ANESTHETIC	MAXIMAL RECOMMENDED DOSE
Bupivacaine	2.5 mg/kg
Bupivacaine with epinephrine	3.0 mg/kg
Levobupivacaine	2.0 mg/kg
Levobupivacaine with epinephrine	3.0 mg/kg
Ropivacaine	2.0 mg/kg
Ropivacaine with epinephrine	3.0 mg/kg

^*These amounts should be used as a guideline only; practitioners should use their clinical judgment when administering local anesthetics.

Modified from Bruce BG, Green A, Blaine TA, Wesner LV: Brachial plexus blocks for upper extremity orthopaedic surgery, J AAOS 20:38, 2012.

Unsatisfactory anesthesia for hand and upper extremity operations prevents the surgeon from accomplishing his or her goals and is likely to compromise the surgical result. For accurate and precise work, the part must be motionless, the procedure should be completely painless, and the patient should be comfortable. All anesthetic techniques carry some risks, and the selection of the technique depends on the needs of the patient and the preferences of the surgeon and anesthesiologist. The selection should be part of the preoperative planning.

At times, general anesthesia is preferred. Factors that favor the use of this type of anesthesia include extensive and prolonged hand and upper extremity operations, performance of procedures on other parts of the body (chest or abdomen or harvesting of various tissue grafts), extensive operations in young children, the presence of infection in a region that would preclude injecting a local anesthetic agent, and the preference of a particularly uneasy or anxious patient.

Regional anesthesia has many advantages in hand and upper extremity surgery. Satisfactory regional anesthesia can be achieved for emergency procedures performed on patients with a full stomach; in these situations and in elective operations, a regional anesthetic blocks vasoconstrictive afferent impulses from the surgical wound and avoids some of the unpleasant postoperative complications of general anesthesia. Outpatient surgery can be performed safely using regional anesthetic blocks, which reduce the need for postoperative nursing care. A regional anesthetic may allow operations to be done on the hand and upper extremity in patients with unstable cardiac or severe pulmonary or renal problems that would create an increased risk with general anesthesia.

Regional anesthesia is less satisfactory in children or extremely nervous, anxious, or uncooperative adults. It should be avoided in patients with documented, true allergies to local anesthetic agents and in patients taking anticoagulants. A regional anesthetic agent may be difficult to administer in patients with contractures or involvement of joints that limit positioning of the limb for satisfactory blocks and in patients whose veins or blood pressure elevation do not allow the use of the intravenous technique. Care should be taken when administering regional anesthetic agents to avoid complications such as overdosage, intravascular injection (when doing nerve blocks), pneumothorax (when doing supraclavicular brachial plexus blocks), and the dissemination of infection.

For operations on the hand and upper extremity, four methods of regional anesthesia are in widespread use: (1) brachial plexus blocks using the interscalene, axillary, or supraclavicular approach; (2) intravenous regional blocks; (3) peripheral nerve blocks distal to the axilla, including blocks of the median, radial, ulnar, and digital nerves; and (4) local infiltration of anesthetic agents. It is helpful to have the patient satisfactorily sedated before surgery. In many situations, especially in elective surgery, simple nerve blocks at the wrist or fingers require little premedication. The use of regional anesthesia requires that sufficient time be allowed in the immediate period before surgery for preparation of the patient, for the administration of the regional anesthetic agents, and for the anesthetic to become effective before the skin incision is made.

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.

Preparation and Draping for Elective Surgery

Regardless of the procedure, the method of preparing and draping the upper extremity and hand should be the same. This helps to standardize the routine and allows movement about the operative field while minimizing the risk of bacterial contamination. The preparation of other areas for graft donor sites varies depending on the requirements of the procedure. If skin, tendon, bone, nerve, or other grafts are required, the patient should be positioned to allow easy access to the specific areas. Care should be taken to pad and protect neurovascular structures. The electrocautery grounding pads should be attached in a safe and secure manner. Usually, the hand and forearm are scrubbed before the time of the surgery. The hair is removed with electric clippers from the areas where skin incisions will be made on the hand, forearm, and elsewhere as needed; this often is done before the patient is transported to the operating room. A well-padded tourniquet is applied to the arm or the forearm, depending on the surgeon’s preference; however, it is not inflated until all preparations have been completed (unless a Bier block is being used). After the patient has been satisfactorily anesthetized, the hand and forearm are scrubbed by an assistant while the surgeon scrubs his or her own hands. The surgeon puts on gloves and prepares the skin with an antiseptic solution of choice. Iodophor soaps and skin preparation solutions and combinations of chlorhexidine and alcohol have been found to be effective (Table 64-2). Wetting the padding beneath the tourniquet with these solutions should be avoided to minimize skin reactions. A waterproof sheet is placed on the well-padded hand surgery table, followed by a sterile drape-sheet. Combinations of sterile towels and sheets are applied, leaving exposed the upper extremity and hand and other areas that may require access during the operation. The gloves used in preparation of the surgical field are removed, and the surgeon dons a gown and gloves and sits down, usually on the axillary side of the forearm. The operating lights are adjusted, and the skin incisions are outlined.

TABLE 64-2 Antiseptic Solutions

Alcohol	Good immediate skin disinfectant, but dries quickly and has less long-term effect
Alcohol	95% alcohol better than 75% because of dilution by moist skin
Hexachlorophene (pHisoHex)	Forms a film that retains bacteriostatic properties
	Easily washed off
	Requires multiple applications to be effective
	May be toxic in infants
	Effective against gram-positive organisms; less effective against gram-negative organisms
Iodine	Side effects
Alcoholic (tincture)	Frequent skin irritation (can be lessened by adding iodine)
Aqueous (Lugol’s solution)	True allergic reactions
Iodophors (povidone-iodine [Betadine])	Advantages over iodine
Iodine and polyvinyl pyrrolidine or povidone	Slower release of iodine
	Fewer skin reactions
	Effective against gram-negative and gram-positive organisms
Chlorhexidine (Hibiclens) 70% alcoholic solution	Some studies have shown it superior to Betadine and pHisoHex
Chlorhexidine (Hibiclens) 70% alcoholic solution	Repeated washings may have a cumulative effect

Adapted from Green DP: General principles. In Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, editors: Green’s operative hand surgery, ed 6. Philadelphia, 2011, Elsevier.