II. Indications
- Anesthesia of Median Nerve distribution distal to wrist
III. Contraindications (Relative)
IV. Precautions
- Avoid Median Nerve
- Injection is harmful if improperly done
V. Anatomy: Relationships
- Flexor carpi radialis (radial side)
- Median Nerve
- Palmaris Longus (Ulnar side)
- Forms palmar aponeurosis at midline of wrist
- Opose thumb and 5th finger to find palmaris longus
VI. Preparation
- Needle: 27 gauge 1.5 inch
- Skin preparation (e.g. Hibiclens or Betadine)
- Anesthetic
- See Regional Anesthesia for anesthetic options
- Local Anesthetic 2-5 ml (Ultrasound) or 5-10 ml (landmark)
VII. Technique
-
Wrist position
- Forearm supinated
- Dorsiflex wrist to 30 degrees resting on towel roll
-
Ultrasound-Guidance (preferred)
- High frequency linear probe in short axis
- Start with probe over mid-Forearm
- Median Nerve is "starry night" ovoid structure between flexor digitorum superficialis and profundus
- Slide Ultrasound probe distally until a vessel is not adjacent to nerve
- Ultrasound-guided injection site will be proximal to landmark-guided injection
- Use standard Ultrasound-guided Regional Anesthesia technique
- Injection site
- Proximal wrist crease AND
- Radial side of following landmark
- Wrist midline (1 cm medial to flexor carpi radialis tendon) IF palmaris longus absent OR
- Palmaris longus tendon
- Find by opposing thumb with pinky or
- Flex middle finger against resistance
- Needle insertion
- Apply antiseptic to skin (e.g. Betadine)
- Aim 45 degrees distally toward middle-ring finger
- Insert needle 1-2 cm until no resistance
- Do not inject if Paresthesias (see below)
- Warning: Distal Paresthesias with needle with injection
- Indicates needle is at Median Nerve
- Do not inject here!
- Remove needle and replace further to the ulnar side
VIII. References
- Eicken and Rempell (2016) Crit Dec Emerg Med 30(4):3-11
- Pfenninger (1994) Procedures, Mosby, p. 1036-54
- Salam (2004) Am Fam Physician 69(4):896 [PubMed]
- Yurgil (2020) Am Fam Physician 101(11):654-64 [PubMed]
