The Wrist and Hand

INJECTIONS AND ASPIRATIONS

Distal Radius Hematoma Block

Description of Procedure

Position the patient either sitting with the wrist resting on a mayo stand or supine (our preference) with the wrist comfortably by the side.
Prepare the overlying skin with alcohol, Betadine, or chlorhexidine gluconate (our preference).
Palpate the bony landmarks of the wrist noting the position of the radial and ulnar styloids and the dorsal fracture step-off. The entry site is on the dorsal of the wrist directly central on the radius at the level of the fracture.
Optional: The overlying skin is anesthetized with 2 to 3 cc of 1% lidocaine without epinephrine using a 25G to 30G needle. The use of local anesthetic is debatable. Some physicians feel it is not helpful because only the skin will be anesthetized, and a second injection is required. We do not routinely use local anesthetic prior to skin penetration. However, the needle should penetrate the skin quickly to minimize pain.
Using a 5 to 10 cc syringe with a 22G needle pierce the skin and advance the needle down to the fracture site. It is critical that the needle enter the fracture. If intact bone is felt, then walk the needle distally and proximally until it falls into the fracture.
Once the needle is in the fracture site, aspirate hematoma to confirm placement. A rush of blood will be seen. Now inject ≤5 cc of 1% lidocaine (Fig. 4-1).

Tips and Other Considerations

For the dorsally displaced fracture, always err on inserting the needle more proximal. This allows the needle to angle distally into the fracture site. If you insert the needle even the slightest bit distal to the fracture site, it is impossible to insert the needle into the fracture (Fig. 4-2).
A hematoma block is only effective for acute fractures. In our experience, the best results are obtained in fractures that are ≤3 days old. With each successive day, the efficacy of the block is reduced.
We have found that it takes at least 5 to 10 minutes for the block to work. This delayed effect is different from the near immediate effectiveness of lidocaine when infiltrated in the skin.
Use caution when injecting >5 mL of lidocaine since it may increase carpal tunnel pressure.
We do not recommend performing hematoma blocks on the volar side of the wrist.

FIGURE 4-1

FIGURE 4-2

Intra-articular Wrist Injection / Aspiration

Description of Procedure

The patient can be either seated or supine. The dorsum of the wrist is sterilely prepped.
Palpate Lister tubercle on the dorsum of the wrist. The radiocarpal joint line can be palpated as a depression just distal to Lister tubercle (Fig. 4-3).
The wrist joint has multiple compartments and depending on the pathology, you may wish to place the needle in a particular area.
- If the radiocarpal joint is desired, then position the wrist in neutral extension. Pierce the skin with a 22G to 25G needle just distal to the joint line on the dorsum of the wrist. Angle the needle 10° to 15° proximally to clear the proximal pole of the scaphoid and enter the joint (Fig. 4-4).
- If the midcarpal joint is desired, then place the wrist in a small amount of flexion (approximately 10°). Pierce the skin 1.5 cm distal to Lister tubercle (1 cm distal to your radiocarpal entry point). Your needle will enter the wrist between the capitate and the proximal carpal row (proximal scaphoid or lunate) (Fig. 4-5).

FIGURE 4-3

FIGURE 4-4

FIGURE 4-5

Tips and Other Considerations

Because the wrist is a small joint, if you encounter difficulty entering the joint, then place the patient in finger traps with 10 lb of traction (alternatively an assistant can pull traction). This opens the joint spaces, making placement easier.
In cases of trauma and infection, the dorsum of the wrist is often massively swollen. In these cases, use of fluoroscopy to mark your entry site is required.

Carpal Tunnel Injection

Description of Procedure

The patient can be either supine or seated with the volar aspect of the wrist exposed.
Determine the location of the palmaris longus tendon (if present) by having the patient press the pads of the thumb and small finger together while simultaneously flexing the wrist 30°. The palmaris longus typically lies directly over the median nerve (Fig. 4-6).
The entry point is at the distal wrist crease just ulnar to the palmaris longus. Using a 25G needle pierce the skin at this point with the needle angled distally 45° to the skin. Often you will feel the needle pierce the transverse carpal ligament with a tactile “pop” (Fig. 4-7).
Aspirate (if suppurative carpal tunnel syndrome is suspected) or inject 2 cc of 1% lidocaine mixed with 1 cc of triamcinolone (40 mg/mL). If resistance is felt or if the patient experiences paresthesias, the needle should be removed to the level of the skin and redirected more ulnarly.

FIGURE 4-6

FIGURE 4-7

First Dorsal Compartment Injection

Description of Procedure

The wrist is ulnarly deviated slightly (10° to 15°). Optional: A small bump, which maintains the wrist in slight ulnar deviation, is fashioned for the patient to rest their hand on (Fig. 4-8).
Have the patient give a “thumbs up” sign. The extensor pollicis longus and abductor pollicis brevis tendons can be seen and palpated in the first dorsal compartment. These tendons are most easily felt just distally to the radial styloid. Follow them proximally to the level of the radial styloid and, mark this point (Fig. 4-9).
With the thumb relaxed, pierce the skin with a 25G needle at the marked point. The needle should enter the skin at a 45° angle with the tip pointing distally. To avoid injection directly into a tendon slowly move the thumb; the needle should remain in the same position (Fig. 4-10).
Inject 1 cc of 1% lidocaine and 1 cc of triamcinolone (40 mg/mL). The fluid should flow easily; if resistance is met either the needle is in a tendon or not in the correct compartment. As you inject, a visual sign that the needle position is accurate is the expansion of first dorsal compartment distally.

FIGURE 4-8

FIGURE 4-9

FIGURE 4-10

Base of Thumb Carpometacarpal Joint Injection

Description of Procedure

Locate the apex of the anatomic snuffbox on the dorsoradial side of the hand. The entry site is near the apex of the snuffbox (Fig. 4-11).
Passively flex and extend the thumb to palpate the joint line. Once the joint line is located, it is easiest to enter with the thumb in flexion.
Pierce the skin and joint capsule at a perpendicular angle and administer 0.5 cc of 1% lidocaine and 0.5 cc of triamcinolone (40 mg/mL) for the treatment of arthritis or 1 cc of 1% lidocaine for anesthesia during reduction maneuvers (Fig. 4-12).

FIGURE 4-11

FIGURE 4-12

Tips and Other Considerations

This is a small joint, therefore it is helpful to have an assistant pull traction on the thumb to open the joint space or use a single finger trap (5 lb).
A 25G needle is helpful to enter this small joint.

Digital Nerve Block

Description of Procedure

STANDARD DIGITAL NERVE BLOCK

At the level of the webspace, the digital nerves are located relatively volar, just at the periphery of the flexor tendon sheath. There exist smaller dorsal nerve branches which run along the dorsal aspect of the digit.
Because the nerves are located volarly, we recommend a volar approach to the nerve in most cases, however if you only plan to work on the dorsal aspect of the digit a dorsal approach can be used.
Position the hand with the palm up and the digits extended. Palpate the flexor tendon sheath; the needle is inserted centrally over the tendon sheath.
Using a 25 guage needle, pierce the skin of the centrally over the metacarpophalangeal (MCP) joint. Angle the needle 30° toward the webspace, and inject 0.5 mL 1% lidocaine without epinephrine. Withdraw enough to redirect but not out of the skin. Redirect the needle 30° to the opposite webspace. Inject an addition 0.5 cc to anesthetize the other digital nerve (Figs. 4-13 and 4-14).

FIGURE 4-13

FIGURE 4-14

FLEXOR TENDON SHEATH BLOCK

Position the hand with the volar aspect up. Palpate the flexor tendon sheath of the digit of interest. The entry site of the injection is the same as the standard digital nerve block, centrally over the sheath at the level of the MCP joint, however the direction of the needle is different.
Using a 25G needle, pierce the skin at this point, and advance the needle perpendicular to the skin. The needle will enter the flexor tendon sheath and should be advanced until the firm endpoint of the volar plate is felt.
Withdraw the needle 1 to 2 mm and inject 2 to 3 cc 1% lidocaine. There should be minimal resistance to the injection if correctly placed. There are two ways to confirm correct placement: (1) Palpate the flexor tendon sheath distally over the proximal phalanx, and as you inject you should be able to feel a pressure wave. (2) If the needle is correctly placed as you inject, the patient will feel a rush of fluid up the digit (Figs. 4-15 and 4-16).

FIGURE 4-15

FIGURE 4-16

Tips and Other Considerations

We prefer to use a flexor tendon sheath block for all of our digital blocks. It provides excellent anesthesia of the digit with a single needle stick. We have had no failures with this technique even when working on the dorsum of the digit.
To perform a trigger finger injection, use the same technique as the flexor tendon sheath block, but inject 1 cc of 1% lidocaine mixed with 1 cc of triamcinolone (40 mg/mL).

CLOSED REDUCTIONS

Distal Radius Fracture

Indication

Closed reduction of a distal radius fracture is indicated in the initial management of displaced distal radius fractures. It should be urgently performed in the setting of median nerve dysfunction prior to surgical management. In a select group of patients, closed reduction and immobilization may be used for definitive treatment of a distal radius fracture.
We routinely perform manipulation of distal radius fractures using a hematoma block (see above) for anesthesia. The methods described are for the common dorsal displaced distal radius fracture (e.g., Colles fracture). Volarly angulated fractures (e.g., Smith fractures) are more difficult to treat nonoperatively and shear fractures (e.g., Barton fractures) are usually impossible to treat nonoperatively.

Tolerances

Radial shortening < 3 mm.
Radial inclination > 15°.
Dorsal tilt < 10°.
Ulnar variance within 2 mm of uninjured side.

Description of Procedure

A variety of techniques can be used to reduce the distal radius. The basic principle is to provide longitudinal traction while recreating the injury mechanism to realign the radius. The differences between techniques only involve the method of traction applied depending on the level of patient comfort and number of assistants available. The technique is similar in children and adults, and any differences are mentioned below.

STANDARD TECHNIQUE

After performing a hematoma block, position the patient supine with the ipsilateral shoulder at the edge of the bed. The elbow should be flexed to relax many of the forearm muscles.
An assistant grasps the arm to provide countertraction. Grasp the patient’s hand firmly around the thumb using the same side as that of the patient’s injured side (if the patient’s right wrist is fractured then use your right hand). Firmly pull toward the ceiling to provide traction (Fig. 4-17).
Place your contralateral hand dorsally just proximal to the fracture site to provide a fulcrum. As you continue to pull traction hyperextend the wrist, recreating the injury mechanism (Fig. 4-18).
To complete the reduction, slide your thumb distally over the distal fragment, and provide a firm anterior and distal force while simultaneously flexing, ulnar deviating, and pronating the wrist (Fig. 4-19).

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