The Effect of Forearm Nerve Blocks on Pain-free Tourniquet Time Compared to Local Anesthetic for Awake Hand Surgery

Wide-awake surgery with local anesthesia is a widely described approach to performing numerous minor hand procedures, such as tendon repairs and percutaneous fracture pinning, but is less frequently used for longer procedures such as open reduction internal fixation (ORIF). This is in part due to the need for a tourniquet for improved visualization, however pain-free tourniquet time with local anesthesia is roughly 20 minutes, shorter than the average time for ORIFs (Gillis), for example. While general anesthesia may still be avoided with more proximal blocks such as a brachial plexus or bier blocks, these still require presence of an anesthesiologist during the procedure, increasing human resource utilization and costs. Development of an anesthetic technique for hand surgery which could be performed by surgeons in a clinic setting, that still provides sufficiently long pain-free tourniquet times could decreases costs and wait times. The investigators hypothesize that the pain patients experience after 20 minutes of tourniquet application with local anesthetic infiltration is not due to direct pressure on the proximal arm, but rather distal digital ischemia pain. Previously, it has been shown that ultrasound-guided regional block of the median, radial, and ulnar nerves in the forearm is effective analgesia for awake hand surgery (Winter). Currently, there are no randomized studies investigating if forearm nerve blocks can prolong pain-free tourniquet time compared to local anesthesia infiltration, by blocking this ischemic pain in the distal arm. The investigators' objective is therefore to determine if forearm nerve blocks prolong pain-free tourniquet time compared to local anesthetic infiltration.