Digital Block

1. See Also
   1. Local Skin Anesthesia
   2. Lidocaine Local Skin Anesthesia (Xylocaine)
   3. Lidocaine-Epinephrine-Tetracaine (LET Anesthesia)
   4. EMLA cream
2. Indications
   1. Finger Laceration or other finger related procedure
   2. Toe Laceration or other finger related procedure
   3. Toenail Removal (in Ingrown Toenail)
3. Preparation
   1. Document digital Neurologic Exam prior to procedure
   2. Clean and prepare injection site with betadine
4. 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
5. 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
6. 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
7. References
   1. Mandracchia (July, 1998) Hospital Medicine, p. 36-43
   2. Mortiere (1996) Wound Management, PFP Printing, p.31-3
   3. Moy in Pfenninger (1994) Procedures, Mosby, p. 148-9