A Review of Hand Neuroanatomy, Anesthesia, and Bedside Blockade

Many hand-related pathologies can be appropriately managed at the bedside without operative escalation, thereby reducing resource allocation, healthcare costs, and exposure to general anesthesia. Plastic surgery trainees have variable experience and knowledge in managing hand pathologies outside the operating room. A comprehensive clinical reference for hand anesthesia has yet to be seen in the current plastic surgery literature. This review aims to guide the safe and effective administration of regional anesthesia in the hand and wrist for bedside procedures. This review was guided by clinical experience at a high-volume Level I trauma center in the Northeastern United States. A board-certified hand surgeon and plastic surgery residents discussed practical skills and concepts commonly applied to hand procedures performed in the emergency department. A review of the literature was performed, investigating anesthetic agents, considerations for use, neuroanatomy of the hand, and versatile blockade techniques. In contrast to local infiltration, nerve blockade reaches deeply innervated structures while avoiding multiple painful injection sites, tissue distortion, and wound contamination. Nerve blocks are discouraged in patients who are unable to communicate symptoms of intraneural injection. However, bedside nerve blocks in awake children achieve high efficacy and low complication rates, particularly when ultrasound-guided injection or sedation is employed. Local anesthetic systemic toxicity can be avoided through knowledge of anatomical landmarks, anesthetic characteristics, and appropriate dosing. The hand has complicated yet predictable neurovascular anatomy. With proper anesthetic administration, a remarkable degree of patient comfort and a high level of procedural complexity can be achieved outside the operating room.