In hand and wrist surgery, wide-awake surgery is favored for simultaneous evaluation of active joint movement and surgical correction. Local anesthesia is most frequently performed yet a blind technique with compromised reliability, potential systemic toxicity, and limited application. Ultrasound-guided sensory selective peripheral nerve block (SSPNB) can provide safe and reproducible wide-awake anesthesia to more invasive or extensive surgeries.
This report was approved by the Institutional Review Board of the hospital. A 57-year-old male patient (171cm; 55kg) was diagnosed with right distal radioulnar joint arthritis and ulnar impaction syndrome. After unsuccessful medical treatment, Sauve-Kapandji operation was performed under the infraclavicular brachial plexus block (BPB). The procedure was completed in the usual manner and the postoperative x-ray was impeccable, however he complained of clicking in his right wrist particularly during supination and pronation. Corrective surgery of proximal ulnar stump stabilization and screw removal was performed under infraclavicular BPB only to result in persisted snapping and request another correction. The surgeon consulted us regarding an anesthesia modality to preserve the supination during the surgery.
Ultrasound-guided SSPNB was planned. First, cutaneous sensory nerves of the medial forearm were individually examined and blocked; the medial antebrachial cutaneous nerve, the posterior antebrachial cutaneous nerve, and the sensory branches of the ulnar nerve and the median nerve. Additionally, the posterior interosseous nerve (PIN) and the anterior interosseous nerve (AIN) were independently blocked to maintain analgesia of the interosseous membrane.
After 20 minutes upon the completion of the block, cold and pain sensation were evaluated using ice and pinprick respectively to confirm the acceptability of the surgical anesthesia and the patient was asked to flip his palm facing up and down to ensure his full range of motion was practiced and the problematic clicking was represented. The surgical procedure was performed and the proximal ulnar stump stabilization was adjusted monitoring the patient’s active supination-pronation and the ECU tendon was tightly sutured to the palmaris longus tendon after confirming no further clicking presented. Neither rescue block nor additional local infiltration was required throughout the surgery. At 1 year post-initial visit, he reported no discomfort in supination and pronation.
Our study supported the adequacy of the ultrasound guided selective sensory nerve block by exercising it to more invasive surgery involving osteotomy with larger surgical field proximal to the wrist joint. Further clinical studies are warranted to provide useful groundwork for the use of the ultrasound guided selective sensory nerve block.