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Digital Nerve Block

Welcome to the Digital Nerve Block regional anesthesia page. Here we will cover indications, contraindications, materials and steps for you to master this procedure. Let’s begin with the overview below.

Overview

Involves local anesthesia of the digit to safely and reliably provide pain relief as well as total loss of feeling if needed for surgery. Digital blocks are simple to perform, essentially devoid of systemic complications and can be used in an office, operating room, or emergency department setting.[1] There are multiple accepted techniques that can be used to perform a digital nerve block.[1][2][3][4] Here, we review the “traditional” dorsal and volar subcutaneous approaches.

Indications

While most commonly used for finger surgery (i.e. laceration repair), digital blocks can also be used to perform minor procedures or provide acute pain relief.[5][6]

Contraindications

There are few true contraindications to this block. They include:

  1. Infection (cellulitis) at the site of injection
  2. Allergy to local anesthetic being used
  3. Patient refusal

Some relative contraindications to consider are:

  1. Patient needs a neural exam of the affected digit
  2. Anticoagulation use or bleeding disorder (pressure and tourniquet can be applied to the affected area if necessary)
  3. Patient with prior neural lesion or active injury

Anatomy

Four digital nerves innervate each digit. Two dorsal digital nerves innervate the dorsal aspect of the digit, and two palmar nerves innervate the palmar aspect of the digit. The digital nerves arise from the median, ulnar, and radial nerves.

Dorsal (A) and palmar (B) images of the hand with area of digital nerve innervation (blue) of the middle digit. Click the image for a full size version in a new tab.

Materials

Technique

Blocks should be performed with aseptic technique using a skin antiseptic, sterile field, and sterile equipment if possible. Allow for appropriate dry time for your antiseptic. Block needles should be aspirated prior to every injection to avoid intravascular administration, and injection should be immediately stopped if the patient suddenly complains of pain or high pressure.

Landmark

Traditional Dorsal Approach

  1. Place the patient’s extremity in a pronated position, with the hand resting on a hard surface (i.e. Mayo stand).
  2. Cleanse skin at the base of the digit, including the web spaces.
  3. Introduce needle at a 90 degree angle on the dorsal side of the hand at the base of the digit, just distal to the MCP joint and medial to the midline of the digit.
  4. Advance the needle toward the ventral side of the digit.
  5. Inject approximately 1 mL of anesthetic. This will block the ventral digital nerve.
  6. Withdraw the needle while injecting another 1 mL of anesthetic. This will block the dorsal digital nerve.
  7. Repeat steps 3-6 on the lateral side of the digit.

Palmar (Volar) Subcutaneous

  1. Place the patient’s extremity in a partially supinated position, with the hand resting on a hard surface (i.e. Mayo stand).
  2. Cleanse skin at the base of the digit.
  3. Introduce the needle at the midpoint of the crease at the base of the digit just below the skin.
  4. Slowly inject 1-2 mL of anesthetic.
  5. After withdrawing the needle, massage the anesthetic into the tissues.
  6. Note: A variation of this approach involves advancing the needle 5-6 mm at the midpoint of the digit angled 45 degrees toward the medial aspect of the digit and injecting 1 mL of anesthetic. The operator then brings the needle to the skin surface, redirects the needle 90 degrees to point toward the lateral aspect of the digit, advances the needle 5-6 mm and injects another 1 mL of anesthetic. This approach may offer better anesthesia of the dorsal nerves as well as the palmar nerves.

Volar Subcutaneous Digital Block. The needle is inserted at the base of the digit, just distal to the MCP joint. Click the image for a full size version in a new tab.

Ultrasound

Given the tight spacing and small size of the targeted nerves, ultrasound is generally not required or helpful for completion of the digital block.

Summary & Bullet Points

  • Digital nerve block is a safe and effective way to provide analgesia to a single digit.
  • Very little contraindications exist for this block (overlying infection, medication allergy).
  • Digital blocks can be performed in multiple settings (i.e. office, operating room, and emergency department).
  • Digital blocks have a dorsal approach, a palmar subcutaneous approach, and a palmar medial and lateral approach.

    • References

    [1] Cannon B, Chan L, Rowlinson JS, Baker M, Clancy M. Digital anaesthesia: one injection or two? EMJ 2010;27(7):533-6. PMID: 20360491.

    [2] Martin SP, Chu KH, Mahmoud I, Greenslade JH, Brown AF. Double-dorsal versus single-volar digital subcutaneous anaesthetic injection for finger injuries in the emergency department: A randomised controlled trial. Emerg Med Australas. 2016 Apr;28(2):193-8. doi: 10.1111/1742-6723.12559. Epub 2016 Mar 16. PMID: 26991958.

    [3] Okur OM, Şener A, Kavakli HŞ, Çelik GK, Doğan NÖ, Içme F, Günaydin GP. Two injection digital block versus single subcutaneous palmar injection block for finger lacerations. Eur J Trauma Emerg Surg. 2017 Dec;43(6):863-868. doi: 10.1007/s00068-016-0727-9. Epub 2016 Oct 5. PMID: 27709248.

    [4] Harness NG. Digital block anesthesia. J Hand Surg Am. 2009 Jan;34(1):142-5. doi: 10.1016/j.jhsa.2008.10.010. PMID: 19121740.

    [5] Anesthesia Key contributors. Digital Nerve Block. Anesthesia Key. Aug 9, 2016. Available at https://aneskey.com/digital-nerve-block/. Accessed Aug 2022.

    [6] WikEM contributors. Digital Block. WikEM, The Global Emergency Medicine Wiki. Aug 24, 2021. Available at: https://wikem.org/wiki/Digital_block. Accessed Aug 2022.

    Resource Libaray

    Digital Nerve Block

    Welcome to the Digital Nerve Block regional anesthesia page. Here we will cover indications, contraindications, materials and steps for you to master this procedure. Let’s begin with the overview below.

    Overview

    Involves local anesthesia of the digit to safely and reliably provide pain relief as well as total loss of feeling if needed for surgery. Digital blocks are simple to perform, essentially devoid of systemic complications and can be used in an office, operating room, or emergency department setting.[1] There are multiple accepted techniques that can be used to perform a digital nerve block.[1][2][3][4] Here, we review the “traditional” dorsal and volar subcutaneous approaches.
    Medical professional performing a simulated emergency procedure using a SimKit training model in a clinical environment.

    Indications

    While most commonly used for finger surgery (i.e. laceration repair), digital blocks can also be used to perform minor procedures or provide acute pain relief.

    There are few true contraindications to this block. They include:
    • Infection (cellulitis) at the site of injection
    • Allergy to local anesthetic being used
    • Patient refusal
    Some relative contraindications to consider are:
    • Patient needs a neural exam of the affected digit
    • Anticoagulation use or bleeding disorder (pressure and tourniquet can be applied to the affected area if necessary)
    • Patient with prior neural lesion or active injury

    Anatomy

    Four digital nerves innervate each digit. Two dorsal digital nerves innervate the dorsal aspect of the digit, and two palmar nerves innervate the palmar aspect of the digit. The digital nerves arise from the median, ulnar, and radial nerves.

    Materials

    Technique

    Blocks should be performed with aseptic technique using a skin antiseptic, sterile field, and sterile equipment if possible. Allow for appropriate dry time for your antiseptic. Block needles should be aspirated prior to every injection to avoid intravascular administration, and injection should be immediately stopped if the patient suddenly complains of pain or high pressure.

    Landmark

    Traditional Dorsal Approach

    Place the patient’s extremity in a pronated position, with the hand resting on a hard surface (i.e. Mayo stand).

    Withdraw the needle while injecting another 1 mL of anesthetic. This will block the dorsal digital nerve.

    Introduce needle at a 90 degree angle on the dorsal side of the hand at the base of the digit, just distal to the MCP joint and medial to the midline of the digit.

    Advance the needle toward the ventral side of the digit.

    Cleanse skin at the base of the digit, including the web spaces.

    Inject approximately 1 mL of anesthetic. This will block the ventral digital nerve.

    Repeat steps 3-6 on the lateral side of the digit.

    Ultrasound

    Given the tight spacing and small size of the targeted nerves, ultrasound is generally not required or helpful for completion of the digital block.

    Palmar (Volar) Subcutaneous

    Note: A variation of this approach involves advancing the needle 5-6 mm at the midpoint of the digit angled 45 degrees toward the medial aspect of the digit and injecting 1 mL of anesthetic. The operator then brings the needle to the skin surface, redirects the needle 90 degrees to point toward the lateral aspect of the digit, advances the needle 5-6 mm and injects another 1 mL of anesthetic. This approach may offer better anesthesia of the dorsal nerves as well as the palmar nerves.

    Place the patient’s extremity in a partially supinated position, with the hand resting on a hard surface (i.e. Mayo stand).

    Cleanse skin at the base of the digit.

    Introduce the needle at the midpoint of the crease at the base of the digit just below the skin.

    Slowly inject 1-2 mL of anesthetic.

    After withdrawing the needle, massage the anesthetic into the tissues.

    Ultrasound

    • Digital nerve block is a safe and effective way to provide analgesia to a single digit.
    • Very little contraindications exist for this block (overlying infection, medication allergy).
    • Digital blocks can be performed in multiple settings (i.e. office, operating room, and emergency department).
    • Digital blocks have a dorsal approach, a palmar subcutaneous approach, and a palmar medial and lateral approach.

    Summary & Bullet Points

    [1] Cannon B, Chan L, Rowlinson JS, Baker M, Clancy M. Digital anaesthesia: one injection or two? EMJ 2010;27(7):533-6. PMID: 20360491.

    [2] Martin SP, Chu KH, Mahmoud I, Greenslade JH, Brown AF. Double-dorsal versus single-volar digital subcutaneous anaesthetic injection for finger injuries in the emergency department: A randomised controlled trial. Emerg Med Australas. 2016 Apr;28(2):193-8. doi: 10.1111/1742-6723.12559. Epub 2016 Mar 16. PMID: 26991958.

    [3] Okur OM, Şener A, Kavakli HŞ, Çelik GK, Doğan NÖ, Içme F, Günaydin GP. Two injection digital block versus single subcutaneous palmar injection block for finger lacerations. Eur J Trauma Emerg Surg. 2017 Dec;43(6):863-868. doi: 10.1007/s00068-016-0727-9. Epub 2016 Oct 5. PMID: 27709248.

    [4] Harness NG. Digital block anesthesia. J Hand Surg Am. 2009 Jan;34(1):142-5. doi: 10.1016/j.jhsa.2008.10.010. PMID: 19121740.

    [5] Anesthesia Key contributors. Digital Nerve Block. Anesthesia Key. Aug 9, 2016. Available at https://aneskey.com/digital-nerve-block/. Accessed Aug 2022.

    [6] WikEM contributors. Digital Block. WikEM, The Global Emergency Medicine Wiki. Aug 24, 2021. Available at: https://wikem.org/wiki/Digital_block. Accessed Aug 2022.

    Resource Libaray