they felt pain during the injection process. The results are summarized in a logical stepwise pattern mimicking the procedural steps of an anesthetic injection-beginning with solution selection and preparation, followed by equipment choices, patient education, topical site preparation, and finally procedural techniques. There are now excellent techniques for minimizing anesthetic injection pain, with supporting evidence varying from anecdotal to systematic reviews. Medical students and residents can easily learn techniques that reliably limit the pain of local anesthetic injection to the minimal discomfort of only the first fine needlestick. By combining many of these conclusions and techniques offered in the literature, tumescent local anesthetic can be administered to a substantial area such as a hand and forearm for tendon transfers or a face for rhytidectomy, with the patient feeling just the initial poke.
Article
Background: The time until maximal cutaneous vasoconstriction after injection of lidocaine with epinephrine is often given in textbooks and multiple choice examinations as 7 to 10 minutes. However, in our experience, there is significantly less cutaneous bleeding if one waits considerably longer than 7 to 10 minutes after injection of local anesthesia with epinephrine for most procedures on human skin. Methods: This was a prospective, randomized, triple-blind study where 12 volunteers were injected simultaneously in each arm with either 1% lidocaine with epinephrine (study group) or 1% plain lidocaine (control group), after which the relative hemoglobin concentration of the underlying skin and soft tissues was measured over time using spectroscopy. Results: In the epinephrine group, the mean time at which the lowest cutaneous hemoglobin level was obtained was 25.9 minutes (95 percent CI, 25.9 ± 5.1 minutes). This was significantly longer than the historical literature values of 7 to 10 minutes for maximum vasoconstriction after injection. Mean hemoglobin index values at every time measurement after postinjection minute 1 were significantly different between the study group and the control group, with use of a two-tailed paired t test (p < 0.01). Conclusions: If optimal visualization is desired, the ideal time for the surgeon to begin the incision should be 25 minutes after injection of local anesthetic with epinephrine. It takes considerably longer than 7 to 10 minutes for a new local equilibrium to be obtained in relation to hemoglobin quantity.