Overview
Hand and wrist surgery encompasses a wide spectrum of procedures — from minor day-case operations (carpal tunnel release, trigger finger) to complex trauma surgery (distal radius ORIF, flexor tendon repair). There is no specific PROSPECT guideline for hand and wrist surgery, but extensive evidence supports procedure-specific regional anaesthesia strategies based on the innervation of the hand and wrist.
The key principle is matching the regional technique to the procedure. Minor procedures may require only wrist blocks or local infiltration; complex multi-compartment surgery or procedures requiring tourniquet require proximal brachial plexus block (supraclavicular or axillary).
Key principle: Match block to procedure extent. Wrist blocks for distal hand/wrist procedures with forearm tourniquet or no tourniquet. Supraclavicular or axillary block for surgery requiring upper arm tourniquet or extensive forearm dissection. Axillary block preserves shoulder movement — useful in hand therapy settings.
Hand & Wrist Innervation
Understanding the sensory innervation is essential for choosing the correct block or combination of blocks.
Median Nerve
Palm (radial 3½ digits), thenar eminence, volar surface index/middle/ring fingers, dorsal tips index/middle/ring. Carpal tunnel syndrome.
Ulnar Nerve
Medial palm and dorsum (ulnar 1½ digits), little finger and ulnar half ring finger. Guyon's canal, ulnar-sided wrist pain.
Radial Nerve
Dorsum of hand (radial 3½ digits, to PIP joints). Does not cover volar hand. Dorsal wrist ganglion, first web space.
Musculocutaneous Nerve
Lateral forearm skin (as lateral antebrachial cutaneous nerve). Not hand — relevant for forearm tourniquet coverage.
Medial Antebrachial Cutaneous
Medial forearm skin. Relevant for forearm/wrist tourniquet tolerance. Blocked by axillary or supraclavicular approach.
Complete Hand Coverage
Requires blocking all three — median + ulnar + radial. Achieved by wrist blocks, axillary, supraclavicular, or infraclavicular approach.
Block Selection by Procedure
| Procedure | Recommended Block | Alternative | Tourniquet |
|---|---|---|---|
| Carpal tunnel release | Wrist blocks (median ± ulnar) | Local infiltration, WALANT | Forearm — tolerates wrist block |
| Trigger finger release | Local infiltration / WALANT | Wrist block (median) | Finger tourniquet |
| Distal radius ORIF | Supraclavicular or axillary block | Infraclavicular | Upper arm — needs proximal block |
| Flexor tendon repair | Axillary or supraclavicular block | Wrist blocks + sedation | Forearm or upper arm |
| Hand fractures (metacarpal/phalanx) | Wrist blocks or digital blocks | Axillary block | Finger tourniquet |
| Wrist arthroscopy | Wrist blocks or supraclavicular | Axillary block | Upper arm — consider proximal |
| Dupuytren's fasciectomy | Axillary or supraclavicular block | Wrist blocks | Upper arm |
| Wrist arthrodesis / fusion | Supraclavicular block | Axillary + MCN supplement | Upper arm |
| Replantation / microsurgery | Supraclavicular or axillary block | Brachial plexus catheter | Upper arm; sympathectomy beneficial |
Brachial Plexus Blocks for Hand & Wrist
Supraclavicular Block
First-lineBlocks brachial plexus at trunk/division level — dense, reliable coverage for entire upper limb below shoulder. Rapid onset. Excellent for forearm and hand surgery.
Axillary Block
Excellent for handBlocks terminal branches at axilla — median, ulnar, radial, musculocutaneous. No phrenic nerve risk. Ideal for hand surgery — shoulder and upper arm mobility preserved.
Infraclavicular Block
AlternativeBlocks brachial plexus at cord level — reliable coverage including musculocutaneous nerve without separate injection. Good for forearm/hand with tourniquet tolerance.
Dosing — Proximal Brachial Plexus Blocks for Hand/Wrist
| Agent | Concentration | Volume | Duration | Best use |
|---|---|---|---|---|
| Ropivacaine | 0.5% | 25–35 mL | 10–16 h | Surgical anaesthesia + extended analgesia |
| Mepivacaine 1.5% + Ropivacaine 0.5% | Mixed | 20 mL + 15 mL | ~8 h | Day-case — fast onset, good duration |
| Lidocaine 1.5% | 1.5% | 25–30 mL | 3–5 h | Short procedures — fast onset, shorter duration |
| Bupivacaine | 0.5% | 20–25 mL | 14–20 h | When prolonged postoperative analgesia needed |
Wrist Blocks
Wrist blocks provide selective sensory blockade of the median, ulnar, and radial nerves at the wrist — ideal for hand and finger surgery with forearm or finger tourniquet. No motor block of forearm muscles. Excellent safety profile due to distal location (LAST risk very low).
Complete hand anaesthesia at the wrist requires blocking all three terminal nerves: median + ulnar + radial. Each can be blocked individually (targeted for specific procedures) or all three together for complete hand coverage.
Individual Nerve Blocks at Wrist
| Nerve | Target | Agent | Volume | Coverage |
|---|---|---|---|---|
| Median nerve | Proximal to carpal tunnel, between FCR and palmaris longus tendons (or just radial to PL) | Lidocaine 1% or Ropivacaine 0.5% | 3–5 mL | Volar radial 3½ digits, thenar eminence |
| Ulnar nerve | Radial to FCU tendon, proximal to wrist crease; or via Guyon's canal | Lidocaine 1% or Ropivacaine 0.5% | 3–5 mL | Ulnar 1½ digits volar and dorsal, hypothenar |
| Radial nerve (superficial branch) | Subcutaneous infiltration across dorsal wrist radial to EPL, or target superficial branch at radial styloid | Lidocaine 1% or Ropivacaine 0.25% | 5–8 mL | Dorsum of hand, radial 3½ digits to PIP |
US guidance recommended for median and ulnar nerve blocks at wrist — improves accuracy and reduces volume needed. Radial nerve superficial branch is subcutaneous — landmark-based subcutaneous ring infiltration is acceptable.
WALANT — Wide Awake Local Anaesthesia No Tourniquet
WALANT involves local infiltration of lidocaine + adrenaline directly into the surgical field — the adrenaline provides haemostasis, eliminating the need for a tourniquet. The patient is fully awake, allowing intraoperative tendon and motor assessment. Excellent for carpal tunnel, trigger finger, and tendon repair in selected patients.
| Component | Concentration | Volume | Notes |
|---|---|---|---|
| Lidocaine + Adrenaline | 1% lidocaine + 1:100,000 adrenaline | 10–20 mL per field | Wait 25–30 min after injection for full vasoconstriction |
Carpal Tunnel Release — Specific Guidance
- Paracetamol 1g PO
- NSAID / COX-2 if tolerated (ibuprofen 400 mg or celecoxib 200 mg)
- Wrist blocks (median ± ulnar) if GA planned
- WALANT — ideal for open or endoscopic CTS (awake, motor check possible)
- Wrist block (median ± ulnar) under sedation
- GA + wrist blocks for anxious patients
- Forearm tourniquet well tolerated with wrist blocks
- Paracetamol 1g QDS regular (3–5 days)
- Ibuprofen / celecoxib regular (3–5 days)
- Oxycodone 5 mg PRN if pain not controlled
- Wound elevation
- Hand therapy referral
Distal Radius ORIF — Specific Guidance
Distal radius fracture fixation typically requires an upper arm tourniquet and involves significant periosteal dissection — a proximal brachial plexus block (supraclavicular or axillary) is required for adequate surgical anaesthesia and postoperative analgesia.
Rebound pain warning: As with shoulder surgery, single-shot brachial plexus block for distal radius ORIF is associated with significant rebound pain at 12–18h. Establish oral multimodal analgesia before block wears off and discharge with adequate rescue analgesia.
- Paracetamol 1g PO
- NSAID / COX-2 PO
- Supraclavicular or axillary block — pre-op
- Supraclavicular block: Ropivacaine 0.5% 25–30 mL
- GA + block, or block alone + sedation
- Dexamethasone 8 mg IV — extends block, antiemetic
- Paracetamol 1g IV (if not given pre-op)
- Paracetamol 1g QDS regular
- COX-2 / NSAID regular ≤5 days
- Opioid PRN rescue — before block wears off
- Elevation + ice
- Hand therapy Day 1 (if surgeon permits)
Systemic Analgesia
Hand and wrist surgery is generally associated with mild-to-moderate postoperative pain — systemic multimodal analgesia is usually sufficient alongside regional techniques for minor procedures.
| Agent | Dose | Route | Frequency | Notes |
|---|---|---|---|---|
| Paracetamol | 1 g | PO/IV | QDS | Cornerstone — regular throughout |
| Ibuprofen | 400 mg | PO | TDS | Most commonly used; add PPI |
| Celecoxib | 200 mg | PO | BD | COX-2 preferred if GI risk |
| Dexamethasone | 8 mg | IV | Single intraop | If regional block used — extends duration, antiemetic |
| Oxycodone IR | 5 mg | PO PRN | 4–6h | Rescue only — most hand cases need minimal opioids |
Most minor hand cases (carpal tunnel, trigger finger, digital fractures) are adequately managed with paracetamol + NSAID alone postoperatively. Opioids are rarely required. For major procedures (ORIF, arthroplasty, replantation), add regional block and consider opioid rescue.
References
- NYSORA. Wrist Block — Landmarks and Nerve Stimulator Technique. nysora.com ↗
- Lalonde DH. Wide-awake local anaesthesia no tourniquet (WALANT): the new philosophy for hand surgery local anaesthetic. Plast Reconstr Surg. 2014;133(5):1234–1242.
- McCartney CJL, Xu D, Constantinescu C, et al. Ultrasound examination of peripheral nerves in the forearm. Reg Anesth Pain Med. 2007;32(5):434–439.
- Luber MJ, Greengrass R, Vail TP. Patient satisfaction and effectiveness of lumbar plexus and sciatic nerve block for total knee arthroplasty. J Arthroplasty. 2001;16(1):17–21.
- Ilfeld BM et al. Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology. 2006;105(5):999–1007.
- Tran DQH et al. Supraclavicular nerve blocks: systematic review and meta-analysis. Reg Anesth Pain Med. 2017;42(5):556–566.
- Iohom G, Nugent M, Grace M, Dowd N, Shorten GD. Regional anaesthesia for distal radial fracture fixation. Eur J Anaesthesiol. 2007;24(4):310–314.
- Inberg E, Olkkola KT, Ahonen J, et al. Infraclavicular nerve block reduces postoperative pain after distal radial fracture fixation: a RCT. PMC. 2020. PMC7254671 ↗