Ischemia Developing in a Fibrotic Finger Following the Use of Anesthetic With Epinephrine, Salvaged by Hyperbaric Oxygen Therapy

Abstract

Background: The use of epinephrine for hand surgery has been rising over the past decade following the popularization of Wide Awake Local Anesthetic No Tourniquet (WALANT). Traditional teaching from the 20th century forbade the use of epinephrine claiming it could induce digital ischemia, yet trial data now contradicts this assumption. Purpose: Digital ischemia after epinephrine injection cases are important to report because epinephrine is being used increasingly in finger anesthesia. We wish to communicate to a growing number of hand surgeons who may be new to WALANT that epinephrine may have adverse effects in a fibrotic poorly perfused environment which is salvageable by hyperbaric oxygen therapy (HBOT). Case presentation: A 22-year-old male sustained a crush injury resulting in right index phalanx fracture. Acute open reduction with K wire fixation was performed under WALANT using 1% lidocaine with 1:100,000 epinephrine. After removal of wires, he was found to require elective open reduction and internal fixation with bone graft for delayed union, which was performed tension free using general anesthetic plus bupivacaine and 1:200,000 epinephrine. Despite mild congestion, phentolamine was not acutely administered when it might have been justified. The patient presented to the clinic five days later with blistering ischemic necrosis of the pulp, which was salvaged by HBOT. Summary: This case of digital ischemia following a crush injury with fibrotic scarring treated with lidocaine and epinephrine is reported as a warning to other hand surgeons performing WALANT. Epinephrine should be used with caution for digital blocks associated with scarred or fibrotic tissue and phentolamine should be used to reverse acute ischemia. HBOT can still salvage compromised tissue once the subacute process of ischemic necrosis has begun.