Many of these injuries happen at night and on weekends—not an ideal time to perform a repair. WALANT permits the elective scheduling of these operations in minor procedure rooms outside the main operating room Monday through Friday, 8 AM to 4 PM, after the wound is washed and the skin is closed in the emergency department. This permits patients to be sober so they can understand their injury and learn how to look after it with intraoperative teaching they can remember.

We all do better surgery at 11 AM than at 11 PM.

It is often difficult to tell which proximal tendon stumps belong to which distal tendons in a “spaghetti wrist” injury. This can be even more difficult with ragged cuts such as might happen with a table saw accident. If you ask the patient to flex the long finger, the proximal long finger profundus and superficialis tendon stumps move the most. This helps you in tendon identification and correct matching of proximal to distal structures (see Clip 34-1).

You can ask the patient to move each finger, and you will see which proximal tendons belong to which distal tendons, because comfortable tourniquet-free patients can control the movement of the proximal stumps.

You can educate your patients during the case about how important it is that they keep their hand elevated and “on strike,” doing absolutely nothing with it for the next week while the tendons heal. At the end of the procedure, they sit up and elevate their hand with total understanding of what to do. If they had been asleep, they might not understand as well what they should do after surgery. They may keep their hand dependent and are more likely to try to use their fingers and hand.

All of the general advantages listed in Chapters 2 and 32 apply to both the surgeon and the patient.

See Chapter 1, Atlas, for more illustrations of the anatomy of diffusion of tumescent local anesthetic in the forearm, wrist, and hand.