Use of Local Anesthesia in Hand Surgery · reconstruction in recent postop period after vascular reconstruction for trauma) ... •Good pre-extant relationship with periop –preop

1/14/2014

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Use of Local Anesthesia in Hand Surgery

Andrew W. Gurman, MD

January 21, 2014

Traditionally, hand surgery has been performed under tourniquet control

Which requires anesthesia

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And that is expensive

• Pre-op consultation

• MD/DO + CRNA

• Pharmacy

• IV

• Pre-testing – EKG, CXR, Labs

• Recovery room

• Total cost = $$$$

The use of epinephrine obviates the need for a tourniquet

11th Commandment of Hand Surgery Thou shalt not use epinephrine in the hand

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Sterling Bunnell

• Father of Hand Surgery

• Injected a local anesthetic with epinephrine

• The finger died

• 60+ years of absolute obedience to #11

• Phentolamine described as antidote

• #11 is disproved

• Bunnell probably used procaine, which has a short shelf life

WALANT

• W ide

• A wake

• L ocal

• A nesthesia

• N o

• T ourniquet

Advantages of WALANT

• Cost

• Patient satisfaction > 90%

• Patient safety – no anesthesia side effects

• Patient safety – no stopping anticoagulants

• Patient safety – no stopping diet, insulin, etc.

• Quality – intra-operative assessment of tension of tendon repairs and transfers

• Quality – assessment of adequacy of release

• Increased compliance when patients watch

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Personal experience

• Started January 1, 2011

• > 1,000 cases

• Age range 12 to 100

• Excellent patient acceptance

• Some cases are just better this way

WALANT technique

WALANT technique

• Buffer the medication

• Slow injection

• Adequate time to “soak in”

• Pre-op and intra-op coaching

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Hemostasis

Sharing

No separate reimbursement when local anesthesia is administered by the surgeon

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WIN – WIN - WIN

• Physicians are rewarded for extra work and liability

• Patients receive better care

• Highmark saves money

LOSE – LOSE - LOSE

• Physicians are forced to perform cases under local if they are not comfortable

• Physicians are not trained in WALANT

• Patients get poorer care

• Costly complications

Thank you

• [email protected]

1/14/2014

1

The Role of Wide Awake

Surgery in an Academic Hand

Surgery Practice

Peter C. Amadio, M.D. Lloyd A. and Barbara A. Amundson

Professor of Orthopedics Mayo Clinic

Disclosures

• None relevant to this talk

Academic Practice

Differences from Private Practice

• Patients may be more complex

• Patients may be more diverse

• Cultures

• Where they live

• Median distance of Mayo patient home from Rochester MN- 100 miles

• Mean distance- far greater

• High volumes/competition for resources

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Academic Practice

Favorable setup for WAS

• Reduced surgical morbidity in an environment where this is already very high due to case mix

• Reduced resource demand in an environment where this is already very high due to case mix

• Anesthesia staff

• Recovery room

• OR time

But not for everyone

• Some patients want to be asleep/unaware for personal or cultural reasons

• In some cases OR time/resource use not much different with/without tourniquet

• CTR

• Trigger, DeQuervain’s etc

Academic Practice Potential for improved quality

• Better outcomes?

• Fewer reoperations?

• Better patient satisfaction?

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Main Indications

• Cases where a tourniquet is contraindicated, and a bloodless field is helpful, such as hand surgery in patients with ipsilateral lymphedema or dialysis access, or with recent upper limb vascular surgery (for example, need for additional reconstruction in recent postop period after vascular reconstruction for trauma)

Main Indications

• Cases where hemostasis could use a boost, such as patients with recent angioplasty who must remain anticoagulated during hand surgery

• Prolonged white finger? Phentolamine rescue

Main Indications

• Cases where patient cooperation is needed, and tourniquet time would exceed 10-15 minutes, such as tendon repair, tendon transfer, tendon graft and tenolysis

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Arthroplasty

• The patient knows everything that is going on, especially if they watch (which I always encourage). A better informed patient is a happier patient and a better partner in postop recovery

Osteotomy

• Most important, patient cooperation is key to setting tension and checking motion after any kind of tendon surgery, and in confirming active motion after contracture releases. Also helpful in osteotomies

Personal Experience

• No problems with hemostasis

• No problems with prolonged ischemia

• No major cardiac problems (one patient developed chest pain intraop despite zero hand pain; because he was wide awake we were able to intervene very quickly; no permanent deficits)

• Patients like it

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Best part

patients love it (so far ages 12-92)

• “thanks, doctor. I really enjoyed the surgery!”

• “People definitely need to put this on their ‘bucket list’. It was great!”

Summary

• Very useful

• Low morbidity

• Phentolamine readily available for rescue but likelihood of needing it is low

1/20/2014

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Exemplary Care Cutting-edge Research World-class Education

Rafael J. Diaz-Garcia, M.D.

Hand and Upper Extremity Fellow

Alex Andoga, BS

Research Assistant

Mark E. Baratz, M.D. Clinical Professor and Vice-Chair

Department of Orthopaedics

University of Pittsburgh Medical Center

Economics of Wide-Awake Hand Surgery


• Healthcare expenditures in the U.S. per year

>$2.6 trillion 1000% increase since 1980

• Congress’ solution: cut Medicare

reimbursement.

• Our solution? Provide care at lower costs.

• Wide-awake hand surgery may be an easy

method to improve value in your practice.

The Problem


Wide-Awake Hand Surgery

Surgery under local anesthesia is a

cost-saving multiplier

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The Costs of the Status Quo

• Anesthesia raises the costs of care

•Direct - Medicare: $105 for 30min

Private: $275 for 30min

• Indirect - Preoperative testing, labs, medical

clearance

Medicare: ~ $120

• Costs of excess materials

•Drapes, basins, tourniquet, etc: $91.81

Potential Savings of $300-600 dollars per patient


Current Patient Treatment Course

Surgeon

Clinic

EMG/NC

S

PCP

Wait

List

Preop

Test/H&P

Sedation

+/- block

Surgeon

Clinic

PACU

Surgery


Does This Really Save Money?

• Leblanc, et al. found that use of main OR time

was 4x as expensive and less than 1/2 as

efficient as ambulatory clinic setting.1

• Chatterjee, et al. found that total cost was

double for endoscopic CTR and quadruple for

open CTR when comparing main OR to clinic.2

1 Leblanc MR, Lalonde J, Lalonde DH. A detailed cost and efficiency analysis of carpal tunnel surgery in the main operating room versus ambulatory setting in Canada. Hand 2007 Dec; 2(4) 2 Chatterjee A, McCarthy JE, Montagne SA, Leong K, Kerrigan CL. A cost, profit and efficiency analysis of performing carpal tunnel surgery in the operating room vs the clinic in the U.S. Ann Plas

Surg 2011; 66.

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Can Wide Awake Surgery Improve Efficiency?

• One group in the UK streamlined their entire

practice for both patients and surgeons.3

•Time from referral to surgery

18 weeks 4 weeks

•Specialist time with patient

2.5 hrs 45min

3 Bismil MSK, Bismil QMK, Harding D, Harris P, Lamyman E, Sansby L. Transition to total one-stop wide-awake hand surgery service-audit: a retrospective review. J R Soc Med Sh Rep 2012;3(23).


Will I Lose Patients?

• 100 consecutive patients were polled post-

operatively.4

• 91% found it was less painful or

comparable to procedures done under

local at the dentists office.

• 86% would prefer to be awake for further

hand surgery.

• 90% would recommend wide awake

surgery to a friend. 4 Teo I, Lam W, Muthayya P, Steele K, Alexander S, Miller G. Patients’ perspective on wide-awake hand surgery—100 consecutive cases. J Hand Surg Eur Vol. 2013 38(9).


Economic Effects of Wide Awake Surgery

• Reduces direct and indirect costs.

• Increased efficiency in the delivery of care in

the ambulatory setting.

• Net result is greater patients cared for, at a

lower cost, with a high patient satisfaction rate.

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So How is this a “Win” for my Practice?

• Efficiency

• Safety

• Satisfaction

• …and the insurers get this.

• Opportunity to improve re-imbursement


Economics of Waste


Medical Waste is Expensive

Phoenix Indian Medical Center (2002-2003)

Solid Bag Waste Disposal: $57/ton

Red Bag Waste Disposal: $450/ton

Marcy Yeshnowski

Tetra Tech

Data reported from Dept HHS/IHS

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The Costs Extend Beyond

Our Backyard


AAHS 2014


Kamilo: The Great Pacific Garbage Patch

• Hawaiian

Islands/Kamilo

Beach

• North Pacific Gyre

• Miles of trash: up

to10 feet deep

National Oceanic and Atmospheric

Administration

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• Trash from all over

the world

• 90% is plastic

• Takes 50-500 years

to degrade


Environment Cost = Economic Cost

Ian Jones / Wild Orchids for Trotsky


The Perfect Storm:

Decreased reimbursement

Pressure to improve safety and satisfaction

Strained global environment

1/20/2014

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The Lean and Green Movement

Leadership of AAHS, ASSH, ASRM & ASPN

•Identify the Obstacles and Opportunities

• Reduce cost

• Reduce waste

• Improve safety

• Patient satisfaction

•Wide awake surgery can be part of the

solution

Hand surgeons doing their part…


Thank You

Julie E. Adams MD

Orthopaedic Surgery

University of Minnesota

Wide-awake hand surgery: strategies for

implementation

• Arthrex, Articulinx, Acumed: consulting

• Biomet: Royalties

• Elsevier: Honorarium

Disclosures

• Wide-awake hand surgery has many benefits

– Patient/surgeon satisfaction

– Cost benefit

– Safety

– Time

Introduction

Ulnar Neuropathy

Decompression vs. Transposition

• Safety concerns

• Charting concerns

• Patient/institutional acceptance

• Anesthesia care providers/nursing buy-in

• “that’s not how we do things here”

• “we don’t have the staffing/space/time to

do monitoring”

Barriers to implementation

Ulnar Neuropathy


• Local-alone, MAC, regional and general cases with

tourniquet in an academic multisite practice

– 2 ASC (hospital owned)

– ASC (in free standing multisubspecialty orthopedic

clinic)

– 3 clinics

– 2 hospitals

Background

Detection

• Ruth Jackson Orthopaedic Society traveling

fellowship: visit to Don Lalonde

• Prior to: dabbled

May 2013

Detection

• Enthusiastic about

WALANT and

implementation.

– Challenges: getting local “in”

with enough time for epi to

work (~ 20-30 minutes)

– Buy-in and logistical barriers

Returned….

Ulnar Neuropathy


• Already had buy-in from partners

– Other attendings in our fellowship program

– Procedure room + epi used by practice partners and me already

• Approached preop nurses and Anesthesiologists at my

highest volume facility (connected to the hospital with

slowest turnover) – Their concerns

– My concerns

– Plan to reconcile

– Avoid discounting concerns of any party (even if they make no sense)

Careful about how I implemented….

Ulnar Neuropathy


• Develop your 30 second narrative and present it in a

respectful way

• Figure out who the stakeholders are and involve them

from the start

• Presenting your plan and having an alternative

• Making it a “win-win”

• Being flexible

• Good pre-extant relationship with periop

– preop nurses, anesthesia.

Arguments that work—generating LEVERAGE

Ulnar Neuropathy


• Develop your 30 second narrative and present it in a

respectful way

– This is why I want to do this

– This is why I think it is safe/ better for our patients/ better for

our hospital or ASC/ environment

– Here is the evidence (Printouts/articles/references)

– “millions of people a day have lidocaine with epi in dental

offices without monitoring and no adverse effects”

– “not different than an injection in the office (which is

currently done without monitoring)”


Ulnar Neuropathy


• Figure out who the

stakeholders are and

involve them from the

start

– Typically charge preop

nurse

– Surgery center/hospital

surgery manager

– Anesthesiology

– Surgical services lead


Ulnar Neuropathy


• Presenting your dilemma and having an alternative

• Making it a “win-win”

– “I would love to give (our institution) more business but….I

suppose I will need to take the patient to (Y institution/do

case in my clinic). I really would prefer to operate at (X).”

– “I could do “n” number of cases per block time with wide

awake, vs “p” number of cases with local and MAC


Ulnar Neuropathy


• Being flexible-accept baby steps from your institution

(or suggest them)

– “Would it be ok to try this on a few select patients and see

how things go?”

– “Let’s do all the monitoring you want initially, and then see

if we truly need it”

– “Let’s do a pilot study”

– “Ok, I understand you don’t feel comfortable with this. Can

you help me understand why? What parameters would you

feel comfortable with?”


Ulnar Neuropathy


• Good pre-extant relationship with periop

– Head preop nurse, anesthesia.

– What do YOU think you need from ME to make this work?

• Preop order in computer for lido with epi

• List of items needed

• Patient supine with pulse ox and BP monitoring, RN at bedside,

consent and preinjection pause.


Ulnar Neuropathy


• If your practice is at multiple sites- EACH ONE is likely

to be different.

• Even if in same hospital system.

• Even if one is the hospital and one is the ASC

• REMEMBER- their past experiences may shape how they

perceive your plans-it may have nothing to do with you!

– Did another surgeon demand MAC anesthesia mid way through a

local alone case?

– Did a patient have pain/bleeding during another local alone case

(maybe without epi?)

Outcomes

Ulnar Neuropathy

Decompression vs. Transposition • “I appreciate you looking at this issue and working to improve patient care and

efficiency and cost effectiveness. I'd like to understand the rationale behind

restricting the BMI at []. If the team requires more reassurance that this is

effective and safe and wants to see "how it goes", I'm ok with that, I’m just

curious.”

• “Thanks for your note and comments. I am and have been on board with you on

this matter. But here at [] we like to lead from behind, so we are ramping up a

little cautiously because at this current juncture a variety of stakeholders have to

be on board….I would actually like to see the studies if you wouldn't mind taking

the time to send me the citations.”

• “Thanks [], I understand, and as I said, I'm ok convincing people this is a good

idea by progressive experience. Thanks again for your support.”

Outcomes- my experience

Ulnar Neuropathy





curious.”









Ulnar Neuropathy





curious.”









Ulnar Neuropathy





curious.”









Ulnar Neuropathy


• ASC #1 (hospital owned/operated; busiest,

most of my practice)

– Wants preop order for lido with epi

– Patient supine/BP and pulse ox/ RN at

bedside/preinjection pause. RN does usual intake (what

are your meds/allergies/when did you eat last?).

– No preop H&P-just need a reason for patient

presentation entered into EMR.


Ulnar Neuropathy


• Hospital #1,2 (owned by same as ASC #1)

– Wants preop order for lido with epi

– Doesn’t yet care about BP/pulse ox

– RN does usual intake (what are your

meds/allergies/when did you eat last?).

– No preop H&P-just need a reason for them there

entered into EMR.


Ulnar Neuropathy


• ASC #2 (owned by same as ASC #1, hosp

1&2)

– Just delighted I am doing cases there.

– Doesn’t yet care about BP/pulse ox

– RN does abbreviated intake (“what are we doing for

you today”)

– No preop H&P-just need a reason for them there

entered into EMR.

– Draws up injection for me.


Ulnar Neuropathy


• Clinic #1, 2 (owned by hosp #1, operated by

physician’s group)

– Our rules

– Pre injection time out

– Pre procedure time out

– RNs or MAs take care of “orders”


Ulnar Neuropathy


• Clinic #3

– No monitoring

– RNs or MAs take care of “orders”

– Ok to do “trauma” cases/I&D’s


Ulnar Neuropathy


• ASC #3

– Still working on it….


Ulnar Neuropathy


• It’s a give and take

• They may require some reassurance and evidence

that it is safe and effective

• Its ok to start out in a limited fashion-that is still a

“win”- just keep asking questions and probing as

time goes on.

• There are some places that are going to have to be

on the trailing edge of change


For AACM Conference and registration details:

aacm.org.ar | [email protected]

On behalf of the American Associati on for Hand Surgery (AAHS) and the Asociaciόn

Argentina de Cirugía de la Mano (AACM), we invite you to participate in the AAHS Pre-Course:

Surgical Advances In Elbow, Wrist And Hand Surgery

October 15, 2014 | 11am – 7pm

Buenos Aires, Argentina

Program Chair: Julie Adams, MD

PROGRAM SCHEDULE

11:00–11:15am Introduction and remarks

Mark Baratz, MD Carlos Eugenio Martinez, MD

Scientific Session: Bony Trauma Symposia

11:15–11:35am Scaphoid Fractures/Non-Unions: Tips and Techniques

Thomas B. Hughes, MD, and Carlos Zaidemberg, MD

11:35–11:40am Questions & Answers

11:40am– PIP Fracture Dislocat ions – Treatment Options 12:10pm Jeffrey Greenberg, MD, Alejandro Badia, MD,

and Cherrie A. Heinrich, MD

12:10–12:15pm Questions & Answers

12:15–12:45pm Challenging Elbow Fractures Scott F. Duncan, MD, Scott Steinmann, MD, and Mark Baratz, MD

12:45–12:50pm Questions & Answer

12:50–1:20 pm Wrist Injuries and Complications of Wrist Injuries Michael S. Bednar, MD, Eduardo Rafael Zancolli, MD, and Miguel Capomassi, MD

1:20–1:25 pm Questions & Answers

1:25–1:45 pm Open Forum for Questions & Answers

1:45–3:00 pm LUNCH BREAK

Scientific Session: Reconstruction

3:00–3:30pm Advances in Wrist and Hand Arthroscopy and Endoscopy Mark Rekant, MD, John Lubahn, MD, and Martin Caloia, MD


3:35–4:05 pm Advances in Wrist and Hand Arthroplasty and Reconstruction Marco Rizzo, MD, Peter Murray, MD, and David Botzenka, MD


4:10–4:40 pm Surgical Management of Scapholunate Instability Julie Adams, MD, Mario Rodriguez Sanmartino, MD, and William Lanzinger, MD


4:45–5:00 PM BREAK

5:00–5:30 pm Reconstruction of Congenital Hand Lesions Steve Moran, MD, Alex Davit, MD, and Hilton Gottshalk, MD


5:35–6:05pm Management of Nerve Injuries: Strategies and Techniques Randip R. Bindra, MD, Michael Neumeister, MD, and Loree Kallianen, MD


6:10–6:45pm Tendon Repair and Reconstruction Donald H. Lalonde, MD, Jerry I. Huang, MD, and Jose Maria Rotella, MD


6:50–7:00pm Open Forum for Questions & Answers; Adjourn

AAHS Precourse

AACM meeting October 15, 2014

Buenos Aires,

Argentina

www.handsurgery.org

www.aacm.org.ar

http://www.handsurg.org

http://www.aacm.org.ar

Thank You!

1/16/2014

1

Don Lalonde MD

Saint John, Canada

Professor Surgery

Dalhousie University

Wide awake hand surgery

Office practice • Office operating room accredited by

CAAASF for pure local anesthesia (50k)

• All sedation cases go to the hospital

• A second room has a stretcher where I

inject local into patients

• I inject 2 or three patients before I do the

first one

• OR

• I inject a patient, then see a few consults

before operating

McKee D,. Optimal time delay between

epinephrine injection and incision to minimize

bleeding Surg Plast. Reconstr. Surg. 131: 811,

2013.)

• Level I evidence from humans 2013

• It takes a mean of 26 minutes for maximal

vasoconstriction after injection of

1:100,000 epinephrine with lidocaine

beneath human skin (NOT 7 minutes –

1987 pig study)

• Helpful to inject the local anesthesia

before bringing the patient into the

operating room.

1/16/2014

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Office practice • Worst case scenario, I would abort

surgery, wrap up hand like a laceration,

and take patient to the hospital (this has

never happened)

How to “talk patients into”

• “You can test your repair during the

surgery to make sure you get a better

result”

• “Have you ever had a problem after an

operation?”

• Preop testing hassle factor

• Fear of needles

The size of the needles for

sedation Vs. wide awake hand

surgery

20 gauge

30 gauge

27 gauge

When patients are afraid of needles, they get

another 20 gauge needle for preop testing!

1/16/2014

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How to inject local anesthesia

so that it hardly hurts at all

Sept 2013 PRS with movies

Injecting carpal tunnel with

minimal pain

How to inject local anesthesia

so that it hardly hurts at all

Sept 2013 PRS with movies

1/16/2014

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Typical intraoperative patient education while

closing skin

(instead of talking about the weather with the

nurses or doctors in the room)

Epinephrine in the finger IS safe

4 of the main papers

• 1. A critical look at the evidence for and against

elective epinephrine use in the finger. Thomson

CJ, Lalonde DH, Denkler KA. Plast Reconstr

Surg.119(1): 260-266, January 2007.

• The cause of the myth was procaine

• procaine responsible for the finger deaths

blamed on adrenaline between 1920 and

1945.

adrenaline morphine

phentolamine naloxone

(α blocker) (Narcan)

=

1/16/2014

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Phentolamine reversal of vasoconstriction

after lidocaine + adrenaline Injection

2cc Lidocaine +

Adrenaline only Lidocaine +Adrenaline

+phentolamine 1 hour

after (1mg in 1cc)

How to use phentolamine alpha blocker

to reverse epinephrine vasoconstriction

• I have never HAD to use phentolamine

rescue in over 2000 fingers, but you can

inject phentolamine if you are

uncomfortable sending them home with a

white finger tip (rare)

• 1mg phentolamine in 1-5cc of saline and

inject it everywhere epi has been injected

in small volumes

• 5mg phentolamine IV will drop your blood

pressure

August 2013

J Am Acad Orthop

Surg. 2013

Aug;21(8):443-7.

1/16/2014

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There are 2 problems with

lidocaine and epinephrine

• Epinephrine “jitters or shakes”

– Solution Warn patients after each injection – “may

feel shaky like you have had a little too much coffee,

nervous, temporary, normal and will go away in 15-20

minutes, you are not allergic to it”

• Fainting – vasovagal attack (always inject

patients laying down)

– Recognize it Patient says “I’m not feeling well”

– or “I think I’m going to be sick”

– Patient yawns or gets pale between the eyes

– Solution get more blood to brain - Flex hips and

knees, put pillow under feet, lower head of bed

Safety of lidocaine and epinephrine • In the US, 500 million dental procedures per

year

http://meps.ahrq.gov/data_files/publications/st368/stat368.shtml

(including most everyone in this room)

• Most with lidocaine with epinephrine with no

monitoring at least 3 billion since 1948

• very few serious complications - we WOULD

have heard from lawyers in the USA

• Monitoring is probably not medically necessary

in most healthy patients who get pure lido + epi

with no sedation so many procedures can be

moved outside the main operating room

Safety of lidocaine and epinephrine

• It is possible for a person to go into atrial

fib or have a heart attack while having a

dental procedure, walking down the street,

or having wide awake surgery (and blame

it on the epinephrine regardless of whether

or not it actually caused it)

• High risk patients should be monitored

• Can use 1:200,000, 1:400,000 or

1:1,000,000 epinephrine + monitoring in

cardiac patients to decrease risk

1/16/2014

7

84 year old man told by cardiologist not fit

for general anesthesia for tendon transfer

(he said no problem with local)

• EI to EPL with 30cc of ½% lidocaine with

1:200:000 epinephrine

• 7mg / kg is more than safe; Dr Vasconez

and colleagues showed 35mg/kg is safe Plast Reconstr Surg.1996 Jun;97(7):1379-1384.

• 70 kg lady X 7 mg/kg = 490 mg of

lidocaine with 1: 100,000 epinephrine

• 490 mg of lidocaine is 49cc of 1%

lidocaine with epi is extremely safe

• I stay at 50cc of 1% lidocaine with epi to

always stay out of trouble without

monitoring

Calculation of safe dose of

lidocaine + epinephrine

Volume and dosage of local infiltration for

most hand operations Oct 2013 J Hand Surg

1/16/2014

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Contraindications to epinephrine

in the finger

• If they have a nice pink finger before I

inject, they will have a nice pink finger

after I inject unless I hurt the blood supply

to the finger with my surgery

• Patients who don’t have good perfusion in

the finger before I inject such as Buerger's

disease Bad renal failure

WALANT flexor tendon repair

• Less rupture

• Less tenolysis

• Better patient assessment and education

during the surgery

• Know if superficialis should be repaired or

not

• Comfortable starting true active movement

after surgery as opposed to place and hold

WALANT tendon transfers

• Can adjust the tension of the transfer

before you close the skin so you get it not

too tight or too loose

• Patient can see transfer works with his

own eyes

1/16/2014

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3 flexor tendon fingers16 year old

First 10cc 1 % lidocaine

with 1:100,000

epinephrine in palm, then

wait 30 minutes

3 flexor tendon fingers16 year old

5 cc in each finger

(2cc in middle and

prox phalanges

1cc distal phalanx)

Same 16 year old boy intra op

3 days, 17 days, 3 months post op

bleeding will stop by itself – no cautery

4 strand modified Kessler with epitenon

1/16/2014

10

Up to half a fist 45/45/45

post op protocol

start 3 days post op

• Up to half a fist of active flexion

• MP 45° active extension (half way

extended)

• PIP 45° active flexion (half way flexed)

• DIP 45° active flexion (half way flexed)

Consider submitting your surgery and

therapy papers to the journal Hand

AAHS meets in a warm place every January

1/16/2014

11

Thank you

Documents

Use of Local Anesthesia in Hand Surgery · reconstruction in recent postop period after vascular reconstruction for trauma) ... •Good pre-extant relationship with periop –preop