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Transthecal digital block: Flexor tendon sheath used for anaesthetic infusion
Vol. ) 6A, No.5 September 1991
REFERENCES J. Rayan OM, Turner WT. Hand compli cations in children from digital sucking. J HAND SURG 1989;14A:933-6. 2. Reid DA Campbell, Price AHK. Digital deformities and dental malocclusion due to finger sucking . Br J Plast Surg 1984;37:445 -52. 3. Rankin EA, Jabaley ME , et al.Acquircd rotational digital deformity in children as a result of finger sucking . J HAND SURG 1988;13A :535-9 .
Reply Unfortunately our search of the literature did not reveal the article of Drs. Campbell Reid and Price. After we finished writing our article and immediately before its submission, the article of Drs. Rankin, Jabaley, and Blair was published. We included it as the last reference of our article without being aware of the presence of Dr. Campbell Reid's article. This was not intentional. Our sincere apologies to Drs. Campbell Reid and Price for the oversight and to the editor for the inconvenience. G. M. Rayan, MD, FACS Orthopaedics IHand and Microsurgery 3433 NW 56th si., Suite 850 Oklahoma City, OK 73112 "Transthecal Digital Block: Flexor Tendon Sheath . Used for Anaesthetic Infusion" To the Editor: It is possible to obtain digital anesthesia by a single injection without the need to enter the flexor tendon sheath . I believe that the technique is easier than the transthecal technique described, but it has the same advantages of requiring only a single injection, requiring only a small volume of anesthetic agent, and of achieving rapid anesthesia. The only disadvantage is that the dorsal digital nerves are not always anesthetized. The injection is given into the crease at the base of the finger rather than in the palm. It is injected into the subcut aneous tissue only, not into the flexor sheath. This allows the anesthetic agent to diffuse through the soft tissues around the digital nerves, which lie toward the palmar aspect of the .finger or thumb. Sometimes the anesthetic agent does diffuse sufficiently far around the finger to anesthetize the dorsal nerves, but this is not reliable. However, this does not prevent this technique from being very useful for treatment of all conditions along the palmar aspect of the finger and on the dorsal aspect of the distal phalanx and most of the
Letters to the editor
957
middle phalanx. The technique has been used for the same indications described by Dr. Chiu . The technique has been easy to teach to junior doctors, and it has a wider margin of latitude than the technique of Dr. Chiu, which requires the needle to enter the flexor sheath . This latitude is increased if the finger is pinched from side to side immediately distal to the web space. This pinching, injecting through the skin of the crease, and using a fine needle make the technique relatively painless. I have found it of great help in children, as was mentioned by Dr. Chiu. Scott Harbison, FRACS 21 St. Jude St. Bowral, N.S. W. 2576 Australia
Reply. In response to Dr. Harbison's comment, I would like to point out that one of the distinct advantages of using flexor tendon sheath as a conduit for anesthetic infusion is implied by Dr. Harbison, namely the predictable inclusion of the dorsal digital nerves within the field of anesthesia. In addition, to fill the flexor tendon sheath momentarily is sufficient to induce rapid onset of totat digital anesthesia . There is no danger of a sustained increase in tissue pressure within the digit since the flexor tendon sheath communicates directly with the proximal potential spaces of the palm, which allows unimpeded egress of anesthetic solution . To sufflate the subcutaneous space with anesthesia solution may cause sustained elevation of compartmental pressure and lead to compression of the neurovascular bundle. Transthecal digital block has proven to be rather easy to learn . The ready acceptance of this technique by the house staff at both New York University Medical Center and Columbia Presbyterian Medical Center may serve as an example. As of now, I would continue to prefer the transthecal digital block technique. David T.W. cu« MD, FACS Associate Director Plastic Surgery Chief, Section of Handl Microsurgery/ Replantation Surgery Columbia-Presbyterian Medical Center 38 E . 61st St. Nell' York, NY 10021
REFERENCES J. Rayan OM, Turner WT. Hand compli cations in children from digital sucking. J HAND SURG 1989;14A:933-6. 2. Reid DA Campbell, Price AHK. Digital deformities and dental malocclusion due to finger sucking . Br J Plast Surg 1984;37:445 -52. 3. Rankin EA, Jabaley ME , et al.Acquircd rotational digital deformity in children as a result of finger sucking . J HAND SURG 1988;13A :535-9 .
Reply Unfortunately our search of the literature did not reveal the article of Drs. Campbell Reid and Price. After we finished writing our article and immediately before its submission, the article of Drs. Rankin, Jabaley, and Blair was published. We included it as the last reference of our article without being aware of the presence of Dr. Campbell Reid's article. This was not intentional. Our sincere apologies to Drs. Campbell Reid and Price for the oversight and to the editor for the inconvenience. G. M. Rayan, MD, FACS Orthopaedics IHand and Microsurgery 3433 NW 56th si., Suite 850 Oklahoma City, OK 73112 "Transthecal Digital Block: Flexor Tendon Sheath . Used for Anaesthetic Infusion" To the Editor: It is possible to obtain digital anesthesia by a single injection without the need to enter the flexor tendon sheath . I believe that the technique is easier than the transthecal technique described, but it has the same advantages of requiring only a single injection, requiring only a small volume of anesthetic agent, and of achieving rapid anesthesia. The only disadvantage is that the dorsal digital nerves are not always anesthetized. The injection is given into the crease at the base of the finger rather than in the palm. It is injected into the subcut aneous tissue only, not into the flexor sheath. This allows the anesthetic agent to diffuse through the soft tissues around the digital nerves, which lie toward the palmar aspect of the .finger or thumb. Sometimes the anesthetic agent does diffuse sufficiently far around the finger to anesthetize the dorsal nerves, but this is not reliable. However, this does not prevent this technique from being very useful for treatment of all conditions along the palmar aspect of the finger and on the dorsal aspect of the distal phalanx and most of the
Letters to the editor
957
middle phalanx. The technique has been used for the same indications described by Dr. Chiu . The technique has been easy to teach to junior doctors, and it has a wider margin of latitude than the technique of Dr. Chiu, which requires the needle to enter the flexor sheath . This latitude is increased if the finger is pinched from side to side immediately distal to the web space. This pinching, injecting through the skin of the crease, and using a fine needle make the technique relatively painless. I have found it of great help in children, as was mentioned by Dr. Chiu. Scott Harbison, FRACS 21 St. Jude St. Bowral, N.S. W. 2576 Australia
Reply. In response to Dr. Harbison's comment, I would like to point out that one of the distinct advantages of using flexor tendon sheath as a conduit for anesthetic infusion is implied by Dr. Harbison, namely the predictable inclusion of the dorsal digital nerves within the field of anesthesia. In addition, to fill the flexor tendon sheath momentarily is sufficient to induce rapid onset of totat digital anesthesia . There is no danger of a sustained increase in tissue pressure within the digit since the flexor tendon sheath communicates directly with the proximal potential spaces of the palm, which allows unimpeded egress of anesthetic solution . To sufflate the subcutaneous space with anesthesia solution may cause sustained elevation of compartmental pressure and lead to compression of the neurovascular bundle. Transthecal digital block has proven to be rather easy to learn . The ready acceptance of this technique by the house staff at both New York University Medical Center and Columbia Presbyterian Medical Center may serve as an example. As of now, I would continue to prefer the transthecal digital block technique. David T.W. cu« MD, FACS Associate Director Plastic Surgery Chief, Section of Handl Microsurgery/ Replantation Surgery Columbia-Presbyterian Medical Center 38 E . 61st St. Nell' York, NY 10021