II. Indications

  1. Finger Laceration or other finger related procedure
  2. Toe Laceration or other finger related procedure
  3. Toenail Removal (in Ingrown Toenail)

III. Preparation

  1. Document digital Neurologic Exam prior to procedure
  2. Clean and prepare injection site with betadine

IV. Technique: General

  1. Prepare 27 to 30 gauge 1.25 inch needle
  2. Use 10 cc control syringe
  3. Draw up 1% or 2% Lidocaine without Epinephrine
    1. Use 4 cc for a finger and 6 cc for a toe
    2. Consider using part Bupivicaine 0.25%
  4. Precautions
    1. Aspirate before injecting (do not inject into vessel)
    2. Do not use Epinephrine
    3. Inject perineurally and not in the nerve
      1. Withdraw 2 mm if Paresthesias occur (and reinject)
  5. Technique
    1. Follow techniques per specific sites as below
  6. Post-Injection
    1. Consider small penrose drain to digit base post-block
      1. Use only for brief period
    2. Full anesthesia may require 5-10 minute wait

V. Technique: Great Toe (Three sided block)

  1. Avoid ring block (four sided) due to ischemia risk
  2. Injection sites are just distal to MTP joint
  3. Step 1: Inject lateral edge of toe
    1. Needle perpendicular to toe (straight up and down)
    2. Inject from dorsal to plantar surface
    3. Use 1-2 cc of anesthetic
  4. Step 2: Inject dorsum of toe
    1. Partially withdraw needle to tip
    2. Redirect needle across dorsal aspect of toe
    3. Inject from lateral to medial aspect of toe dorsum
  5. Step 3: Inject medial toe aspect
    1. Insert needle perpendicular to medial aspect
    2. Enter skin via area anesthesized in step 2
    3. Inject medial aspect of toe with 1-2 cc
    4. Inject from dorsal to plantar surface
  6. Alternative to Step 2
    1. Some recommend injecting plantar aspect instead

VI. Technique: Digital Block for fingers and toes

  1. Finger Web Space Block (preferred)
    1. Insert needle into web space distal to MCP
    2. Angle needle toward dorsal nerve and inject near bone
    3. Partially withdraw needle to tip
    4. Redirect needle toward palmer nerve and inject
    5. Repeat for opposite side of digit
  2. Alternative to finger web space injection
    1. Distal to web space by 1 cm
    2. Insertion at lateral margin
      1. Midway between palmar and dorsal aspects
    3. Insert needle
      1. Start perpendicular to finger and inject
      2. Redirect and inject angled toward dorsal surface
      3. Redirect and inject angled toward palmar surface
    4. Repeat for medial finger aspect
  3. Toe Digital Block
    1. Insert needle at toe dorsum distal to MTP
      1. Needle should be directly midline of toe
    2. Angle needle to one side of extensor tendon
      1. Inject from toe dorsum to plantar surface
    3. Partially withdraw needle to tip
    4. Redirect needle toward other side of extensor tendon
      1. Inject from toe dorsum to plantar surface
  4. Ring Block (not recommended)
    1. Risk of digit ischemia
    2. Inject 1-2 cc into both sides of digit at web space
      1. Inject 1-2 cc at lateral digit
      2. Inject 1-2 cc at medial digit
    3. Inject 1 cc across dorsal surface of digit
      1. Insert needle to bone, withdraw 2 mm and inject
    4. Inject 1 cc across plantar surface of toe

VII. Technique: Transthecal Digital Block (One Injection Digital Anesthesia)

  1. Indications
    1. Single injection Digital Nerve Block commonly used by hand surgeons
  2. Materials
    1. Bupivicaine (0.25%) 2-3 cc
    2. Syringe with 27-30 gauge needle (1 to 1.25")
  3. Preparation
    1. Patient rests hand in supinated position
    2. Clean and prepare finger with topical antiseptic (e.g. betadine, hibiclens)
  4. Insert needle
    1. Insert needle at volar aspect, overlying MCP crease on palmar surface in midline, over the flexor tendon
    2. Angle needle at 45 degrees toward the distal end of the finger (finger tip)
  5. Advance needle (choose one of the following techniques)
    1. Classic technique depth (into tendon sheath)
      1. Advance needle into flexor tendon sheath (withdraw several millimeters if strike bone)
    2. Modified tenchnique depth (superficial to tendon sheath)
      1. Advance needle into skin to a depth deeper than that which would raise a wheal, but more superficial than the flexor tendon sheath
      2. Follow injection (see below) with massage of the deposited Bupivicaine into the tendon sheath
      3. Cannon (2010) Emerg Med J 27(7): 533-6
  6. Injection
    1. Apply volar pressure proximal to injection site
    2. Deposit anesthetic at or superficial to tendon sheath (depending on technique above)

VIII. References

  1. Arora and Menchine in Herbert (2013) EM:Rap 13(12): 11
  2. Mandracchia (July, 1998) Hospital Medicine, p. 36-43
  3. Mortiere (1996) Wound Management, PFP Printing, p.31-3
  4. Moy in Pfenninger (1994) Procedures, Mosby, p. 148-9

Images: Related links to external sites (from Google)

Ontology: Digital nerve block in hand (C0394723)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 231154009
English Digital nerve block in hand, Digital nerve block in hand (procedure)
Spanish bloqueo de nervio digital en mano (procedimiento), bloqueo de nervio digital en mano

Ontology: Local anesthetic digital nerve block in foot (C0394756)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 231186004
English LA digital nerve block in foot, Digital nerve block in foot, Local anaesthetic digital nerve block in foot, Local anesthetic digital nerve block in foot, Local anesthetic digital nerve block in foot (procedure)
Spanish bloqueo de nervio digital con anestésico local en pie (procedimiento), bloqueo de nervio digital con anestésico local en pie, bloqueo con anestesia local de nervio digital en pie, bloqueo con anestesia local de nervio digital en pie (procedimiento)

Ontology: Digital block (C0860122)

Concepts Therapeutic or Preventive Procedure (T061)
Dutch digitaal blok
French Bloc digital
German Digitalblock
Italian Blocco delle dita
Portuguese Bloqueio digital
Spanish Bloqueo de dedos
Japanese 手指の神経ブロック, シュシノシンケイブロック, テユビノシンケイブロック
Czech Digitální blok
English Digital block
Hungarian Digitális block