Chapter 40 Lacerated Nerves
ADVANTAGES OF WALANT VERSUS SEDATION AND TOURNIQUET IN REPAIR OF LACERATED NERVES
You are able to see how much tension there is on your nerve repair with the patient′s active movement before you close the skin. You may decide to let the patient go back to work 3 to 7 days postoperatively with a relative motion flexion splint (see the relative motion flexion splint in Clip 40-1 and other videos in Chapters 35 and 36).
During surgery you will have the unhurried time to explain to the patient all of the problems of a nerve laceration. You can explain in simple terms what to expect over the next few months, including his or her ability to return to work and the best way to take pain medications after surgery. Your patient can remember and absorb all of this in a pain-free, unsedated state.
All of the general advantages listed in Chapter 2 apply to both the surgeon and the patient.
WHERE TO INJECT THE LOCAL ANESTHETIC FOR REPAIR OF DIGITAL NERVE LACERATIONS
See Chapter 1, Atlas, for more illustrations of the anatomy of diffusion of tumescent local anesthetic in the forearm, wrist, and hand.
SPECIFICS OF MINIMALLY PAINFUL INJECTION OF LOCAL ANESTHETIC FOR REPAIR OF LACERATED NERVES
Inject the anesthetic solution a minimum of 30 minutes before surgery to allow the lidocaine and epinephrine to take optimal effect and provide an adequately dry working field, as outlined in Chapters 3, 4, and 14. Inject the patient in the waiting area outside the procedure room so no time is wasted.
We inject supine patients lying down on stretchers to decrease the risk of their fainting (Chapter 6).
To minimize the pain of injection, inject with a fine 27-gauge needle (not a 25-gauge).
Ask the patient to look away. Press with a fingertip just proximal to the injection site before you put in the needle to add the sensory “noise” of pressure to decrease the pain.
Insert the first needle perpendicularly into the subcutaneous fat. Stabilize the syringe with two hands and have your thumb ready on the plunger to avoid the pain of needle wobble until the skin needle site is numb. Inject the first visible 0.5 ml bleb and then pause. Wait 15 to 45 seconds until your patient tells you that all the needle pain is gone. Inject the rest of the first 4 ml slowly (over 2 minutes) without moving the needle.
Inject the first 4 ml of 1% lidocaine with 1:100,000 epinephrine buffered 10:1 with 8.4% sodium bicarbonate in the most proximal injection point in the distal palm.
Ideally, wait 30 minutes to let the digital nerves get numb so the next injections will be pain free. Then inject 2 ml subcutaneously in each of the injection points in the subcutaneous fat in the center of the proximal and middle phalanges.