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Clinical Professor (Honorary) Department of Orthopaedics & Traumatology
The Chinese University of Hong Kong
Sha Tin, Hong Kong
Robert N. Hotchkiss, MD
Attending Surgeon
Hand and Upper Extremity Service
Hospital for Special Surgery
New York, New York
Jonathan Isaacs, MD
Herman M. & Vera H. Nachman
Distinguished Research Professor Chief
Division of Hand Surgery
Department of Orthopaedic Surgery
Virginia Commonwealth University Health System
Richmond, Virginia
Michelle A. James, MD
Chief of Orthopaedic Surgery
Shriners Hospital for Children Northern California
Professor of Orthopaedic Surgery
University of California Davis School of Medicine
Sacramento, California
Neil F. Jones, MD, FRCS
Emeritus Chief of Hand Surgery
Distinguished Professor of Orthopedic Surgery
Distinguished Professor of Plastic and Reconstructive Surgery
Ronald Reagan UCLA Medical Center
David Geffen School of Medicine at UCLA
University of California Los Angeles
Los Angeles, California
Consultant in Hand Surgery and Microsurgery
Shriners Medical Center for Children Pasadena, California
Jesse B. Jupiter, MD Professor
Department of Orthopedic Surgery
Massachusetts General Hospital Boston, Massachusetts
Sanjeev Kakar, MD Professor of Orthopedics
Department of Orthopedic Surgery College of Medicine
Mayo Clinic Rochester, Minnesota
Morton L. Kasdan, MD
Emeritus Professor of Plastic Surgery University of Louisville Louisville, Kentucky
Graham J.W. King, MD, MSc, FRCSC Professor
Department of Surgery
Western University Director
Roth McFarlane Hand and Upper Limb Centre
St. Joseph’s Health Centre London, Ontario, Canada
L. Andrew Koman, MD
Professor and Chair
Department of Orthopaedic Surgery and Rehabilitation
Wake Forest School of Medicine
Executive Director
Musculoskeletal Service Line
Wake Forest Baptist Health
Winston-Salem, North Carolina
Scott H. Kozin, MD
Clinical Professor of Orthopaedic Surgery
Lewis Katz School of Medicine at Temple University
Sidney Kimmel Medical College at Thomas Jefferson University
Chief of Staff, Shriners Hospital for Children
Philadelphia, Pennsylvania
Steve K. Lee, MD
Attending Orthopaedic Surgeon
Hand & Upper Extremity Surgery
Chief
Hand and Upper Extremity Service
Department of Orthopaedic Surgery
Director of Research
Center for Brachial Plexus and Traumatic Nerve Injury
Hospital for Special Surgery
Professor of Orthopaedic Surgery
Weill Medical College of Cornell University New York, New York
Fraser J. Leversedge, MD
Professor and Chief
Section of Hand, Wrist & Elbow Surgery
Department of Orthopedic Surgery
University of Colorado School of Medicine Aurora, Colorado
Yu-Te Lin, MD, MS, FACS
Professor
Department of Plastic and Reconstructive Surgery
Chang Gung Memorial Hospital
Chang Gung University College of Medicine Keelung, Taiwan
Graham D. Lister,† MD, FRCS
Kevin J. Little, MD, FAOA
Director
Hand and Upper Extremity Center
Division of Pediatric Orthopaedic Surgery
Cincinnati Children’s Hospital Medical Center
Associate Professor
University of Cincinnati College of Medicine Cincinnati, Ohio
Dean S. Louis,† MD
Formerly Professor of Surgery
University of Michigan
Ann Arbor, Michigan
Susan E. Mackinnon, MD
Department of Surgery
Division of Plastic and Reconstructive Surgery
Washington University in St. Louis St. Louis, Missouri †Deceased.
David McCombe, MBBS, MD, FRACS
Clinical Associate Professor of Paediatrics
University of Melbourne
Consultant Surgeon
Plastics and Maxillofacial Surgery
Department
Royal Children’s Hospital Honorary Fellow
Murdoch Childrens Research Institute Melbourne, Victoria, Australia
Richard Meyer, MD
Assistant Professor of Orthopedic Surgery
Department of Orthopedic Surgery
University of Alabama–Birmingham Birmingham, Alabama
Peter M. Murray, MD
Professor and Chairman
Department of Orthopaedic Surgery Consultant
Department of Orthopaedic Surgery and Neurosurgery
Mayo Clinic Staff Physician
Department of Pediatric Orthopedic Surgery
Nemours Children’s Clinic Jacksonville, Florida
David T. Netscher, MD
Professor
Division of Plastic Surgery Department of Orthopedic Surgery
Baylor College of Medicine Houston, Texas
Christine B. Novak, PT, PhD
Associate Professor
Department of Surgery (Plastic and Reconstructive Surgery)
University of Toronto Toronto, Ontario, Canada
Mukund R. Patel, MD, FACS
Emeritus Associate Clinical Professor Orthopedic Surgery
Downstate Medical Center
State University of New York
Brooklyn, New York
Emeritus Associate Clinical Professor of Orthopedics
New York University Medical Center
New York, New York
J. Megan M. Patterson, MD
Associate Professor
Department of Orthopaedics
University of North Carolina School of Medicine
Chapel Hill, North Carolina
William C. Pederson, MD
Samuel Stal MD Endowed Professor of Plastic Surgery
Professor of Surgery, Orthopedic Surgery, Neurosurgery, and Pediatrics
Baylor College of Medicine
Head of Hand and Microsurgery
Texas Children’s Hospital
Houston, Texas
Mark E. Puhaindran, MBBS, MRCS, MMed
Head & Senior Consultant
Department of Hand & Reconstructive Microsurgery
National University Hospital Singapore
Erin Ransom, MD
Assistant Professor of Orthopedic Surgery
Department of Orthopedic Surgery
University of Alabama-Birmingham Birmingham, Alabama
Matthias Reichenberger, MD, PhD
Professor of Plastic Surgery
University of Heidelberg
Department of Plastic, Reconstructive, Hand & Aesthetic Surgery
ETHIANUM Clinic Heidelberg
Heidelberg, Germany
David Ring, MD, PhD
Associate Dean for Comprehensive Care
Department of Surgery and Perioperative Care
Dell Medical School
The University of Texas at Austin Austin, Texas
Marco Rizzo, MD
Professor
Department of Orthopedic Surgery
Chair
Division of Hand Surgery
Mayo Clinic Rochester, Minnesota
S. Raja Sabapathy, MS, MCh, DNB, FRCS(Ed), FAMS, Hon FACS, Hon FRCS (Glasgow), Hon D Sc
Department of Plastic Surgery, Hand & Reconstructive Microsurgery & Burns Ganga Hospital
Coimbatore, India
Julie Balch Samora, MD, PhD, MPH
Associate Medical Director of Quality
Attending Surgeon
Department of Orthopaedic Surgery
Nationwide Children’s Hospital Columbus, Ohio
Trajano Sardenberg, MD, PhD
Professor
Department of Orthopaedics and Surgery
Botucatu School of Medicine—São Paulo State University
Botucatu, São Paulo, Brazil
John Gray Seiler, III, MD
Partner
Georgia Hand, Shoulder, and Elbow
Atlanta, Georgia
Frances Sharpe, MD
Orthopedic and Hand Attending Department of Orthopedics
Southern California Permanente Medical Group
Fontana, California
Clinical Assistant Professor of Orthopedics Department of Orthopedics
University of Southern California Keck School of Medicine
Los Angeles, California
Alexander Y. Shin, MD
Professor of Orthopedic Surgery and Neurologic Surgery
Mayo Clinic Alix School of Medicine
Consultant
Division of Hand Surgery
Department of Orthopedic Surgery
Mayo Clinic
Rochester, Minnesota
Beth Paterson Smith, PhD
Professor
Department of Orthopaedic Surgery
Wake Forest School of Medicine
Winston-Salem, North Carolina
Thomas L. Smith, MS, PhD Professor
Department of Orthopaedic Surgery
Wake Forest School of Medicine
Winston-Salem, North Carolina
Francisco Soldado, MD, PhD
Unit Director
Upper Extremity and Microsurgery
Department of Pediatric Orthopedics
Barcelona University Childrens Hospital HM Nens
HM Hospitales & Vall Hebron Barcelona Hospital Campus
Barcelona, Spain
Nicole Z. Sommer, MD, FACS
Professor
Department of Plastic Surgery
Southern Illinois University School of Medicine
Springfield, Illinois
Robert J. Spinner, MD Chair
Department of Neurologic Surgery Professor
Departments of Anatomy, Neurologic Surgery, and Orthopedic Surgery
Mayo Clinic
Rochester, Minnesota
Scott P. Steinmann, MD Professor and Chair
Department of Orthopedic Surgery
University of Tennessee College of Medicine
Chattanooga, Tennessee
Emeritus Professor of Orthopedic Surgery Mayo Clinic Rochester, Minnesota
Milan V. Stevanovic, MD, PhD
Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
Keck School of Medicine at University of Southern California Los Angeles, California
Robert J. Strauch, MD
Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
Columbia University Medical Center New York, New York
Magnus Tägil, MD, PhD Professor
Department of Orthopedics
Lund University Lund, Sweden
Ann E. Van Heest, MD Professor
Department of Orthopedic Surgery University of Minnesota Minneapolis, Minnesota
Nicholas B. Vedder, MD
Professor & Chief of Plastic Surgery Department of Surgery
University of Washington Seattle, Washington
Fu-Chan Wei, MD, FACS
Professor
Department of Plastic and Reconstructive Surgery
Chang Gung Memorial Hospital
Kweishan, Taoyuan, Taiwan
Jennifer Moriatis Wolf, MD, PhD
Professor
Department of Orthopaedic Surgery
University of Chicago Chicago, Illinois
Scott W. Wolfe, MD
Professor of Orthopedic Surgery
Weill Medical College of Cornell University
Chief Emeritus, Hand and Upper Extremity Surgery
Attending Orthopedic Surgeon and Senior Scientist
Department of Orthopedic Surgery
Hospital for Special Surgery
New York, New York
Elaine I. Yang, MD
Assistant Attending Physician
Department of Anesthesiology, Critical Care & Pain Management
Hospital for Special Surgery
Clinical Assistant Professor
Department of Anesthesiology
Weill Cornell Medical College
New York, New York
Jeffrey Yao, MD
Professor
Department of Orthopaedic Surgery
Stanford University Medical Center
Palo Alto, California
Dan A. Zlotolow, MD
Professor of Orthopaedics
Department of Orthopaedics
Thomas Jefferson University
Attending Physician
Shriners Hospital for Children
Philadelphia, Pennsylvania
FOREWORD FOR THE EIGHTH EDITION
When I was a resident at the New York Orthopaedic Hospital 55 years ago, I thought that one day I would like to write a small book about some aspect of orthopedics. Two decades later, after collaborating with Dr. Charles Rockwood on Fractures in Adults, I swore that I would never write or edit another book—it was too much work.
Then along came Lew Reines, at that time the president of Churchill-Livingstone’s American subsidiary—and the best editor I knew in the medical publishing business—who said to me, “No, do the big book.” Perhaps forgetting my previous vow, I picked the brains of a few of my trusted colleagues and laid out a table of contents and format for the first edition of Operative Hand Surgery. That was in 1982, and over the next several decades, I enlisted the help of my dear friends and previous practice partners Bob Hotchkiss and Chris Pederson to help me edit subsequent editions. They are both keenly aware of how much I appreciate their loyalty, diligence, and support.
One reason for asking Drs. Hotchkiss and Pederson to help was that I was getting a bit tired of doing all the editing myself. Perhaps more importantly, the tiny subspecialty of hand surgery had exploded to the point where I no longer had the expertise to edit certain chapters. After finishing the fifth edition in 2005, I had finally had enough. Although writing and editing had been my favorite and most enjoyable avocation, it was time for me to quit the medical publishing business.
At that point, Drs. Hotchkiss and Pederson and I gave serious consideration to identifying a younger surgeon who could carry the rather heavy load of being the lead editor of subsequent editions. After about 6 months of deliberation, we decided that Scott Wolfe was the right person for the job, and it turned out to be a fortuitous choice. When he accepted the position, Dr. Wolfe promised me that he would give Operative Hand Surgery the attention, dedication, and priority it deserved. I am happy to say that he has fulfilled that pledge. By spearheading subsequent editions, bringing on exceptionally bright and capable new associate editors, and incorporating innovative features, Dr. Wolfe and the associate editors have continued to produce a book of the highest possible caliber. The perfect book will never be written, but from the publication of the initial Operative Hand Surgery in 1982, it has been our goal to keep trying to make it better with each subsequent edition. If we have succeeded in that objective, credit is due entirely to the editors and contributors. Writing a chapter for a textbook is one of the least rewarding tasks to which a busy surgeon can devote a huge chunk of time and energy. Fortunately for the hand surgery community, our contributors have made that sacrifice, and to all of them I remain deeply indebted.
David P. Green, MD San Antonio, Texas March 2021
As Ben Franklin said: “Tell me and I forget, teach me and I remember, involve me and I learn.” Just over four decades ago, David Green decided to commit the tenets that he and his colleagues had heard from their mentors to an enduring platform for teaching—Green’s Operative Hand Surgery. The remarkable two-volume text contained 53 chapters by 65 authors, an unprecedented compilation of the teachings of the masters of hand surgery. Though I suspect that he had no intention of writing more than one edition, the immediate success of the first book and the simultaneous wave of clinical and scientific progress in hand surgery prompted an expanded second edition 6 years later. But Dr. Green’s vision would not be complete until he could involve the learner in hand surgery. Long before the word online had today’s connotation, Green dreamed of a day when Green’s Operative Hand Surgery would no longer be a black and white, multivolume tome on the bookshelf. Instead, he foresaw a living, renewing, and mobile collection of hand surgical mentors, sharing full-color images and cases of their preferred treatment, and available to walk the learner through operative procedures with live action videos. At the time, his available bandwidth was only 56K, essentially the speed of a dial-up modem, and enough to transmit 100-character email messages on a PalmPilot or Blackberry. The dream began to materialize when the fifth edition appeared as a fully online hand surgical textbook, then expanded further with Bobby Chhabra’s and
Jonathan Isaac’s online updates in the sixth edition, and flourished with Expert Consult and its video library in the seventh edition. With internet bandwidth now over several hundred megabits per second, and the advent of 5G wireless networks, Dr. Green’s dream has become a reality in the eighth edition of Green’s Operative Hand Surgery, yielding instant access to every Author’s Preferred Treatment, over 130 surgical videos, dozens of updates on all-new topics from targeted muscle reinnervation to bionic reconstruction, and surgical “tips and tricks” available at your fingertips through eBooks for Practicing Clinicians on your cell phone or laptop.
Dr. Green’s goal in 1982 was to create a “single, comprehensive, multiauthor book dedicated primarily to operative techniques, combined with an extensive bibliography.” With each successive edition, he strived to make it better. Through the selfless efforts of our 75 international author-experts, and the intense dedication of our coeditors, we hope that Green’s will continue to hone the skills of hand surgeons worldwide by involving present and future students of hand surgery. Welcome to Green’s Operative Hand Surgery, eighth edition. Today a reader, tomorrow a leader.
Scott W. Wolfe, MD March 2021
ACKNOWLEDGMENTS
Now in its eighth edition and 40 years after its first, Green’s Operative Hand Surgery is the longest running textbook of hand surgery. Publishing a multimedia reference of this magnitude requires an enormous team effort and unanimity of purpose. I’d first like to thank David Green for his confidence in entrusting his brainchild to me and for giving me the opportunity to expand our hand educational borders across the globe. With this edition, we welcome several new international authors, who now represent over 20% of our authorship, 12 countries, and five of the seven continents, and who are emblematic of our global connectivity and the burgeoning growth of the International Federation of Societies for Surgery of the Hand. On behalf of our readership, I’d like to express an enormous debt of gratitude to each of our expert authors for their countless hours away from family and work, their exquisite attention to the details and principles of Green’s Operative Hand Surgery, and their dedication to education. Two-thirds of our authors wrote their chapters single-handedly, which, in the spirit of the inaugural edition of Green’s, gives our readers firsthand exposure to their creative thinking, surgical pearls, and technical prowess. What may be less apparent is the luster given to each chapter by our incredible editorial team, whose proficiency and dedication make Green’s the bedrock resource of hand surgery. In this edition, we welcome my longtime friend and colleague Mark Cohen, a prolific writer and exemplary educator, as our newest coeditor and elbow specialist. We are fortunate to have Scott Kozin, past president of the American Society for Surgery of the Hand and a thought leader in pediatrics and congenital hand, to edit our extensive pediatric section. Chris Pederson has contributed his expertise in microsurgical reconstruction of the upper extremity to Green’s for more than a quarter century and five editions to bring these complex chapters to perfection. Lastly, I am indebted to my trusted colleague Bob Hotchkiss, who stepped down after the last edition and who had been David Green’s first coeditor in 1990. Special thanks as well to Jonathan Isaacs, whose innovative ideas and sterling commitment have made the electronic online updates a valuable, current, and easily accessible bridge between the print editions.
I’d particularly like to thank the outstanding staff of Elsevier for ensuring the highest quality print and online publications of the eighth edition. From its inception 6 years ago, our lead content strategist Belinda Kuhn has worked seamlessly with the editorial team to integrate the print and online editions and ensure that Green’s is available everywhere you are. I’m indebted to my go-to person and senior content development specialist Rae Robertson, who choreographed the entire production from its launch to publication, gently coaxing, convincing, and cajoling our writers and editors across the finish line. Special thanks to our artists, Wendy Beth Jackelow and Richard Tibbitts, for bringing these pages to life with abundant new color illustrations, and to Daniel Fitzgerald, our production editor and Brian Salisbury, our book designer, for transforming our concepts and documents into the published multimedia finale.
Most importantly, I want to thank my three amazing children, William, Elizabeth, and Christian, for challenging me and keeping me young, and most of all my wife, Missy, who is my best friend, soulmate, historian, and trusted advisor, and whose sophistication, creativity, and wisdom inspire me every day.
Scott W. Wolfe, MD September 2021
1
Anesthesia
Elaine I. Yang
Acknowledgments: The author wishes to recognize the work of previous author Dr. Michael Gordon for his contributions to Green’s Operative Hand Surgery and to this manuscript.
There are several techniques for providing anesthesia for hand surgery. This chapter provides an overview, illustrating the risks and benefits of each. General anesthesia will be briefly discussed, and regional techniques will be addressed, as well as the unique role that regional anesthesia plays in both operative anesthesia and postoperative analgesia for hand surgery.
GENERAL ANESTHESIA
General anesthesia has long been the technique of choice for surgical procedures, using either traditional endotracheal intubation or the newer laryngeal mask airway (LMA). Considered fast and reliable, it is the standard of care at many institutions. Unfortunately, it is associated with complications because the systemic administration of anesthetic medications can cause derangements of other organ systems, including the brain, the heart, the lungs, the airways, and the gastric, endocrine, and renal systems. General anesthesia necessitates airway manipulation, which causes additional associated complications ranging from minor sore throat and hoarseness to more feared, serious complications, including laryngospasm, aspiration, or failed airway. These serious complications are relatively rare; more prevalent are the minor complications of nausea and vomiting, grogginess, or pain requiring further treatment.1
REGIONAL ANESTHESIA
Regional anesthesia is the anesthetic of choice at our institution and is especially suited to upper extremity surgery, as most patients are ambulatory. For inpatients, regional anesthesia is associated with less time spent in the recovery room, improved pain control, lower opiate consumption, and less nausea and vomiting.2 In an effort to reduce nationwide opioid use, the American Society of Anesthesiologists recommends use of regional anesthesia whenever possible.3 Regional blockade can be used alone as an intraoperative anesthetic or as an analgesic supplement to general anesthesia.
Contraindications
Absolute Contraindications
The two absolute contraindications to regional anesthesia are (1) patient refusal and (2) infection at the site of needle insertion. Often
patients refuse regional anesthesia because they have been inadequately educated or are misinformed. However, many common fears regarding regional anesthesia can be dispelled with a forthright discussion.4 For instance, patient surveys reveal concerns regarding discomfort during needle placement or awareness of the surgical procedure.5 These concerns are easily allayed with adequate premedication and sedation.
Active infection (such as cellulitis or draining wound) at the site of needle insertion is considered an absolute contraindication to regional anesthesia due to the risk of bacterial translocation from the skin to the bloodstream or nervous system. The risk is even greater with neuraxial anesthesia and continuous nerve catheters compared with a singleinjection peripheral nerve blockade. Performance of single-puncture regional techniques on patients with infection elsewhere in the body, while not supported by strong evidence, is not absolutely contraindicated but should still be approached with a thorough risk and benefits assessment.6
Relative Contraindications
Need for assessing postoperative nerve status or compartment syndrome. A successful block hinders motor and sensory conduction and negates nerve testing in the immediate postoperative period. Therefore, if an immediate postoperative assessment of nerve function is required, a regional block should not be used. Distal blocks do not, however, preclude hand function. Distal peripheral nerve blocks have the advantage of greater preservation of upper extremity motor function compared with a brachial plexus block and can be considered if the goal is early hand mobilization.7
Fear of masking postoperative compartment syndrome is another relative contraindication to regional anesthesia. Compartment syndrome is diagnosed from both subjective and objective findings including compartment pressure measurements.8 Excessive pain is the hallmark of a compartment syndrome. Pain in the postoperative period is estimated to precede neurovascular changes by 7.3 hours and can theoretically be masked by the use of nerve blockade provided for analgesia. Ischemic pain, however, is largely unaffected by regional anesthesia.9 Nonetheless, concern for the development of compartment syndrome should be conveyed prior to surgery and an appropriate pain management plan determined at that time. Appropriate vigilance is required and compartment pressures measurements mandatory if there is a suspicion for compartment syndrome, whether or not a nerve block has been performed.
Aggravating a preexisting nerve injury. Another concern is the possibility that regional nerve blockade will incite further nerve injury (double-crush phenomenon) in patients with preexisting nerve injury or paresthesias.10,11 While this is an understandable theoretical
concern, experience has shown that regional nerve blockade remains an appropriate option for patients undergoing uncomplicated procedures such as ulnar nerve transposition12 and the vast majority of elective upper extremity operations.
At our institution, most surgeons and anesthesiologists, in consultation with the patient, opt for the use of regional nerve blockade in cases of existing nerve injury or dysfunction. The demonstrated safety of newer techniques and benefit of pain control outweigh the unlikely risk of further nerve injury. It is important to discuss the advantages and disadvantages with the patient, allowing him or her to participate in decision making, especially when nerve dysfunction preexists. For patients who appear to fear further nerve injury, we often opt to use general anesthesia with local anesthesia at the surgical site to avoid adding a perceived risk and fear to an already anxious patient.
Anticoagulation therapy. A relative concern among regional anesthesiologists is performing regional blockade in patients on anticoagulation therapy. More and more patients presenting for surgery are taking anticoagulants for treatment of underlying coronary artery disease, atrial fibrillation, or cerebrovascular disease or for prevention or treatment of deep venous thrombosis.
Regional neuraxial (spinal or epidural) anesthesia does not contribute to venous thrombosis in patients. In fact, regional anesthesia has been shown to reduce the rate of blood clots following lower extremity and abdominal surgery, though this advantage has been lessened in recent years with the advent of timely thromboprophylaxis.13 Postulated mechanisms include sympathetic blockade leading to improved blood flow and decreased sympathetic stimulation, as well as a direct antithrombotic effect of the local anesthetic solution. However, neuraxial regional anesthesia is contraindicated in the fully anticoagulated patient, given the risk of epidural hematoma and subsequent devastating neural injury. Performance of deep plexus blocks in this setting, though, remains practitioner-dependent. There are case reports of retroperitoneal hematoma following deep lumbar plexus blockade in anticoagulated patients; however, the relative safety of this technique was confirmed in a large study of 670 patients who underwent continuous lumbar plexus blockade while anticoagulated with warfarin.14
In the anticoagulated patient, a perivascular brachial plexus nerve block has the potential to cause excessive bleeding. Yet several case reports document the safety of peripheral nerve blocks in the anticoagulated patient, particularly when the block is placed under ultrasound guidance.15 Despite these reassuring findings, the most recent published regional anesthesia guidelines advocate applying the same recommendations for neuraxial anesthesia to anticoagulated patients undergoing deep perivascular nerve blocks, while performance of superficial nerve blocks should be managed based on site compressibility, vascularity, and consequences of bleeding.16 Patients who have incomplete reversal of their anticoagulation with mild derangements of their coagulation panel must be approached on a case-by-case basis with ample discussion of the risks and benefits.
Bilateral procedures. There may be instances in which regional anesthesia could be used for bilateral procedures; however, there are many risks, and bilateral regional anesthesia should be avoided. The risk of drug toxicity is higher as the dose is nearly doubled. Using a lower amount to avoid toxicity raises the probability of block failure.17 The type of block also influences the risk. Interscalene nerve block commonly results in phrenic nerve paralysis,18 so bilateral interscalene nerve block is absolutely contraindicated due to the risk of respiratory failure. Even supraclavicular blockade has an estimated associated risk of transient diaphragmatic paralysis of around 50%.19 This risk combined with the associated risk of pneumothorax and the necessary high minimum effective dose makes bilateral supraclavicular blockade unreasonable. A safer alternative may be utilization of distal peripheral
nerve blockade20 or performing the blocks using low-volume, shortacting local anesthetics in sequence (i.e., performing the block on the second limb only upon completion of operation on the first limb).17,21
Relative Indications
Microvascular
Surgery Patients
Regional anesthesia with the use of long-acting blocks or continuous nerve catheter infusion for digital replantation and free flaps is considered standard practice at our institution. Continuous sympathetic blockade causes vasodilation and improves blood flow to the replanted digit(s) or free flap and reduces neurogenically mediated vasospasm.22 Improved pain control at the graft site via an effective nerve block also reduces pain-induced sympathetic-mediated vasoconstriction.23 While it remains unclear whether continuous nerve blockade results in improved graft survival,22 the safety and efficacy of peripheral nerve blockade makes it a desirable anesthetic option in microvascular surgery patients.
Patients with scleroderma and pediatric patients undergoing digital sympathectomy and microvascular reconstruction also benefit from prolonged anesthetic blockade.24,25 Finally, patients with complex regional pain syndrome who undergo corrective surgery are also likely to benefit from effective prolonged regional anesthesia.26
Pediatric Patients
Anesthesia for pediatric patients depends greatly on the age and maturity of the child and the experience of the anesthesiologist. Many techniques combine general anesthesia with regional anesthesia. Many practitioners are comfortable placing blocks in anesthetized children, especially under ultrasound guidance, though the dose of anesthetic agent and the anatomy must be carefully calculated.27 Recent data from the Pediatric Regional Anesthesia Network including more than 100,000 blocks demonstrated regional anesthesia as a safe and effective form of postoperative pain control in children with very low rates of complications.28 Ultrasound guidance allows for lower anesthetic volume in nerve blocks while preserving analgesic duration in children.29 A long-term study looking at the use of continuous peripheral nerve catheters in pediatric patients showed this technique to be a safe and effective way to provide prolonged analgesia.30
Pregnant Patients
While elective procedures are generally not performed during pregnancy, circumstances arise that require surgery. When possible, a local or regional technique should be used to minimize the effects on maternal physiology as well as to reduce the possible pharmacologic exposure of the developing fetus. Ideally, surgical procedures should be deferred to the second trimester to minimize teratogen exposure to the fetus during the critical period of organogenesis (15–56 days) and also to limit the risks of preterm labor.31 We recommend performing regional blockade more caudally along the brachial plexus to decrease the likelihood of hemidiaphragmatic paresis in a parturient.
An anesthetic plan must provide safe anesthesia for both the mother and the fetus. When surgery is unavoidable in a previable fetus, the American College of Obstetricians recommends monitoring the fetal heart rate by Doppler ultrasound before and after surgery. With regard to a viable fetus, fetal heart rate and contraction monitoring should occur before, during, and after the procedure. The patient should have given consent for emergency cesarean section, and obstetric staff should be on standby in the event of fetal distress.32
The pregnant patient has an increased cardiac output, increased minute ventilation, increased risk for gastric aspiration, and increased upper airway edema, which can increase the risk of failed intubation. Fetal safety generally relates to avoidance of teratogenicity, avoidance of
fetal asphyxia, and avoidance of preterm labor. Randomized controlled trials examining teratogenicity are not ethically or clinically feasible; however, local anesthetics, volatile agents, induction agents, muscle relaxants, and opioids are not considered teratogenic when used in appropriate dosage. Nitrous oxide is best avoided given its effects on DNA synthesis and its teratogenic effects in animals.33
Patients With Inflammatory Arthritis
Patients with inflammatory arthritis such as rheumatoid arthritis or psoriatic arthritis are especially suitable candidates for regional anesthesia for upper limb surgery as it decreases the need for airway manipulation and blunts the stress response to surgery. Patients with deformity associated with advanced rheumatoid arthritis require careful positioning on the operating room table to avoid injury to other areas of the body.
This patient population often carries a high potential for airway complications and difficult endotracheal intubation owing to cervical spine immobility, atlantoaxial instability, temporomandibular joint ankylosis, and cricoarytenoid arthritis.34 Likewise, patients with inflammatory arthritis often have cardiac and pulmonary comorbidities such as accelerated atherosclerosis and pulmonary arterial hypertension, further increasing their risk under anesthesia. Lastly, many patients in this population are prescribed antirheumatic drugs and systemic corticosteroids, which have the potential for causing immunosuppression and a decreased neuroendocrine stress response. Patients consuming 20 mg of prednisone a day for more than 3 weeks are considered at significant risk for hypothalamic-pituitary-adrenal suppression.35 These patients may require stress dose steroid coverage depending on the invasiveness and stress of the procedure, and steroid treatment should be provided in the event of refractory hypotension.
Advantages and Disadvantages (Box 1.1)
A common concern regarding regional anesthesia is the question of efficacy. Success depends on the experience and confidence of the practitioner performing the block. At our orthopedic hospital, more than 7000 upper extremity blocks are performed annually, and we are able to achieve success in 94% to 98% of patients.36,37 While regional blockade can effectively anesthetize the upper extremity and surgical site, this does not ensure patient comfort. Patients asked to lie motionless on a hard operating room bed might be apt to move to relieve discomfort in the back or knees, therefore disturbing the operative field. We place pillows to support the head and under the knees to reduce low-back strain. Even with adequate motor and sensory blockade, some patients will experience vibration or proprioception, and even vague sensations of pressure in the operative limb. Adequate anxiolysis and sedation will minimize the sensation. Access to the airway should be maintained during surgery in case the block is inadequate or other problems ensue. If the patient’s position, such as lying prone, precludes this access, preoperative securing of the airway may be a better option.
BOX 1.1 Factors Limiting Use of Regional Anesthesia
In spite of the advantages of regional anesthesia, several factors may prevent its use. Each of these problems can be overcome with appropriate planning.
• Time constraints
• Anesthesiologist’s lack of familiarity with the procedure
• Patient’s fear of anesthesia failure
• Concern about complications
• Patient’s desire to be completely unaware during the procedure
Duration of the neural blockade after single injection is variable, anywhere from 45 minutes to over 24 hours after a single injection, depending on the type of anesthetic and volume used. The duration can be extended with additives in the block solution as well as placing a peripheral nerve catheter for continuous local anesthetic administration.
Prolonged regional anesthetic blockade provides improved pain relief for immediate postoperative physical therapy and does not necessarily inhibit active participation. In a study comparing continuous patient-controlled perineural infusion (0.2% ropivacaine in a patientcontrolled opioid analgesic pump) following arthroscopic rotator cuff repair, regional anesthesia resulted in decreased use of pain medications with a comparable incidence of motor weakness.38 Similarly, selective nerves can be continuously blocked via a tunneled forearm catheter to allow for extended pain-free early active motion after hand surgery.39,40
The advantages of regional nerve block have been well demonstrated in the ambulatory surgery population. These advantages include lower pain scores, decreased nausea and vomiting, and shorter stays in the postanesthesia care unit.38,41,42 While these effects are considerable in the immediate postoperative period, ongoing studies demonstrate long-term outcome differences between different types of anesthesia.43,44 Evidence supports that in patients undergoing open reduction and internal fixation of displaced distal radius fracture, regional anesthesia provides decreased pain and improved functional outcomes at 3 and 6 months.45
Equipment and Pharmacologic Requirements
Medications commonly used in regional anesthesia are listed in Table 1.1
Regional anesthesia may be administered in a designated block room or the preoperative area, in addition to in the operating room. It is crucial to have available appropriate monitoring and resuscitation equipment, including airway management supplies and resuscitative medication, should an acute complication arise. High-flow oxygen, airway management equipment, and suction capability are crucial for emergency airway management in the event of seizure or high or total spinal block. Medications including inotropes, anticholinergics, and vasopressors should be immediately available to treat symptomatic arrhythmias, bradycardias, and hypotensive episodes. Other available medications should include benzodiazepines or propofol to treat seizures and an intralipid to treat bupivacaine-induced cardiovascular collapse (Box 1.2).46
Local Anesthetic Additives
In recent years, the use of additives in local anesthetics to increase efficacy and onset of block, as well as overall block duration, has been readily investigated.47 Historically, sodium bicarbonate has been used to increase onset of sensory and motor blockade in epidural anesthesia. Sodium bicarbonate raises the pH (alkalinization) of the solution, thereby facilitating passage across lipid membranes. When used perineurally, this advantage appears to be more unpredictable for certain types of blocks and may not be clinically significant.48 Epinephrine, on the other hand, remains one of the most widely used adjuncts for prolonging the effect of short- and intermediate-acting local anesthetics by decreasing systemic uptake of the local anesthetic through vasoconstriction. Epinephrine is also an excellent marker for detection of intravascular injection. The advantage of epinephrine as an adjunctive in long-acting local anesthetic peripheral nerve blocks is not as apparent, especially when juxtaposed with concerns of neurotoxicity in at-risk patients.49
Dexamethasone is another additive that has gained popularity in recent years because of its ability to prolong peripheral nerve blockade.
TABLE 1.1
Characteristics of Commonly Used Drugs
aHigher doses with the use of 1:200,000 epinephrine.
BOX 1.2 Prevention of Systemic Toxicity
• Avoid intravascular injection.
• Use epinephrine to slow systemic absorption.
• Use benzodiazepine as a premedication.
• Use ultrasound guidance to fractionate the dose.
Through its proposed ability to inhibit nociceptive C-fibers, dexamethasone has been used with both short- and long-acting local anesthetics in upper extremity surgeries. The reported results indicate some success, though recent randomized trials and metaanalyses suggest that this effect can be achieved just as well via intravenous administration, which has a well-characterized safety profile.50,51 While investigations into concerns for neurotoxicity with dexamethasone have not yielded conclusive results, we recommend caution when using this adjunct in patients with preexisting nerve injuries.
Alpha-2 selective adrenergic agonists such as clonidine and dexmedetomidine have an analgesic benefit when added to local anesthetics for peripheral blocks.52-54 These agents inhibit current channels that facilitate neurons to return to normal resting potential from a hyperpolarized state. Clonidine and dexmedetomidine selectively disable C-fiber neurons from generating subsequent action potentials, resulting in analgesia. Disadvantages of using these additives include dosedependent systemic effects of sedation, bradycardia, and hypotension.
Opioid agonists such as tramadol and buprenorphine are also used as additives to local anesthetics.55,56 Tramadol, which acts as a weak mu-opioid agonist while stimulating serotonin release and inhibiting reuptake of norepinephrine, prolongs blockade when given perineurally. Tramadol does not reliably have a clear advantage over intravenous (IV) or intramuscular administration.57,58 Buprenorphine, on the other hand, has been consistently shown to increase block duration and reduce postoperative analgesia when given perineurally, an effect not related to systemic absorption of the drug.59 The mechanism of action of buprenorphine is an ability to inhibit voltage-gated sodium channels in a fashion similar to local anesthetics.60 Further studies are needed to elucidate any potential neurotoxic effects of this adjunctive agent.
Finally, additives such as ketamine, midazolam, and magnesium, while showing some promise, do not have an adequately characterized safety profile perineurally to be recommended as additives to local anesthetics.61-63
Historical Techniques
Regional nerve blockade is essentially the deposition of local anesthetic near a nerve. Historically, nerve blocks were blind techniques,
performed solely based upon anatomic relationships to superficial landmarks. Practitioners noted that patients would report paresthesias as the needle advanced, leading to development of the paresthesia technique. This technique required a cooperative and conscious patient capable of providing verbal feedback, as the anesthetic practitioner would intentionally attempt to elicit a paresthesia as a means of nerve localization. Others began experimenting with the use of a nerve stimulator, applying a low-current electrical impulse through the needle near a nerve to stimulate muscle contraction.64 Studies were unable to demonstrate outcome differences.65 Nerve localization using nerve stimulation was employed to decrease actual needle-to-nerve contact and reduce nerve injury. A randomized prospective trial comparing the two techniques, however, was unable to determine a difference in postoperative neurologic symptoms.66 Another advantage of the nerve stimulator technique was decreased reliance on patient feedback and allowing the technique to be performed on sedated patients.
Ultrasound was next introduced to improve needle placement. Ultrasound allows visualization of anatomic structures, blood vessels, and nerves, as well as of the advancement of a needle and the distribution of local anesthetic.67 With satisfactory visualization of target structures, this technique does not require patient feedback and can be used safely in the sedated or anesthetized patient.68 When target structures are deep, however, needle visualization can be difficult. In such cases, it is safer to engage patient feedback whenever possible. Several studies have demonstrated the advantages of the ultrasound technique including shorter performance time, faster block onset, greater block success, and decreased dosing requirements compared with traditional techniques.69-71 For practitioners and patients, ultrasound guidance facilitates a steeper learning curve to proficiency, reduces the number of needle passes leading to decreased pain during performance, and increases patient satisfaction.72 A recent metaanalysis of 16 randomized controlled trials showed that ultrasound decreased the incidence of complete hemidiaphragmatic paresis and vascular punctures and was more likely to result in a successful brachial plexus block compared with the nerve stimulation technique.73 Despite these benefits, ultrasound-guidance does not appear to decrease the incidence of neurologic injury.36,73 Certainly, this is an area in need of further study and review as we attempt to minimize risks of anesthetic complications.
Continuous Peripheral Nerve Catheters
The use of continuous peripheral nerve catheters (CPNC) has gained favor both in the inpatient setting and the outpatient setting. Catheters have been successfully inserted along various levels of the brachial plexus depending on the desired location of blockade, from above the clavicle, such as interscalene and supraclavicular locations, to below
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