Wide Awake Flexor Pollicis Longus
and Digital Nerve Repairs on a Patient
in the Prone Position
, Gilles Candelier
, Daniel McKee
and Donald Lalonde
Wide awake, local anesthesia, no tourniquet hand surgery is a growing field of hand surgery with many advantages described in the
literature. This technique is safely performed with the patient in prone position and offer several advantages.
prone, hand, surgery, thumb, walant, flexor
Wide awake local anesthesia no tourniquet (WALANT) hand
surgery has several advantages in flexor tendon repair.
an awake patient in supine position, the thumb tends to flex
making exposure difficult. We describe our first experience
using this technique with a wide awake patient positioned on
his abdomen (prone) for improved exposure of the thumb
We performed a primary repair of a laceration of flexor pollicis
longus (FPL) and both palmar digital nerves at the level of the
proximal phalanx. The patient was positioned in a prone posi-
tion during the injection of local anesthesia and for surgery. We
injected local anesthesia (20 mL of 1%lidocaine with
1:100,000 epinephrine:2 mL of bicarbonate 8.4%) using tumes-
cent local anesthesia technique in order to reduce pain, provide
adequate anesthesia, and provide adequate vasoconstriction
without a tourniquet (Figure 1).
Waiting at least 26 minutes
after injection and before cutting is important to achieve max-
We waited 45 minutes in this case.
There was no need for any additional local anesthesia injec-
tions during the procedure which took 70 minutes from incision
to closure. No tourniquet was required, and visualization was
Center of Ultrasound Guided Hand Surgery, Private Hospital Les
Franciscaines, Versailles, France
Center of Hand Surgery Private Hospital of Saint Martin, Caen, France
Division of Plastic and Reconstructive Surgery, Dalhousie University, Saint
Saint John, Canada
Thomas Apard, Private Hospital Les Franciscaines, 7 bis rue de la Porte de Buc,
Versailles 78000, France.
Figure 1. Tumescent local anesthesia with lidocaine and epinephrine
in all possible areas of dissection.
Plastic Surgery Case Studies
Volume 5: 1-3
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In the usual supine position with the patient on his back, the
wrist is supinated and the thumb position causes the surgeon to
tilt his head to accommodate. We found the prone position
offered improved exposure of the palmar thumb because it
tends to lay flat against the table. This was especially advanta-
geous when we performed wide awake microsurgical digital
The prone position can also be helpful to decrease hand
movement during local anesthetic needle insertion. Our patient
was somewhat anxious in the beginning, so the prone position
was helpful since it made it harder for him to look at his hand.
He was easily distracted with a movie playing on a laptop
computer easily positioned at his eye level (Figure 2). He was
comfortable lying on his abdomen with a pillow for head sup-
port. After the repair, he was able to move the thumb without
difficulty when we asked him to so, we could perform the
intraoperative total active movement examination.
With wide awake surgery, we were able to enjoy the advan-
tages of prone position for thumb FPL and digital nerve micro-
surgery repair, while avoiding the risks associated with prone
position in patients under general anesthesia. We were able to
educate the patient with verbal postoperative instructions as we
closed the skin and applied the splint.
Prone positioning in patients who are unconscious, unpro-
tected, and under general anesthesia has a list of potential risks
and complications associated with it.
These risks do not
apply to fully awake patients. Awake patients who can tolerate
lying on their abdomen while sleeping can tolerate the same
position while undergoing WALANT. If the patient becomes
uncomfortable in this position, they can tell the surgical team to
switch them to a supine position for the remainder of the oper-
ation. Surgeons have been safely using prone positioning for
awake patient for decades when excising skin lesions from the
occiput, posterior neck, or back, under local anesthesia in the
The ideal patient positioning for wide awake hand surgery is
where both the patient is fully comfortable, and the surgeon
gains technical advantages and improved visualization from
the positioning. We have already found the arm above the head
position to be helpful in wide awake ulnar nerve transposition
at the elbow.
We suggest that surgeons consider the prone
position for thumb surgery in the wide awake patient. We will
continue to explore the advantageous of this position for other
procedures in the upper extremity while using WALANT.
Statement of Human and Animal Rights
All procedures followed were in accordance with the ethical standards
of the responsible committee on human experimentation (institutional
and national) and with the Helsinki Declaration of 1975, as revised in
2008. Informed consent was obtained from all patients for being
Figure 2. Intraoperative prone position for wide awake thumb surgery.
2Plastic Surgery Case Studies
included in the study. Additional informed consent was obtained from
all patients for which identifying informationisincludedinthis
Statement of Informed Consent
Informed consent was obtained from all individual participants
included in the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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Apard et al 3