II. Indications

III. Contraindications (Relative)

IV. Precautions

  1. Avoid Median Nerve
  2. Injection is harmful if improperly done

V. Anatomy: Relationships

  1. Flexor carpi radialis (radial side)
  2. Median Nerve
  3. Palmaris Longus (Ulnar side)
    1. Forms palmar aponeurosis at midline of wrist
    2. Opose thumb and 5th finger to find palmaris longus

VI. Preparation

  1. Needle: 23 to 27 gauge 1.5 inch
  2. Skin Preparation (e.g. Hibiclens or Betadine)
    1. See Regional Anesthesia
  3. Anesthetic
    1. See Regional Anesthesia for Anesthetic options
    2. Local Anesthetic 2-5 ml (Ultrasound) or 5-10 ml (landmark)

VII. Technique

  1. Images
    1. medianNerveBlockWristLandmark.jpg
    2. medianNerveBlockWristUltrasound.jpg
  2. Wrist position
    1. Forearm supinated
    2. Dorsiflex wrist to 30 degrees resting on towel roll
  3. Ultrasound-Guidance (preferred)
    1. High frequency linear probe in short axis
    2. Start with probe over mid-Forearm
    3. Median Nerve is "starry night" ovoid structure between flexor digitorum superficialis and profundus
      1. Slide Ultrasound probe distally until a vessel is not adjacent to nerve
      2. Ultrasound-guided injection site will be proximal to landmark-guided injection
    4. Use standard Ultrasound-guided Regional Anesthesia technique
  4. Injection site
    1. Proximal wrist crease AND
    2. Radial side of following landmark
      1. Wrist midline (1 cm medial to flexor carpi radialis tendon) IF palmaris longus absent OR
      2. Palmaris longus tendon
        1. Find by opposing thumb with pinky or
        2. Flex middle finger against resistance
  5. Needle insertion
    1. Apply antiseptic to skin (e.g. Betadine)
    2. Aim 45 degrees distally toward middle and ring fingers
      1. Some guidelines recommend directing needle proximally at 45 degrees
    3. Insert needle 1-2 cm until no resistance
    4. Do not inject if Paresthesias (see below)
  6. Warning: Distal Paresthesias with needle with injection
    1. Indicates needle is at Median Nerve
    2. Do not inject here!
    3. Remove needle and replace further to the ulnar side

VIII. References

  1. Eicken and Rempell (2016) Crit Dec Emerg Med 30(4):3-11
  2. Pfenninger (1994) Procedures, Mosby, p. 1036-54
  3. Salam (2004) Am Fam Physician 69(4):896 [PubMed]
  4. Yurgil (2020) Am Fam Physician 101(11):654-64 [PubMed]

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