Background and aims In hand trauma the first indication lies on axillary brachial plexus anesthesia. However, many patients report discomfort by loss of identity of the limb. Distal hand block eliminated this discomfort with motor maintenance, useful in tendon sews.1 The digital ‘gradient of pressure’ (GOP) was used in four cases.
Methods Male patient, 28 years-old, ASA I, had his hand detonated by an explosion (figure 1). At the hospital under scalene brachial block carried out by the anesthesiologist on duty, the entire limb resulted numb. During stay at the Infirmary multiple cleanings were required with IV morphine, triggering tolerance. A new debridement was necessary under general GA. In the recovery room, with pain NPS=8, patient refuted new numbed limb consenting to analgesia of the hand with single 6 ml, 2% of lidocaine at each distal involved nerve (figure 2).The GOP technique was used in both median and radial nerves.
Results The medial nerve run between the pronator teres and flexor digitorum superficialis muscles and the radial nerve between the brachial and brachioradial muscles (figure 2). Both were blocked in the fascial muscle spaces. We observed latency, 20 min; analgesic time, 9 hours; unaffected digital movements.
Conclusions Both GOP and LOR techniques are useful when PNS and US are not available. They are based on superficial and deep anatomic references and by anesthesiologist’s digital feeling when the needle identifies sudden absence of resistance (epidural space) or decrease of resistance (fascial spaces), respectively. Surgical tendon sewing under analgesia with the preserved movements may be useful to the plastic surgeon.3
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