Case series --- surgeries to maintain flexion/extension offingers Ultrasound-guided selective nerve blocks for triggerfinger DEANESTESIOLOGIA REVISTABRASILEIRA

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REVISTA

BRASILEIRA DE

ANESTESIOLOGIA

^Publicação^Oﬁcial^da^Sociedade^Brasileira^deAnestesiologia www.sba.com.br

CLINICAL INFORMATION

Ultrasound-guided selective nerve blocks for trigger finger surgeries to maintain flexion/extension of fingers --- Case series

Fernanda Moreira Gomes Mehlmann, Leonardo Henrique Cunha Ferraro

^∗

, Paulo César Castello Branco de Sousa, Graziella Prianti Cunha,

Esthael Cristina Querido Avelar Bergamaschi, Alexandre Takeda

UniversidadeFederaldeSãoPaulo(Unifesp),EscolaPaulistadeMedicina(EPM),GrupodeAnestesiaRegionaldaDisciplinade Anestesiologia,DoreMedicinaIntensiva,SãoPaulo,SP,Brazil

Received9September2017;accepted22June2018 Availableonline3November2018

KEYWORDS Selectivenerve blocks;

Ultrasound;

Flexionandextension oftheﬁngers;

Triggerﬁngerrelease

Abstract

Background: Apatient’sabilitytomovehis/herfingersduringhandsurgerymaybehelpfulto surgeonsbecauseitallowstheeffectivenessoftheinterventionevaluationandpredictionof handfunctioninthepostoperativeperiod.Thepurposeofthiscaseseriesistodemonstratethe efficacyofanultrasound-guidedperipheralnerveblocktechniquetomaintainthehandflexor andextensormusclesmotorfunctionanddiscussthebenefitsofthetechniquefortriggerfinger surgery.

Casereport: Tenpatientsscheduledtoundergotriggerfingersurgerywereselected.Thegoal wastomaintainflexionandextensionofthefingersduringtheprocedure.Thus,ultrasound- guidedulnar,radial,andmedialnerveblockwasperformedinthedistalthirdoftheforearm, at5---7cmproximaltothewrist.Theblockwasperformedwith5mLof0.375%bupivacaineon eachnerve.Allprocedureswereuneventfullyperformedmaintainingtheflexionandextension ofthefingers.Intwocases,itwasobservedthatthemotricitymaintenanceandthepatients’

abilitytomovetheirﬁngerswhenrequestedallowedthesuccessofthesurgicalprocedureafter thethirdintraoperativeevaluation.

Conclusion:Thiscaseseriesshowsthatitispossibletomaintainthemotorfunctionofthehand flexorandextensormusclestoperformfingertriggersurgeriesusingspecificultrasound-guided distalblocks.

Thisisanopenaccess articleundertheCCBY-NC-NDlicense(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

∗Correspondingauthor.

E-mail:leohcferraro1@hotmail.com(L.H.Ferraro).

https://doi.org/10.1016/j.bjane.2018.06.012

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PALAVRAS-CHAVE Bloqueiosseletivos;

Ultrassom;

Flexãoeextensãodos dedos;

Liberac¸ãodedoem gatilho

Bloqueiosseletivosguiadosporultrassomparacirurgiasdededoemgatilhopara manutenc¸ãodaﬂexão/extensãodosdedos---Sériedecasos

Resumo

Justificativa: Acapacidadedeum pacientemover osdedosduranteacirurgia damãopode serútilparaocirurgiãoporquepermiteaavaliaçãodaeficáciadaintervençãoeaprediçãoda funçãodamãonopós-operatório.Oobjetivodestasériedecasosédemonstraraeficáciade umatécnicadebloqueiodenervoperiféricoguiadoporultrassomnamanutençãodafunção motora dosmúsculosflexoreseextensores damão ediscutirosbenefícios datécnicapara cirurgiasdeliberaçãodededoemgatilho.

Relatodecaso: Foramselecionados10pacientesemprogramaçãoparacirurgiadeliberaçãode dedoemgatilho.Oobjetivoeramanteraflexãoeaextensãodosdedosduranteoprocedimento.

Dessaforma,obloqueiodosnervosulnar,radialemediano,guiadosporultrassom,foifeito noterçodistaldoantebraço,5a7cmproximaisaopunho.Obloqueiofoifeitocom5mLde bupivacaínaa0,375%emcadanervo.Todososprocedimentosforamfeitossemcomplicaçõese commanutençãodaflexãoeextensãodosdedos.Emdoiscasos,observou-sequeamanutenção damotricidadeeacapacidadedospacientesdemoverosdedosquandosolicitadopermitiuo sucessodoprocedimentocirúrgicoapósaterceiraavaliaçãointraoperatória.

Conclusão:Estasériedecasosmostraqueépossívelmanterafunçãomotoradosmúsculos flexoreseextensoresdamãoemcirurgiasdeliberaçãodededoemgatilhopormeiodebloqueios distaisespecíficosguiadosporultrassom.

Este ´eum artigo Open Access sob umalicenc¸aCC BY-NC-ND(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Introduction

Fingermotionduringhandsurgeriescanbeusefulfor sur- geonsbecauseitallowsevaluatingtheeffectivenessofthe intervention andpredicts thefunction of the hand in the postoperativeperiod.

To achieve this goal, the technique of subcutaneous inﬁltration oflocalanesthetics withepinephrinebasedon anatomicallandmarkshasbeenused.^1---4Epinephrineisused, inthesecases,todecreasebleedingandtoavoidtheintra- operative use of tourniquet. However, depending on the extentofsurgery,alargeamountoflocalanestheticshould beused,whichincreasestheriskofseriouscomplications, suchassystemicintoxicationbythesedrugs.^5,6Inaddition, inﬁltrationoflargevolumesoflocalanestheticintothesur- gical site may alter the anatomy and hinder the surgical procedure.

An option for subcutaneous inﬁltration of local anesthetic is the peripheral nerve block. Currently, with the aid of ultrasound to guide nerve blocks,it is possible to anesthetize only the terminal sensory branches and pre- serve the nerve motor function.⁷ In addition, it is known that the use of ultrasoundallows the use of smaller vol- umes of local anesthetic compared with blockades using anatomical landmarks and reduces the risk of systemic intoxication.^8,9

Theaimofthiscase seriesistodemonstratetheeffec- tiveness of an ultrasound-guided peripheral nerve block technique in maintaining the motor function of the hand flexorandextensormusclesandtodiscussthebenefitsof thistechniqueintriggerfingersurgery.

Casereport

Wereportacaseseriesof10patientswhopresentedforsur- gicaltreatmentoftriggerﬁngeronanoutpatientclinicofa quaternaryuniversityhospital.Aftergivingwritteninformed consent,allpatientsreceivedroutinemonitoringforasur- gicalprocedurewithcardioscopy,sphygmomanometer,and pulseoximeter,andaperipheralvenousaccesswasobtained inthelimbcontralateraltotheprocedure.

For finger trigger surgery, the maintenance of flexion andextension of the finger phalanges is necessary. Thus, ablockadeinvolvingtheulnar,radial,andmedialnervewas performedinthedistalthirdoftheforearm,5---7cmprox- imal to the wrist, where the probability of these nerves presentingmotor endingstotheflexor andextensormus- clesof thehandis lower.^10,11 Atthis site,theulnarnerve isvisible medially totheulnar artery,the radialsensitive branchisvisiblelaterallytotheradialartery,andthemedian nerveis visible betweentheterminalmusclefibers ofthe flexor muscles: carpi radialis, digitorum profundus, dig- itorum superficialis, pollicis longus, and palmaris longus (Figs. 1 and 2).^12,13 After skin asepsis and antisepsis with chlorhexidine,puncturesiteanalgesiawasperformedwith 1% lidocaine (1mL) and the ultrasound-guided peripheral nerveblockwith0.375%bupivacaine(5mL)oneachnerve(S Series,FujifilmSonosite,Seattle,USA).Inaddition,atthe elbowlevel,3mLof2%lidocainewereinjectedaroundthe lateralcutaneousnerveoftheforearm, duetotheuseof pneumatictourniquetinthemiddlethirdoftheforearm.

Thermal sensation evaluation was made with gauze and alcohol, testing the sensitivity of the dermatomes

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Brachioradialis muscle

Extensor carpi radialis

Flexor pollicis longus

Radial nerve – sensitive branch

Radial artery

Ulnar artery Median nerve

Anesthesia site Ulnar nerve

Flexor carpi ulnaris Superficial flexor of fingers

Palmaris longus

Figure1 Relationshipbetweenthemedian,ulnar,andradial nerveswiththeﬂexormusclesofthehandintheanteriorregion oftheforearm.Itisobservedthattheproximalthirdofthefore- armmuscles,theportionthatreceivesthemotornerveendings, isproximaltotheanestheticsite,whichismadeinthedistal partoftheforearm.

Extensor carpi ulnaris

Extensor digit minimi

Extensor indicis

Extensor pollicis longus Radial nerve – sensitive branch

Extensor pollicis brevis Extensor of fingers

Ramos profundos do nervo radial

Figure2 Relationbetweenmedian,ulnar,andradialnerves withthehandextensormusclesintheforearmposteriorregion.

Itisobservedthattheproximalthirdoftheforearmmuscles, theportionthatreceivesthemotornerveendings,isproximal totheanesthetic site,whichismadeinthedistalpartofthe forearm.

Table1 ModiﬁedBromagescale.¹⁴ Grade Deﬁnition

4 Completemusclestrengthinrelevantmuscle groups

3 Reducedstrengthbutabletomoveagainst resistance

2 Abilitytomoveagainstgravitybutnotagainst resistance

1 Discrete(shaking)movementsofmusclegroups 0 Absenceofmovement

Table2 Surgicalsite,blockadelatency,surgicaltime,and tourniquettime.

Triggerﬁngerrelease n

Secondﬁnger 2

Thirdﬁnger 6

Fourthﬁnger 2

Latency(min)^a 10±4.8

Surgicaltime(min)^a 41±5.6

Tourniquettime(min)^a 31±3.15

a Meanandstandarddeviation.

innervated by the ulnar, median, and radial nerves in the hand. In addition, for motor function evaluation, the modifiedBromagescale¹⁴(Table1)wasusedfortheflexors andextensorsofthefingers.

Thelossofthermalsensitivityoftheareascorresponding tothe blockednerves without change in motorforce was considered the criterionfor proceedingtosurgery. During theprocedure,patientsreceivedmildsedationwith1---2mg ofintravenousmidazolamforcomfort,whichdidnotinter- ferewithpatientcommunicationsothathecouldmovehis handwhenrequested.Forallprocedures,atourniquetwas usedattheforearmlevel.

All procedures were uneventful, with maintenance of flexionandextensionofthefingers,whichallowedthesur- gical procedure evaluation throughout the intraoperative period(Table2),facilitatingtheevaluationoftheresultof thesurgerythroughouttheprocedure.Thiswasparticularly importantintwocasesinwhichthemaintenanceofmotor functionandpatientcollaborationwhenmovingthe oper- atedfingerasrequestedenabledthesuccessofthesurgical procedureafterthethirdintraoperativeevaluation,which wouldnothave beenpossible ifthe patienthadnoactive motion.Onlyonecasehadfingerextensionparalysisatthe end of the procedure, which was solved after tourniquet release.

Aftersurgery, the patients wereadmitted tothe Post- AnesthesiaCareUnit(PACU)andremainedmonitoreduntil theyreachedoutpatientdischargeconditions.Whileinthe PACU, the patient postoperative analgesia was assessed usinganumericalpainscale(0=nopainand10=worstpos- siblepain)andbytotalanalgesicconsumptionondemand.

AllpatientsdidnotreportpaininPACU.Allpatientswere dischargedonthesamedayofsurgery,withouttheneedfor hospitalreadmission.

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Discussion

Maintainingthemotorfunctionofﬁngerscanhelptoevalu- atetheintraoperativesurgicaloutcomeduringsomesurgical procedures, especially for tenorrhaphy surgery, tenolysis, and trigger ﬁnger release. Forsuch, it is fundamental to understand theanatomyofmotor nerveprimarybranches andterminalnerveentrypointstomusclesofforearm.

In proximal forearm, the median nerve sends out branchestothepronator,flexorcarpiradialis,longpalmar, and superficial flexor muscles of the fingers. The ante- riorinterosseousnerve,anexclusivelymotorbranchofthe mediannerve,innervatesthedeepflexormusclesfortheII andIIIfingers,flexorpollicislongus,andpronatorquadratus.

Indistalforearm,approximately5cmproximaltothewrist, themediannerveemitsitsfirstsensorybranchknownasthe palmarcutaneousnervethatpassesexternallytothecarpal tunneltoinnervatethethenareminenceonthepalmarsur- face of the hand. In addition tothis branch, the median nervealsoemitsterminalsensorialdigitalbranchestothe palmarsurfaceofthethumb,forefinger,middlefinger,and lateral half of the annular finger and innervates the dor- salportionofthedistalphalangesoftheindexandannular fingers.

The ulnarnerve,afterpassing throughtheelbow ulnar sulcus,followsthepathtowardthehandandpassesunder the cubital tunnel (humeral ulnar aponeurotic arcade) formedbythetendonarchthatconnectsthehumeruswith thehead oftheflexorcarpi ulnarismuscle.In thecubital tunnel,theulnarnervesendsmotorbranchestotheflexor carpi ulnaris muscleand deep flexor of the IV and V fingers.Approximately 5cmproximal tothewrist,the ulnar nerveemits asensorybranch knownasdorsal ulnarcuta- neousbranch,responsibleforthesensitivityofthemedial anddorsalregionofthehand,medialportionoftheannular fingerandlittlefinger.Justbeforeenteringthewrist,near thestyloidprocessoftheulna,theulnarnerveemitsanother sensorybranch called the palmarcutaneous nerve,which supplies the cutaneous sensitivityof the hypothenar emi- nence.Theulnarnervefinallyentersthewristthroughthe Guyon’scanal,whereitdividesintoterminalmotorandsen- sorybranches.Thesensoryterminalbranchleavestheulnar nerveinside the Guyon’scanal tosupply cutaneoussensi- bilitytothepalmarsurfaceoftheVfingerandmedialhalf oftheIVfinger.Themotorterminalbranchinnervatesthe dorsalandpalmarinterosseousmuscles,IIIandIVlumbrus, andadductormuscleofthethumb.

The radial nerve,beforecrossingthe humerus posteriorly,throughthespiralorradialgroove,emitsthreesensory branches: the posterior cutaneous nerve of the arm, the lateralcutaneousnerveofthelowerarm,andtheposterior cutaneousnerveoftheforearm.Onlythendoes itcrosses from medial to lateral before entering the anterior arm compartment through the lateral intermuscular septum.

Initsdescendingpaththroughtheanterolateralportionof the arm, the radialnerve sends branches tothe brachioradialis and extensor carpi radialis longus muscles before entering the radial tunnel near the lateral epicondyle of thehumerus. The radialtunnelis formedby thehumerus posteriorly, brachial muscle medially, and brachioradialis andextensorcarpi radialismusclesanterolaterally. Within

theradialtunnel,theradialnervedividesintotwoterminal branches:posteriorinterosseousnerve,anexclusivelymotor branch,andsuperﬁcialradialnerve,anexclusivelysensory branch.

Anatomicalstudiesoncorpseshaveshownthattheprox- imal third of the forearm muscles is, in most cases, the muscular portion that receives the motor nerve endings.

Thus,the closer tothe wrist,the lowerthe likelihood of thesenerveshavingmotorendingsfortheflexorandexten- sormusclesofthehand.Therefore,adistalanestheticblock would provide a sensory anesthesia of the hand without loss of motor function of major muscle groups responsi- bleforfingerflexionandextension.Inthiscaseseries,we demonstratedthatall patientsmaintainedtheflexionand extensionoftheirfingersafterthedistalblockadeofthese nerves.

Posteriorlyinthiscaseseries,itwaspossibletoevaluate theimpactofusingatourniquetonﬁngermotricity.Itwas observed that, despite using a tourniqueton average for 30minutes, in only one case the loss of the radial motor functionwasobserved,whichwasrecoveredafterreleasing thetourniquet.

Finally,withthistechnique,itwaspossibletousesmaller volumesoflocalanesthetic,comparedwiththeanatomical landmarkstechnique,andincreasethesafetyofprocedures.

Thiscaseserieshassomelimitations.First,weconsider formotilityonlytheflexionandextensionofthefingers;for example,wedonotevaluateadduction,abduction,pinching andthumbopposition,thelattermaybecompromisedbya possibleblockadeofthenarmuscles.Inaddition,weopted fortheapplicationonlyin triggerfinger releasesurgeries.

Furtherstudiesareneededtoevaluatetheefﬁcacyofthis techniquefor other hand surgeries, suchas tenolysisand tenorrhaphy.

Inconclusion,thiscaseseriesshowsthatitispossibleto performspecificblocksinfingertriggersurgeriesandmain- tainthehandflexorandextensormusclesmotricity,which allowsthecontrol ofthemotorfunctionof theprocedure bythesurgicalteam.

Conﬂicts of interest

Theauthorsdeclarenoconﬂictsofinterest.

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