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CASE REPORT
ULTRASOUND GUIDED SELECTIVE NERVE BLOCKS IN THE
MANAGEMENT OF HAND INJURY: A CASE REPORT
N. Mariappan1, S. Saravana Kumar2
HOW TO CITE THIS ARTICLE:
N. Mariappan, S. Saravana Kumar. ―Ultrasound Guided Selective Nerve Blocks in the Management of Hand
Injury: A Case Report‖. Journal of Evidence based Medicine and Healthcare; Volume 1, Issue 11, November
17, 2014; Page: 1430-1435.
INTRODUCTION: Regional anesthesia has proved to be very useful in ambulatory upper limb
surgery. This technique along with ultra-sonogram guide has refined the whole concept of
peripheral nerve blocks. Peripheral nerve blocks have proved to be a valuable tool for the
anesthetist. With more number of day-case surgeries being done now the ultrasound guided
regional anesthesia (USRA) are being used with great success, comfort and safety to the
patients.[1] Ultrasound-guided brachial plexus blocks, ultra sound-guided ankle blocks, femoral
and sciatic nerve blocks have been reported in many studies. In our day to day practice the
peripheral nerve blocks under ultra sound guide are effective in trauma of the extremities,
diabetic foot patients for surgical procedures, in the management of chronic pain in the distal
parts and in a variety of hand surgeries.[2] The main advantages are comfort to the patient, cost
effectiveness and good post-operative analgesia. The procedure can be safely performed in
patients with medical problems and in patients who are otherwise high risk for general
anesthesia.
KEYWORDS: Peripheral nerves blocks, ultrasound guided hand injury, permanent pacemaker
Anesthesia, Analgesia.
CASE REPORT: A 34 years old male patient with Idiopathic ventricular tachycardia with a
pacemaker implanted 2 years back presented to us with assault injury to his right palm. The
wound was sutured elsewhere for control of bleeding. The wound suturing was not acceptable
and there was some necrosis of the skin edges. Clinically there was no injury to the deeper
structures. It was planned to do exploration, debridement and skin suturing.
A basic workup investigation was done. The patient had a checkup for the permanent
pacemaker (PPM) two weeks before the injury. Cardiologist opinion was obtained along with an
echocardiogram.
The patient was assessed by the anesthesiologist. It was decided to do the surgery under
selective nerve blocks, continuous ECG monitoring and to avoid the use of diathermy in
monopolar mode. If need be bipolar diathermy can be used with short bursts of energy. The
procedure was planned as a day-case surgery and to discharge the patient after a period of
observation.
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CASE REPORT
Fig. 1: Pre-operative and intraoperative pictures
Fig. 2: ECG shows left bundle branch block
Anesthesia procedure: The anesthesia procedure was explained to the patient in view of his
cardiac status and consent was obtained. With the patient in supine position with arm abducted
and supinated skin preparation was done. A higher frequency 12 MHZ linear transducer was used
which showed the nerves in short-axis view with hyper echoic with honey comb texture.
Fig. 3: The anesthesia procedure under ultra sound guide a) ulnar nerve
b) median nerve and c) both ulnar artery and ulnar nerve seen in the center
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CASE REPORT
An in plane approach was used. The median nerve was blocked in the mid forearm and
the ulnar nerve was blocked at the junction of the upper and middle third of the forearm. The
nerves are identified as round to slightly elliptical structures and the local anesthetic agent
injected in a circumferential fashion around the nerves.
Table 1: The volume of drugs injected for blocks and the duration of action.
For ulnar nerve block
Agent
concentration
volume
onset
duration
ropivacaine
0.5%
8 ml
5 min
4 hours
For median nerve block
Agent
Concentration
Volume
Onset
Duration
ropivacaine
0.5%
8 ml
7 min
4 hours
ECG monitoring was continued throughout the surgical procedure and also in the post operative period. No other analgesics or sedatives were administered.
Surgical procedure: After waiting for a period of 10 minutes following the block, the limb was
thoroughly prepared and draped. All the sutures were removed; the wound edges were debrided
and through wash were given. Exploration was done. There was partial injury to the superficial
fibers of the hypothenar muscles. All the other deeper structures were found to be intact. The
injured muscles were repaired with 4-0 vicryl sutures. The skin was sutured with 4-0 ethilon and
a drain was kept. Duration of surgery was 45 minutes. Care was taken not to use diathermy
during the surgery. Dressing was done and the limb was kept elevated.
Fig. 4: Post-operative picture
Patient was kept on ECG monitoring for 6 hours and was discharged in the evening. The
patient was prescribed antibiotic and paracetamol for pain, if needed. Patient was explained
about the insensate limb for few hours and the need to protect against heat or pressure.
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CASE REPORT
Review of the patient next day showed he was free of post -operative pain for almost 10
hours. There was no need to use analgesics for pain control. ECG showed no abnormalities.
Healing of the wound was uneventful.
DISCUSSION: The advantages of regional blocks are well documented. Peripheral nerve blocks
were performed by landmark based techniques or neuro-stimulation techniques.[3] Using ultra
sonogram, nerve blocks are done with much lesser volume of drug is placed circumferentially
around the nerve.
Advantages:
 Faster sensory onset
 Greater block success rate
 Lesser dose of drugs used
 Avoids complication of hematoma formation and damage to the nerve.
 Effective post-operative analgesia
 Can be combined with general anesthesia if the duration of surgery is prolonged, Not
associated with post-operative nausea or vomiting (PONV) Can be safely used in patients
with risk of respiratory depression.
 Saves hospital stay costs. This type of anesthesia procedure is cost-effective alternate to
general anesthesia[4, 5]
 Complications like pneumothorax and intravascular injection are avoided.
Contraindications include:
 Patient refusal
 Allergic to local anesthetic drug
 Infection at the site of proposed injection
 Preexisting neuropathy
 Patients on anticoagulant therapy
Patients with permanent pacemakers pose a special risk for both elective and emergency
surgeries. The following protocols are to be followed in such patients
For elective surgery
 Establish whether the device is complex
 Cardiologists review if not checked in the last 3 months for the status of PPM
 Use bipolar diathermy with short bursts of energy
 If the operative field is greater than 50 centimeters interference is unlikely. But ECG
monitoring must be continued.
In case of emergency surgical procedures
 Follow the instructions as for elective surgery
 ECG monitoring
 Make availability of a defibrillator with external pacing functions
 Early Post-operative checkup for the pacemaker.
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CASE REPORT
CONCLUSION: The use of ultra sound-guided peripheral nerve block has been an effective tool
for an emergency situation in a patient with a cardiac pacemaker. The procedure can be applied
to most of the surgical procedures in the extremities.[6,7,8] This procedure shortens block
performance time, reduces the number of needle passes, shortens the block onset time and
lesser dose of local anesthetic drugs used.[9,10,11] This case is reported since the patient had a
pacemaker and was in an emergency situation which was managed comfortably with ultrasoundguided nerve block technique.
REFERENCES:
1. Hammons T, Piland NF, Small SD, Hatlie MJ, Burstin HR. Ambulatory patient safety. What
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really worth it? Best Pract Res Clin Anaesthesiol 2002; 16: 145–57
4. Schlosser RJ, Nielsen KC, Evans H, Klein SM, Tucker MS, Steele SM. Peripheral nerve blocks
for outpatient surgery. In: Hadzic A, ed. Textbook of Regional Anesthesia and Acute Pain
Management. New York: McGraw Medical, 2007; 889–902
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blocks. Reg Anesth Pain Med 2010; 35: S10–5
6. Klein SM, Nielsen KC, Greengrass RA, Warner DS, Martin A, Steele SM. Ambulatory
discharge after long-acting peripheral nerve blockade. Anesth Analg 2002; 94: 65–70
7. Sadashivaiah JB, John JC. Feasibility and cost effectiveness of ultrasound guided
supraclavicular brachial plexus block as the sole anaesthetic technique for hand surgery. J
One-Day Surg 2008; 18 (Suppl): A15
8. McCahon RA, Bedforth NM. Peripheral nerve block at the elbow and wrist. Contin Educ
Anaesth Crit Care Pain 2007; 7: 42–4
9. Tedore TR, YaDeau JT, Maalouf DB et al. Comparison of the transarterial axillary block and
the ultrasound-guided block for upper extremity surgery: a prospective randomized trial.
Reg Anesth Pain Med 2009; 34: 361–5
10. Eichenberger U, Stockli S, Marhofer P et al. Minimal local anesthetic volume for peripheral
nerve block. A new ultrasound guided, nerve dimension-based method. Reg Anesth Pain
Med 2009; 34: 242–6
11. Guerri-Guttenberg RA, Ingolotti M. Classifying musculocutaneous nerve variations. Clin Anat
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CASE REPORT
AUTHORS:
1. N. Mariappan
2. S. Saravana Kumar
PARTICULARS OF CONTRIBUTORS:
1. Consultant Plastic Surgeon, Department of
Plastic Surgery, K. M. Hospital,
Madhavaram, Chennai.
2. Assistant Professor, Department of
Anaesthesia, Stanley Medical College,
Chennai.
NAME ADDRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Dr. N. Mariappan,
# 50, Janakiraman Street,
Kuppu Reddy Nagar,
Korattur, Chennai-600080.
E-mail: [email protected]
[email protected]
Date
Date
Date
Date
of
of
of
of
Submission: 23/10/2014.
Peer Review: 24/10/2014.
Acceptance: 10/11/2014.
Publishing: 14/11/2014.
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Page 1435