Perioperative Antibiotics

Although surgical site infections are rare after hand surgery, postoperative infection can be a disastrous complication in the hand, causing impairment of hand function, delaying rehabilitation and return to work. Severe infection may require multiple surgical procedures and result in permanent damage to the hand. The routine use of perioperative antibiotics for many orthopaedic procedures in the hand remains questionable. In two recent large series—one retrospective study involving 8850 patients and one prospective, randomized study involving 1340 patients—there was no significant difference in the frequency of infection in patients who received perioperative antibiotics and those who did not. The prospective study also found no difference between elective and emergency surgery, between operations lasting 2 hours and those lasting longer, or between “clean” and “crush/dirty” wounds. Even in “high-risk” patients (smokers, those with diabetes mellitus, and those with longer operative procedure times) in the retrospective study, prophylactic antibiotics did not reduce the frequency of surgical site infection. The authors of both studies concluded that antibiotic prophylaxis should not be routinely administered for surgery of the hand.

Arrangement and Routine in the Operating Room

Because surgical results depend considerably on the skill, judgment, and precise work of the surgeon, it is important to keep intraoperative distractions to a minimum. Disorganization, fatigue, and uncertainty diminish the efficiency of the operating team. It is important for the surgeon to establish a standard routine that is followed regularly (Fig. 64-1). Each assistant can then depend on this routine. The activities of the assistants in following this routine should not be disrupted by the surgeon with irregular, unexpected, or inconsistent demands. A standard routine makes it possible for assistants to know what is expected of them at each step in the operation and allows them to perform without hesitation, delay, or wasted motion.

FIGURE 64-1 Standard routine is used in operating room, regardless of procedure being performed. Light passes over surgeon’s left shoulder. Assistant’s head is 8 to 10 cm higher than surgeon’s head. Assistant holds patient’s hand firm and motionless. Basic instruments always are arranged in same order. Surgeon’s elbows rest on sturdy table, knees are almost level with hips, and feet rest flat on floor. Vertical draping prevents contamination of operative field by patient’s face or by anesthesiologist. Surgeon sits holding the back comfortably erect on a firm and stable stool.

The operating room should always be pleasant. If a local anesthetic is being used and the patient is awake, loud or inappropriate noises or bursts of conversation may alarm the patient and should be avoided. Sometimes music of the patient’s choosing is comforting.

If the surgical procedure is being arranged with the operating room staff, it is helpful to make requests regarding special needs for the case under consideration. Making advance arrangements for instruments, sutures, operating microscope, special implants, additional assistants, and other items enhances the efficiency of the operating team on the day of the procedure. Radiology support, including the use of C-arm fluoroscopy, should be arranged beforehand as well.

The operating surgeon usually sits on a firm, comfortable, and stable stool and occasionally stands for some procedures. When sitting, the surgeon’s knees are almost level with the hips and the feet rest flat on the floor without strain. The working surface of the operating hand table should be at elbow height to provide a comfortable support for the forearms. When the light is directed from above the surgeon’s left shoulder (for a right-handed surgeon), it shines directly on the operative field, and shadows are avoided.

Seated opposite the surgeon, the assistant should view the operative field from 8 to 10 cm higher than the surgeon to allow a clear line of vision without having to bend forward and obstruct the surgeon’s view. Although mechanical hand holders are available, they are not as good as a motivated and well-trained assistant. It is especially helpful for the assistant to be familiar with each procedure. Usually, the primary duty of the assistant is to hold the patient’s hand stable, secure, and motionless, retracting the fingers to provide the surgeon with the best access to the operative field (Figs. 64-2 and 64-3).

FIGURE 64-2 Assistant holds patient’s hand firm and motionless and exposes operative field for midlateral digital incision.

FIGURE 64-3 Ideal position for assistant to stabilize patient’s hand as surgeon makes zigzag incision.

The hand operating table should be stable and immobile. Space should be sufficient for the patient’s hand and for resting the elbows and forearms of the surgeon and assistant, minimizing muscle fatigue. For most procedures, the surgeon should sit on the axillary side of the involved extremity, allowing the anatomy of either hand to be seen in the same relative position. Some procedures on the dorsum of the hand and wrist may be performed more easily from the cephalic side. If the surgeon changes sides, it is important to keep in mind the change in routine to avoid anatomical disorientation.

The tray holding the basic instruments often is placed on a shelf extending from the operating table, level with the working surface. The instruments always should be arranged in the same order (Fig. 64-4). This arrangement allows the surgeon to save time by routinely reaching for instruments from the basic tray. With practice, this can be done without the surgeon looking at the instruments.

FIGURE 64-4 Basic instruments for any surgical procedure on hand. Octagonal knife handle is preferable to flat handle because knife is more commonly held by precision pinch in hand surgery. Instruments shown are knife handle, small rat-tooth forceps, dissecting scissors, small hemostats, ruler, marking pencil, double-hook Lovejoy retractors, and probe.

Using the so-called drop technique, the surgeon discards an instrument after using it, and the nurse returns it to its place on the tray. The discarded knife, tissue forceps, and dissecting scissors that are used constantly are not retrieved by the nurse, unless requested by the surgeon. Special instruments should be readily available on another large table so that they can be handed quickly to the surgeon on request. Additional knife blades and special sutures and needles also should be immediately available.

Brachial Plexus Blocks

The traditional approaches for administering anesthesia to the major components of the brachial plexus include the axillary, interscalene, and supraclavicular and infraclavicular routes (Fig. 64-5). The axillary and interscalene approaches we use most commonly probably are safer than the supraclavicular route, which carries the risk of a low incidence (1% to 5%) of pneumothorax. Infraclavicular and supraclavicular blocks are more commonly done now with ultrasound guidance. The interscalene block covers the supraclavicular nerves emanating from the third and fourth cervical roots and is ideal for shoulder surgery. Interscalene blocks can also be used for elbow surgery. Supraclavicular blocks are useful for surgery in the upper arm distal to the shoulder, whereas infraclavicular blocks can provide regional anesthesia for surgery of the elbow, forearm, wrist, and hand. An axillary block provides anesthesia similar to that of an infraclavicular block. Access to the axillary space requires the patient to abduct the arm 90 degrees, which may be difficult for those with trauma or contractures. Needle placement for brachial plexus blocks was traditionally based on anatomic landmarks and nerve localization with a nerve stimulator, but more recent approaches use an ultrasound approach. A meta-analysis of 13 studies comparing neurostimulation with ultrasound-guided blocks found that ultrasound-guided blocks were more likely to be successful, took less time, had a faster onset, and decreased the risk of vascular puncture. A study of the multiple-injection technique for axillary block showed that ultrasound guidance resulted in fewer needle passes, a shorter time to onset of anesthesia, and less procedure-related pain than nerve stimulation techniques. Limitations of ultrasound include availability, a limited plane of view, and highly operator-dependent image quality.

FIGURE 64-5 Distribution of brachial plexus blocks. A, Interscalene. B, Supraclavicular. C, Infraclavicular axillary, single injection. D, Axillary, multiple injections and high humeral block.

(Redrawn from Chelly JE, editor: Peripheral nerve block, ed 3, Philadelphia, 2008, Lippincott Williams & Wilkins.)

Short- and long-acting local anesthetic agents can be used for brachial plexus blocks. The dose depends on the agent used, the technique used, and the preference of the administering physician. Although the amount of anesthetic used is not standardized, maximal amounts have been recommended (see Table 64-1).

Complications of brachial plexus blocks are few (<1%). Reported systemic complications include cardiac arrest, respiratory failure, and seizures. Peripheral nerve injury can be caused by mechanical trauma from needles or catheters, drug neurotoxicity, ischemia, compression, or stretch, but permanent neurologic sequelae occur in fewer than 1% of patients. Pneumothorax is most common with supraclavicular blocks (as high as 6%) but has been reported with interscalene and infraclavicular blocks. Ultrasound-guided technique has been suggested to reduce the risk of pneumothorax: a prospective study found no clinically apparent pneumothoraces in 510 patients who had ultrasound-guided supraclavicular blocks.

Contraindications to axillary brachial plexus block include infection in the axilla, axillary lymphadenopathy, and malignancy.

Dysesthesias and “brachialgia” may persist after brachial plexus blocks, and the patient should understand this before the block. It also might create difficulty in patients who require fine manipulation of the hands in their occupation.

Intravenous Regional Anesthesia

The intravenous regional anesthesia technique using a double tourniquet (Bier) is useful, especially for procedures of relatively short duration (60 to 90 minutes). A specially designed double tourniquet is used. The patient should be satisfactorily premedicated, and intravenous infusion should be in place in the contralateral arm. The usual anesthetic agent is lidocaine. In most situations, 30 to 60 mL of 0.5% lidocaine provides sufficient and safe anesthesia. The dosage used should take the patient’s age and body weight into consideration. Satisfactory anesthesia can be obtained in a short time. The tourniquet is left inflated for a minimum of 30 minutes after injection of the anesthetic agent into the extremity. In the usual situation, the limb is exsanguinated; the proximal tourniquet is inflated to a level 100 mm Hg greater than the systolic pressure (usually 250 to 300 mm Hg); and, using sterile technique, the anesthesiologist intravenously introduces the previously determined volume of anesthetic agent (Fig. 64-6). As the more proximal tourniquet becomes uncomfortable, the distal tourniquet is inflated and the proximal tourniquet is deflated. Reported reactions during intravenous regional anesthesia include cardiac arrhythmias (bradycardia and cardiac arrest), unconsciousness, vertigo, and nystagmus.

FIGURE 64-6 Continuous intravenous regional anesthesia (see text).

The use of a forearm tourniquet for intravenous regional anesthesia has been suggested, with reported advantages of safety, preservation of hand motor function, lower anesthetic dose, and reduced risk of complications.

Peripheral Nerve Blocks

The median, radial, and ulnar nerves can be blocked at the elbow and wrist, and these blocks are extremely helpful for brief procedures (Fig. 64-7). A tourniquet may not be required or may be used only for a short period (usually ≤ 30 minutes). It is essential to know the location of the respective nerves before attempting regional blocks. Blocks at the wrist can be especially useful for procedures such as tenolyses and capsulotomies because motion of the fingers can be observed during surgery. The patient can be kept comfortable, and a tourniquet can be used longer than 30 minutes if the patient is adequately sedated.

FIGURE 64-7 Technique of peripheral nerve blocks. A, Ulnar nerve, superficial branch. B, Median nerve. C, Superficial radial nerve.

Digital Nerve Blocks

Digital nerve blocks provide excellent anesthesia for procedures on the fingers (Fig. 64-8). Usually, perineural injection around the digital nerves proximal to the finger web spaces is a safer technique than injection of the nerves at the base of the fingers. Because ischemia may develop after injection of an anesthetic agent in a circle around the base of the finger, this technique should be avoided. Digital blocks using a transthecal (flexor sheath) approach have shown no advantage compared with the traditional digital block technique (Fig. 64-9). We rarely use epinephrine in the local anesthetic agent in the digits, although it can be used safely.

FIGURE 64-8 Digital nerve blocks.

FIGURE 64-9 For procedures that require anesthesia from mid-middle phalanx distally (e.g., nail bed regions and distal interphalangeal joint distributions and fusions) digital anesthesia can be easily achieved by single volar injection technique. A, Just proximal to palmar digital crease through pinched skin 3 to 5 mL of local anesthetic is injected superficial to flexor sheath. B, Anesthesia achieved (colored area) from block of proper and dorsal sensory digital nerve branches. Note, if more proximal anesthesia is needed additional block can be given at metacarpophalangeal joint dorsally as shown.

If hemostasis is required, traditionally a Penrose drain or a French rubber catheter applied around the finger has provided satisfactory and safe ischemia. Commercially available finger tourniquets and the finger of a rubber glove cut to allow it to be rolled onto the finger as a tourniquet also are effective tools. Pressures achieved beneath these tourniquets cannot be determined accurately; caution is advised. At times, especially in the elderly and patients with vascular disorders in the fingers (e.g., Raynaud disease, atherosclerosis, diabetes), vascular insufficiency may develop in the digit, and care should be taken when using digital tourniquets in these patients (Fig. 64-10).

FIGURE 64-10 Broad-based finger tourniquet can be cut from Esmarch wrap, which usually accompanies upper extremity packages. A, Long and short strips 2.5 cm wide are cut from opposite sides of Esmarch bandage. B, Short strip is loosely applied across finger base and is held in place with curved hemostat. Longer strip is used to exsanguinate finger. C, Tension is applied to short section, and hemostat is applied close to dorsal skin with the two limbs of short Esmarch section fully opposed.

Local Infiltration

Local infiltration of an anesthetic agent may be used for more proximal conditions that do not require deep, extensive dissection. This method is satisfactory for trigger digit release, small scar revision, and excision of benign masses from the skin and subcutaneous tissues of the forearm, hand, and fingers.