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.

Background

Injuries to the hands and digits are amongst the most common presenting traumatic injuries and frequently require the use of local anesthetics. Traditionally, the use of epinephrine has been avoided in local anesthesia of the hand owing to concerns of potential ischemic necrosis. ^1,2 However, this dogma from the last century was shown to be related to 21 cases before 1950 in which the necrosis was more likely related to the acidic effect of the expired procaine than the epinephrine. ^1-3 Ilicki et al did a large literature review of randomized control trials, case series, retrospective reviews, and other literature; they reported no complications and recommend the safety of epinephrine in digit anesthesia. ⁴ Additionally, autoinjectors have led to an increase of accidental high doses of 1:1000 epinephrine injection into digits, which has not resulted in any cases of lasting necrosis. ^5,6 Phentolamine, an alpha blocker, has been shown to reverse the effects of epinephrine faster than placebo and is the recommended treatment for epinephrine related vasoconstriction. ⁷ Thus epinephrine is once again being used to facilitate hand surgery using Wide Awake Local Anesthesia No Tourniquet (WALANT) by decreasing bleeding and avoiding tourniquet use. ² Few cases of finger necrosis related to epinephrine have been reported in the modern literature. Some have related the ischemia to the atherosclerosis already present in the hands of their older patients. ^8,9 However, none have been related to fibrotic scarring following a crush injury nor have there been any reported to be treated with Hyperbaric Oxygen Therapy (HBOT) salvage. HBOT is where a patient breathes 100% oxygen in a pressurized chamber to above 1 atmosphere. Indications are listed in Table 1. ¹⁰

Table 1.

Hyperbaric Oxygen Therapy Indications according to Undersea & Hyperbaric Medical Society 13th Edition.

Hyperbaric oxygen therapy indications
Crush injuries
Compartment syndrome
Necrotizing soft tissue
Infection Diabetic foot ulcers
Chronic refractory osteomyelitis
Radiation soft tissue necrosis
Compromised flaps and grafts

We present a case where digital pulp necrosis was observed following the use of bupivacaine with 1:200,000 epinephrine in a highly fibrotic and scarred finger. This is the first case we can find in the published literature of epinephrine related digital ischemic necrosis successfully salvaged by Hyperbaric Oxygen Therapy (HBOT) without the use of Phentolamine.

Case Presentation

A 22-year-old healthy male sustained a crush injury associated with an open displaced right index middle phalanx fracture. This was initially managed in office using the WALANT technique using 1% lidocaine and 1:100,000 epinephrine (3 cc injected at the volar base of the digit) with reduction and K wire fixation. The finger developed delayed skin healing and required reclosure at two weeks under WALANT using 1% lidocaine and 1:100,000 epinephrine 3 cc injected at the volar base of the digit in the office, which proceeded to heal the soft tissue. At seven weeks the K wires were removed, the fracture was found to be mobile and in delayed union. An elective open reduction and internal fixation with distal radius bone graft was performed in the hospital operating room under general anesthetic, using an arm tourniquet. Closure of the mid-lateral incision was not found to be under tension. Additional local anesthetic used was bupivacaine with 1:200,000 epinephrine (3 cc injected at the volar base of the digit) at the end of the case. Although mild congestive vascular compromise was noted, it was not considered severe enough to offer phenolamine acutely. Five days later he represented to the office due to discoloration of the pulp which was observed to be blistered and dusky (Figure 1). This was outside the window of phentolamine rescue and thus 36 episodes of HBOT at 2 atmospheres were provided. These treatments lead to the successful salvage of his soft tissue ischemia by healing of the pulp and the nonunion (Figure 2) with good color and capillary refill. One year later, the same finger underwent extensor tenolysis using a digital tourniquet, lidocaine, and no epinephrine (3 cc injected at the volar base of the digit). No ischemic changes were observed (Figure 3).

Figure 1.

Twenty-two-year-old male with necrotic right index finger 5 days after epinephrine injection into fibrotic and scared digit from two-month prior crush injury.

Figure 2.

Hyperbaric Oxygen Therapy (HBOT) salvage of necrotic distal finger after epinephrine injection into fibrotic scar.

Figure 3.

End of case photograph, 1 year later lidocaine without epinephrine was used for extensor tenolysis.

Discussion

This case of digital ischemia following the use of epinephrine in a fibrotic scarred finger following a crush injury two months prior is reported as a warning to other hand surgeons performing WALANT; epinephrine should be used with caution for digital blocks associated with scarred tissue caused by a prior history of crush injury. Following a crush injury scarring progressively builds up over the first 3 months, which would explain the success of the second injection of 1:100,000 epinephrine at two weeks followed by ischemic compromise in a more fibrotic environment at seven weeks. The effect of epinephrine was further isolated by the finding that one year later, using lidocaine without epinephrine no vascular compromise was identified.

When vascular compromise is suspected following epinephrine injection, phentolamine should be used to reverse the vasoconstriction, which was not performed in this case. In the event of congestion and ischemia other standards of care also exist: these include leach therapy (hirudotherapy), ^11,12 antiplatelet therapy such as Aspirin, antithrombotics, and thrombolytics. Yet there is little consensus regarding the ideal strategy. ¹³

This case also demonstrates the unique application of HBOT. Compromised tissue from epinephrine can be salvaged by HBOT once the process of ischemic necrosis is suspected and is an important tool for the clinician to consider when treating a sensitive location such as a digit.