Hand and Finger Injuries: One ER Physician's Story

As an emergency room physician, I frequently see hand injuries.

I injured my hand when I was 18 years old, and since then I have taken a special interest in treating hand injuries.

While working in a restaurant I accidentally stuck my index finger into a mechanical cheese grating machine and ground off the tip of my finger. I suffered traumatic nail bed damage, an open fracture, and tendon injury to the dorsum (back side) of my finger.

I went directly to the local emergency department where I was seen by a resident physician who took some X-rays and then prepared to repair the extensive lacerations.

During the procedure the doctor injected lidocaine (a common local anesthetic) directly into the area surrounding my wounds to anesthetize my finger, which was incredibly painful - more painful than the initial injury. The doctor put in several stitches to stop the bleeding and bandaged my finger with a splint. I was referred to a hand surgeon for follow-up the next day.

The hand surgeon examined my wounds and told me he needed to repair the tendon injury and fix the fragmented piece of bone. To do this, he had to remove the stitches. Scared at the prospect of multiple painful shots in the tip of my finger again, I initially refused. The hand surgeon explained he would inject the anesthetic at the base of my finger, which would be much less painful. In fact, he continued, injecting my fingertip was improper, and he was so upset he called the emergency room and spoke with the resident physician and instructed him as to how to properly anesthetize a finger wound.

The hand surgeon explained step-by-step the anesthetizing procedure (called a digital block), my injury was fixed with much less pain, and today my finger works normally.

A digital block is the proper way to anesthetize a digit (finger or toe) and minimizes the amount of pain of the injection. The nerve endings of the fingers are heavily concentrated on the palmar aspect (the finger surface on the palm side of the hand). Injecting anesthetic into those areas, with their abundance of nerve endings, is quite painful. Instead, it is better to put the medicine in the dorsal (back) side of the hand or foot.

The nerve branches that supply the fingers run adjacent to the bone on either side of the knuckles of the hand. Injecting the anesthetic medicine around these nerve branches can accomplish complete anesthesia (numbness) of the whole finger.

In this procedure, the doctor first cleans the back of the hand around the knuckles and between the fingers. Then, a small amount of anesthetic is injected on both sides of the digit. Some physicians add lidocaine to the back and front of the finger, forming a ring of anesthetic completely around the base (called a "ring block"). It takes between 5-10 minutes for the anesthetic to completely take effect, causing the finger to feel heavy and numb. Typically the anesthesia lasts between 1-2 hours, and the doctor is able to repair any injuries.

Hand injuries are a common reason for emergency room visits. When they are handled properly and the procedures are done correctly, a digital block can aid the physician in repairing the injury, thereby lessening the amount of pain for the patient.