The Brazilian Perspective of WALANT in Fracture Fixation From the Hand to the Elbow

Abstract

The wide-awake local anesthesia no tourniquet (WALANT) technique is currently being used by several hand surgeons. This technique enables surgeries to be performed with the patient fully awake and without a tourniquet, thus allowing the intraoperative assessment of function. The purpose of this article was to describe our WALANT techniques for metacarpal, scaphoid, distal radius, radial head, and olecranon fracture fixation with its pearls and pitfalls. The authors demonstrate their infiltration technique, detailing how to perform it using lidocaine with 1:100,000 epinephrine and 8.4% sodium bicarbonate. The authors describe where to start the tumescent anesthesia in each type of fracture described. To achieve a painless surgery under WALANT, it is crucial to administer the subcutaneous anesthetic injection around the incision site and at the periosteum to surround the entire fractured bone circumferentially. Before making the incision, the fracture site must be manipulated and the patient should not experience any pain. As a routine in every WALANT procedure, we wait at least 25 minutes to start the surgery, as this is the optimal time interval to achieve maximal vasoconstriction within the limits of tumescent anesthesia. In all operated cases, it was possible to conduct intraoperative assessment of the range of motion of the elbow, wrist, hand, and fingers, in addition to evaluating the fixation stability through active motion and ensuring earlier rehabilitation. The wide-awake local anesthesia no tourniquet (WALANT) technique is currently being used by several hand surgeons. This technique enables surgeries to be performed with the patient fully awake and without a tourniquet, thus allowing the intraoperative assessment of function. The purpose of this article was to describe our WALANT techniques for metacarpal, scaphoid, distal radius, radial head, and olecranon fracture fixation with its pearls and pitfalls. The authors demonstrate their infiltration technique, detailing how to perform it using lidocaine with 1:100,000 epinephrine and 8.4% sodium bicarbonate. The authors describe where to start the tumescent anesthesia in each type of fracture described. To achieve a painless surgery under WALANT, it is crucial to administer the subcutaneous anesthetic injection around the incision site and at the periosteum to surround the entire fractured bone circumferentially. Before making the incision, the fracture site must be manipulated and the patient should not experience any pain. As a routine in every WALANT procedure, we wait at least 25 minutes to start the surgery, as this is the optimal time interval to achieve maximal vasoconstriction within the limits of tumescent anesthesia. In all operated cases, it was possible to conduct intraoperative assessment of the range of motion of the elbow, wrist, hand, and fingers, in addition to evaluating the fixation stability through active motion and ensuring earlier rehabilitation. Osteosynthesis of hand fractures under local anesthesia or digital block has been commonly used in hand surgery for decades.1Belsky M.R. Eaton R.G. Lane L.B. Closed reduction and internal fixation of proximal phalangeal fractures.J Hand Surg Am. 1984; 9: 725-729Abstract Full Text PDF PubMed Scopus (113) Google Scholar For more proximal fractures, the use of a tourniquet would preclude local anesthesia. With the advent of the wide-awake local anesthesia no tourniquet (WALANT) technique, more proximal fractures in the upper extremity could be addressed in a similar fashion.2Lalonde D. Wide Awake Hand Surgery. Thieme Publishers, 2015Crossref Google Scholar,3Lalonde D. Eaton C. Amadio P.C. Jupiter J.B. Wide-awake hand and wrist surgery: a new horizon in outpatient surgery.Instr Course Lect. 2015; 64: 249-259PubMed Google Scholar Brazil is a country of continental dimensions, with a great diversity in services of hand surgery, including payments and costs of medical treatments, especially between the public and private sectors. Currently, many hand surgeons are using the WALANT technique, and its use is growing every day. In public hospitals in Brazil, there is a chronic lack of available locations for elective procedures, owing to the lack of nurse and physician anesthetists, among other issues. However, surgery under local anesthesia, without sedation, an anesthetist, or tourniquet and with epinephrine to control the bleeding can be performed under a large-scale, outpatient scheme and with lower expenses than the conventional model. The literature presents several reports using the WALANT technique in upper and lower limb fractures, describing the individual characteristics and advantages of the specific fractures.4Hyatt B.T. Rhee P.C. Wide-awake surgical management of hand fractures: technical pearls and advanced rehabilitation.Plast Reconstr Surg. 2019; 143: 800-810Crossref PubMed Scopus (17) Google Scholar, 5Ahmad A.A. Ikram M.A. Plating of an isolated fracture of shaft of ulna under local anaesthesia and periosteal nerve block.Trauma Case Rep. 2017; 12: 40-44Crossref PubMed Scopus (12) Google Scholar, 6Ahmad A.A. Yi L.M. Ahmad A.R. Plating of distal radius fracture using the wide-awake anesthesia technique.J Hand Surg Am. 2018; 43: 1045.e1-1045.e5Abstract Full Text Full Text PDF Scopus (34) Google Scholar In this context, and considering the most common fractures of the upper limb below the elbow, the aim of this review was to compile and describe our WALANT techniques for metacarpal, scaphoid, distal radius, radial head, and olecranon fracture fixation with their pearls and pitfalls. The advantages of using the WALANT technique are well known. Because there is no sedation or general anesthesia, there is no need for fasting and interrupting medications before surgery (eg, antidiabetic and anticoagulants). Moreover, the patient does not need to go to a recovery room and there are no side effects of general anesthesia, such as nausea, vomiting, and pain after waking up.7Lalonde D.H. Latest advances in wide awake hand surgery.Hand Clin. 2019; 35: 1-6Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Futhermore, the possibility of actively testing joint range of motion and fracture stability are other benefits of the technique.8Gregory S. Lalonde D.H. Fung Leung L.T. Minimally invasive finger fracture management: wide-awake closed reduction, K-wire fixation, and early protected movement.Hand Clin. 2014; 30: 7-15Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar It has already been proven to be safe, efficient, and comfortable for the patients in several hand surgery articles.3Lalonde D. Eaton C. Amadio P.C. Jupiter J.B. Wide-awake hand and wrist surgery: a new horizon in outpatient surgery.Instr Course Lect. 2015; 64: 249-259PubMed Google Scholar, 7Lalonde D.H. Latest advances in wide awake hand surgery.Hand Clin. 2019; 35: 1-6Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 9Lalonde D.H. Conceptual origins, current practice, and views of wide awake hand surgery.J Hand Surg Eur Vol. 2017; 42: 886-895Crossref PubMed Scopus (110) Google Scholar, 10Neto P.J.P. de Andrade Moreira L. de Las Casas P.P. Is it safe to use local anesthesia with adrenaline in hand surgery? WALANT technique.Rev Bras Ortop. 2017; 52: 383-389PubMed Google Scholar If the surgeon keeps within the limit of 7 mg/kg of lidocaine and avoids intravascular injections, the side effects are mild, if present at all.11Lalonde D. Martin A. Tumescent local anesthesia for hand surgery: improved results, cost effectiveness, and wide-awake patient satisfaction.Arch Plast Surg. 2014; 41: 312-316Crossref PubMed Scopus (104) Google Scholar In some cases, the reduction and fixation of fractures can be performed using minimally invasive techniques in which minimal damage to the port of entry occurs. There are savings generated by shorter hospital stay, faster recovery, and lower complication rates.12Lin Y.C. Chen W.C. Chen C.Y. Kuo S.M. Plate osteosynthesis of single metacarpal fracture: WALANT technique is a cost-effective approach to reduce postoperative pain and discomfort in contrast to general anesthesia and wrist block.BMC Surg. 2021; 21: 358Crossref PubMed Scopus (2) Google Scholar,13Huang Y.C. Chen C.Y. Lin K.C. Yang S.W. Tarng Y.W. Chang W.N. Comparison of wide-awake local anesthesia no tourniquet with general anesthesia with tourniquet for volar plating of distal radius fracture.Orthopedics. 2019; 42: e93-e98Crossref PubMed Scopus (31) Google Scholar The combination of a less invasive anesthetic technique with a less invasive surgical fixation of fractures provides a better result when both techniques are performed together. On the other hand, although most patients are amenable to wide-awake procedures, it is our opinion that they should not be used when the patient does not agree or is not comfortable with this technique. Patients who are anxious or under stress may not tolerate a wide-awake procedure. Given that the patient will participate and stay awake during surgery, the surgeon should spend enough time explaining the entire procedure to the patient, making sure that he or she fully understands and agrees. On the other hand, it should be noted that this technique is not suited for everyone because not all surgeons appreciate interactive discussions with patients.14Lalonde D. Minimally invasive anesthesia in wide awake hand surgery.Hand Clin. 2014; 30: 1-6Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar, 15Huang Y.C. Hsu C.J. Renn J.H. et al.WALANT for distal radius fracture: open reduction with plating fixation via wide-awake local anesthesia with no tourniquet.J Orthop Surg Res. 2018; 13: 195Crossref PubMed Scopus (31) Google Scholar If it is anticipated that the procedure will cause pain after surgery, ropivacaine or bupivacaine can be added to the anesthetic solution, providing a long-lasting effect. Another contraindication would be peripheral vascular diseases or ischemia, which could get worse with the use of adrenaline.16Thomson C.J. Lalonde D.H. Denkler K.A. Feicht A.J. A critical look at the evidence for and against elective epinephrine use in the finger.Plast Reconstr Surg. 2007; 119: 260-266Crossref PubMed Scopus (192) Google Scholar Rarely, allergy or hypersensitivity to the components of the local anesthetics may preclude the use of the WALANT technique. Fortunately, the incidence of true allergy is less than 1%.17Speca S.J. Boynes S.G. Cuddy M.A. Allergic reactions to local anesthetic formulations.Dent Clin North Am. 2010; 54: 655-664Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Other side effects are vasovagal or “lidocaine rush,” both uncommon and transient benign side effects. If the surgeon injects the local anesthesia while the patient is laying down and explains the possible occurrence of these side effects, potential problems can be mitigated. Anesthetic solution: 40 mL of 1% lidocaine with a 1:100,000 epinephrine concentration and 4 mg of 8.4% sodium bicarbonate. Our tumescent anesthesia begins proximal to the carpometacarpal joint always using a 30-gauge needle (Fig. 1A, B ). If the surgery is simply to insert a retrograde Herbert screw through the metacarpal head, the guide wire will still extend all the way proximally to the base of the metacarpal and thus adequate analgesia proximal to the carpometacarpal joint is necessary. We continue distally with the tumescent anesthesia on the radial and ulnar sides of the metacarpal bone with a 25-gauge or 27-gauge needle (Fig. 1C). The local anesthetic can be palpated subcutaneously, and it can be seen as it expands the tissues and the skin turns white where the tumescent anesthesia has been injected (Fig. 1D). The aim is to move up to the base of the proximal phalanx. A total of 3–4 mL of the solution is injected at the fracture site and an additional 3–5 mL at the wrist to block the ulnar and/or the median nerve, depending on the fracture location. A maximum of 40 mL should be used; however, 20–25 mL is usually sufficient to cover the base of the metacarpal up to the proximal phalanx. Because local anesthesia is performed a few minutes before the procedure, the spread of the anesthetic solution is enough to not cause prolonged increase in compartment pressure. To achieve a painless surgery under WALANT, it is crucial to administer the subcutaneous anesthetic injection around the incision site and at the periosteum to surround the entire fractured bone circumferentially. Before making the incision, the fracture must be manipulated and the patient should not experience any pain. The patient is requested to keep their fist clenched throughout the procedure, as keeping all finger metacarpophalangeal joints flexed throughout the procedure aids in reduction and avoids rotational deformity. The choice of the length and the width of the intramedullary headless cannulated screw used is extremely important for the success of the surgery. The length of the selected screw must be sufficient to provide axial stability both proximal and distal to the fracture site. The width chosen must be sufficient to provide interference fit in the intramedullary canal and achieve rotational stability at the fracture site. Usually, 3.0-mm wide and 30-mm long screws are sufficient to stabilize metacarpal neck fractures. It is important that the screw provides a stable lever arm relative to the fracture, with similar lengths proximal and distal to the fracture site. Anesthetic solution: 40 mL of 1% lidocaine with 1:100,000 epinephrine concentration and 4 mg of 8.4% sodium bicarbonate. Some patients are more amenable to local anesthesia and, with less side effects (nausea, sleepiness, sore throat), it is a viable option for those patients who do not want to use a cast for several weeks but also do not want a bigger procedure. Vertically oriented fracture patterns, which are inherently more unstable, would mostly benefit from intraoperative active motion testing after scaphoid fixation. The tumescent anesthesia is initially injected proximal to the volar wrist crease and advanced distally around the scaphoid and trapezium subcutaneously (Fig. 2A ). Subsequently, 2–3 mL of the solution is injected deeper at the distal scaphoid and scaphotrapezium joint (Fig. 2B). Proximal to the wrist crease, it is possible to block the median nerve by injecting 3 mL of the solution between the palmaris longus and flexor carpi radialis tendons (Fig. 2C). Next, local anesthesia is injected on the dorsum of the wrist, starting around the Lister tubercle and then around the proximal pole of the scaphoid and laterally around the radial styloid. Finally, the radioscaphoid joint is injected with 2–3 mL of the anesthetic solution (Fig. 3).Figure 3Tumescent anesthesia dorsally starting around Lister tubercle delineated with the marking pen If the surgeon to perform an fixation, the and and joints are with mL of the solution on each Anesthetic solution: mL of lidocaine with epinephrine concentration and 3 mg of 8.4% sodium bicarbonate. can be performed with this technique in patients and patients who use a It is important to that this anesthetic technique does not other procedures, such as it to the If a volar is the volar incision site is and the tumescent anesthesia is all around the site (Fig. ). Next, the fracture is with a 25-gauge needle (Fig. We then with the periosteal block from the side (Fig. all around and volar periosteum from proximal to distal in a and using 2–3 skin We continue from the side and the periosteal The under the should also be with local This periosteal block is critical to the success of local the surgeon must that the entire radial periosteum is with the anesthetic must to the around the ulna if an ulnar fixation. The of or screw guide from a radial fixation may the ulna and cause pain and that should be anticipated the ulna if The advantages intraoperative assessment of the range of motion of the wrist, hand, and of fixation stability through active earlier and allowing to the of the volar with the flexor tendons the flexor thus possible or to or when the is as by et Leung A. and flexor Surg Am. PubMed Scopus Google all fractures are amenable to volar and some of the fixation would benefit from an active range of motion this fixation to to fracture, or characteristics the more distally to stabilize the volar ulnar for Anesthetic solution: mL of lidocaine with a epinephrine concentration and 3 mg of 8.4% sodium bicarbonate. We a incision on the proximal ulna to approach the olecranon proximal however, the tumescent anesthesia should be injected all the way from the proximal ulna to distally because of the intramedullary screw The for the tumescent anesthesia is as in Moreover, we always both the periosteum and the fracture site (Fig. We start by injecting the tumescent anesthesia with a 30-gauge needle proximally and then continue in the subcutaneous with a 25-gauge We the entire with mL of local anesthesia. Subsequently, the fracture site (Fig. and the periosteum of the proximal ulna (Fig. are also all the way from the proximal to the distal of the to local anesthesia. It is extremely important to the needle to the especially proximally and We the ulnar nerve to that the needle is from the ulnar nerve block may because the anesthesia and this should be to the The ulna has a thus we at least bone as in is when the fracture site with local anesthesia. mL of the solution is injected the periosteum and fracture site. As a routine in every WALANT procedure, we wait at least 25 minutes to start the surgery, as this is the optimal time interval to achieve maximal vasoconstriction within the limits of tumescent Lalonde D.H. A. time between epinephrine injection and incision to Reconstr Surg. PubMed Scopus Google Scholar Anesthetic solution: 40 mL of 1% lidocaine with a 1:100,000 epinephrine concentration and 4 mg of 8.4% sodium bicarbonate. Tumescent anesthesia is to the and distally (Fig. ). The is infiltration with mL of the solution (Fig. the radial is the ulnar should be with 2–3 because if the guide wire of the cannulated or the the ulnar the patient usually some The WALANT technique is currently being used by a of hand surgeons. This technique enables surgeries to be performed with the patient fully awake and without a tourniquet, thus allowing the intraoperative assessment of function. and metacarpal fractures with rotational are great the need for the of the and stability of the osteosynthesis is The benefits of the technique effects of general anesthesia and the reduction of the surgery anesthesia are with in of and However, a block a and in Brazil we a few that do not perform this anesthetic technique. local anesthesia performed by the surgeon is an option when the general anesthesia is the A literature reports the use of WALANT technique for specific fracture surgery of the upper its and The aim of this article was to present our and demonstrate our infiltration technique from metacarpal fractures in the hand to olecranon fractures at the elbow, detailing how to perform The tumescent anesthesia of injecting of lidocaine solution with epinephrine the subcutaneous to the that will be at the surgical can be by the vasoconstriction of the in fractures of the metacarpal et S. Lalonde D.H. Fung Leung L.T. Minimally invasive finger fracture management: wide-awake closed reduction, K-wire fixation, and early protected movement.Hand Clin. 2014; 30: 7-15Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar and S.G. J.B. and the wide-awake approach for metacarpal Plast Surg. 2014; 41: Full Text Full Text PDF PubMed Scopus Google Scholar and B.T. Rhee P.C. Wide-awake surgical management of hand fractures: technical pearls and advanced rehabilitation.Plast Reconstr Surg. 2019; 143: 800-810Crossref PubMed Scopus (17) Google Scholar and P.C. The current and possible of wide-awake local anesthesia no tourniquet hand surgery in Clin. 2019; 35: Full Text Full Text PDF PubMed Scopus Google Scholar that among the benefits of phalangeal and metacarpal fracture closed reduction and fixation of using the WALANT technique is a range of motion during the intraoperative the patient to and extend the fingers, it is possible to the of there is stability of the fracture and that there is no between the osteosynthesis and the skin or then safe, in faster recovery and of function. If the fixation all there should be no in any fracture fixation. The use of active by the local anesthesia, to with a fixation and B.T. Rhee P.C. Wide-awake surgical management of hand fractures: technical pearls and advanced rehabilitation.Plast Reconstr Surg. 2019; 143: 800-810Crossref PubMed Scopus (17) Google Scholar that the 3 most common for the of the WALANT technique are of anesthetic solution, not injecting the anesthetic solution in all possible that to be addressed by or of and time between anesthesia and the of the surgical procedure. the authors a time of minutes before starting the surgical procedure. the use of wide-awake anesthesia in fractures of the distal of the radius, et Y.C. Hsu C.J. Renn J.H. et al.WALANT for distal radius fracture: open reduction with plating fixation via wide-awake local anesthesia with no tourniquet.J Orthop Surg Res. 2018; 13: 195Crossref PubMed Scopus (31) Google Scholar of fracture of the distal extremity of the radius operated between and patients to open reduction internal fixation using the WALANT technique with a volar and 3 with a the anesthetic technique, they 3–5 mL of 1% lidocaine in the fracture dorsally and mL at the incision site or A of minutes was before the surgical procedure. using a volar when the was they mL of the anesthetic For the an infiltration of mL of the solution was performed in the of the and in the periosteum between the and of the patient not tolerate the procedure using the WALANT technique and anxious during subcutaneous We the that there are some patients who will not be amenable to local anesthesia for this fracture fixation surgery, and the surgeon to that to Patients who are extremely anxious and do not to stay awake are not are and the patient does not We that the performed by the surgeon are and should be in the of an In some cases, such as olecranon and distal radius, the patient has to be to a sedation or general anesthesia fasting and testing as The use of WALANT for surgical fixation of fractures can be the hand and wrist, and fractures also present this Ahmad et A.A. S. Ahmad A.R. Wide-awake anesthesia for olecranon fracture 2021; PubMed Scopus (17) Google Scholar a safe, and anesthetic technique with WALANT for olecranon fracture fixation. a total of mL of subcutaneous local anesthesia was using a 27-gauge needle the skin Subsequently, of local anesthesia was injected for the of painless surgery during reduction and plating of the olecranon The between each injection was In 40 mL of the solution was with mL at the subcutaneous and mL at the In our WALANT technique for olecranon fracture we used more of the anesthetic solution, because we to more for this if we to lidocaine in as we There is a when these fracture fixation surgeries under who to start using these techniques should start with cases, such as and with in the of an is especially in in which there is a possibility that the need for sedation is Another is the possibility of The surgeon must be to use however, when the solution of lidocaine and adrenaline is 25 minutes to the procedure, this should not be a fractures in our could be with minimally invasive the fracture and the the of and has minimal interference with the of bone the of the pain control and minimal bleeding during surgery under the of lidocaine and adrenaline in all of minimally invasive osteosynthesis techniques reduction in postoperative reduction in the to and a better There is the possibility of the patient during the surgery, allowing in early range of motion and better rehabilitation.

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