HAND/PERIPHERAL NERVE

Do Not Use Epinephrine in Digital Blocks:

Myth or Truth? Part II. A Retrospective Review
of 1111 Cases
Saeed Chowdhry, M.D.
Background: Epinephrine in digital blocks has been condemned by traditional
Lynn Seidenstricker, M.D. medical theory. The authors provide a retrospective review of 1111 cases involving
Damon S. Cooney, M.D. digital block anesthesia with epinephrine in conjunction with an extensive literature
Ron Hazani, M.D. review.
Bradon J. Wilhelmi, M.D. Methods: The authors conducted a retrospective review of 1111 cases involving
Louisville, Ky.; Chicago digital and hand surgery. Observations were made concerning the location of and
and Springfield, Ill.; Knoxville, Tenn.; indication for surgery, age, sex, type of block used, type and dose of anesthetic, use
and Pittsburgh, Pa. of epinephrine and concentration, use of a tourniquet, follow-up, and complica-
tions. Dorsal and transthecal techniques were used exclusively. Patients with vascular
compromise did not receive epinephrine and were excluded from the study.
Results: One thousand one hundred eleven cases were reviewed, distributed
among 692 male patients and 419 female patients. Sites of surgery ranged through-
out the hand and all fingers for a variety of indications. Five hundred patients
received injections of 1% plain lidocaine with a dosage range of 2 to 10 cc
and an average of 5.7 cc. Six hundred eleven patients received injections of
1% lidocaine with epinephrine (1:100,000) in a dose range of 0.5 to 10 cc
and an average dose of 4.33 cc. Nine hundred eighty-six patients (88.75
percent) followed up in the clinic. No patients suffered from digital gangrene
in the epinephrine group.
Conclusions: After reviewing 1111 cases, there were no complications asso-
ciated with the use of epinephrine in digital blocks. The authors suggest that
correct application of epinephrine in digital blocks is appropriate, and
defend its use. (Plast. Reconstr. Surg. 126: 2031, 2010.)

T
raditional medical education discourages the
use of epinephrine for digital block anesthesia.
The teachings of most textbooks refer to the
theory that epinephrine-induced vasoconstriction of
end arteries can potentially lead to ischemia and
necrosis.1–10 After an exhaustive literature review, no
study has determined that epinephrine in and of
itself has resulted in finger gangrene.11–13
Initial use of local anesthetics dates back to 1884
with Karl Koller’s use of cocaine in the conjunctival
sac to anesthetize the cornea.14 –19 Strauss broadened
the medical use of cocaine to include the first de-
scription of the digital block when treating an in-
grown toenail in 1889.17–19 Procaine was developed
From the University of Louisville; Mt. Sinai Medical Center;
College of Medicine, University of Tennessee; Southern Illi-
nois University; and the University of Pittsburgh.
Received for publication February 22, 2010; accepted June
14, 2010.
Copyright ©2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181f44486
soon thereafter in 1904 by Einhorn in Germany.13,16
Because of the vasodilatory effect of these anesthet-
ics, Braun postulated the addition of ephedrine in
1905 to provide a vasoconstrictive and hemostatic
effect.14,20,21 Lofgren and Lundquist ultimately de-
veloped lidocaine, in 1943.13,22 In contrast to the
ester-containing medications, which have a short 30-
to 40-minute duration and higher allergic profiles,
the amide-containing anesthetics such as lidocaine
have a longer duration of 1 to 2 hours, rapid onset,
improved efficiency, and lower allergenicity.12–14,16
Epinephrine induces a potential hemostatic ef-
fect by binding the alpha-1 and alpha-2 receptors
and causing vasoconstriction through activation of
the phosphatidylinositol system and adenylate cyclase
pathways.20–23 These results have been measured in
digital vessels with Doppler laser flowmetry.24
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

www.PRSJournal.com 2031
 Plastic and Reconstructive Surgery • December 2010
The use of epinephrine in conjunction with lo-
cal anesthetics has the benefit of enhancing the an-
esthetic effect, prolonging its duration, and provid-
ing a temporary hemostatic effect.1,9,17,24 –27 Because
of the vasoconstrictive properties of epinephrine,
caution should be exercised in its preparation, con-
centration, and administration.26,27 Tissue ischemia
and sloughing have been described with concentra-
tions of 1:20,000. Current recommendations sup-
port concentrations in the range of 1:100,000 to
1:800,000, with a maximum dose not exceeding 1
mg.28 –30 Systemic effects such as hypertension are
generally not realized with less than 0.5 mg of epi-
nephrine (50 ml of 1:100,000).1,31 Digital blocks re-
quire only a small fraction of this amount; only 5 ml
is typically used, making systemic effects rare. Epi-
nephrine in patients with pheochromocytoma, hy-
perthyroidism, severe hypertension, cardiac disease,
and peripheral vascular disease should be used with
caution, as smaller doses of the drug can have more
severe adverse ramifications for these patients.1,9,32
Previously performed prospective, randomized,
double-blind studies demonstrated no increased in-
cidence of finger gangrene with the adjunctive use
of epinephrine as opposed to the use of plain local
anesthetic.26,27 The current study uses a larger pa-
tient population to further support these previous
findings and add weight toward disproving the old
dogma of avoiding epinephrine in digital surgery.
PATIENTS AND METHODS
Over the past 7 years, all cases of digital and hand
surgery performed by the senior author (B.J.W.)
were reviewed retrospectively. Observations were
made concerning the location of and indication for
surgery, age, sex, type of block used, type and dose
of anesthetic, use and concentration of epinephrine,
use of a tourniquet, follow-up, and complications.
Table 1. Number and Type of Procedures Performed
Procedure Epinephrine
Laceration 246
Fracture 128
Trigger finger surgery 58
Amputation 42
Tenosynovitis 33
Infection 16
Rupture, tear (tendon, band) 14
Foreign body 13
Contracture/stiffness 23
Osteophyte 12
Other TS 10
Abscess 9 5
Dislocation 7 6
Total 611
PVD, peripheral vascular disease; TS, tendon surgery.
2032
Indications for use included common digital injuries
such as nail bed injuries, paronychia, felon, frac-
tures, dislocations, incision and drainage, and lac-
erations. Only 27-gauge or smaller caliber needles
were used for injection. The dorsal and transthecal
techniques were used exclusively. The circle tech-
nique was avoided, and no patient received more
than 10 cc of anesthetic. Finally, patients with inju-
ries that caused vascular compromise or with pe-
ripheral vascular disease affecting the upper extrem-
ity and digits did not receive epinephrine.
RESULTS
One thousand one hundred eleven cases were
reviewed, distributed among 692 male patients
and 419 female patients. One thousand one hun-
dred eleven procedures performed involved fin-
ger surgery, and 611 of these received digital
blocks with epinephrine. Patient age ranged from
6 months to 93 years, with a mean age of 41.6 years.
Indications for and sites of surgery ranged
throughout the hand and all fingers for a variety
of indications including but not limited to trau-
matic crush injuries, lacerations, amputations,
contracture releases, and fractures. Tables 1 and
2 best delineate the sites of and indications for
surgery. Five hundred patients received injections
of 1% plain lidocaine with a dose range of 2 to 10
cc and an average of 5.7 cc. Six hundred eleven
patients received injections of 1% lidocaine with
epinephrine (1:100,000) in a dose range of 0.5 to
10 cc and an average dose of 4.33 cc. One hundred
patients presented with injuries that caused vas-
cular compromise or had peripheral vascular dis-
ease and did not receive epinephrine. Nine hun-
dred eighty-six patients (88.75 percent) followed
up in the clinic. Attempts were made to contact
patients who did not follow up; however, these
Vascular Compromise
Plain or PVD Total
194 32 440
123 21 251
40 5 98
34 15 76
21 8 54
13 3 29
13 5 27
12 3 25
19 2 42
11 2 23
9 1 19
2 14
1 13
500 100 1111
Volume 126, Number 6 • Use of Epinephrine in Digital Blocks
Table 2. Sites of and Indications for Surgery
Surgical Site Epinephrine Plain
Right thumb 52 44
Right index finger 64 56
Right middle finger 72 60
Right ring finger 63 54
Right small finger 57 29
Left thumb 61 56
Left index finger 58 51
Left middle finger 84 56
Left ring finger 51 50
Left small finger 49 44
Total 611 500
patients were noncompliant. No patients suffered
from digital gangrene in the epinephrine group.
In addition, no patients suffered from nerve in-
juries or unusually delayed wound healing in the
epinephrine group on follow-up.
DISCUSSION
Historically, several factors have been impli-
cated in finger gangrene following digital blocks.
Among these are excessive tourniquet pressure,
ring block technique, epinephrine, high-volume
injection, and burns from hot soaks to anesthe-
tized fingers.28 –34
Garlock initially reported gangrene following
digital block surgery. He injected undocumented
volumes of 0.5% and 1% procaine and applied a
digital tourniquet. He presumed the finger gan-
grene was a result of endothelial injury secondary
to the tourniquet pressure.28 Tourniquets have
been shown to cause nerve and muscle injury in
animal models when pressures exceed 500 mmHg.35,36
Endothelial injury as a direct result of tourniquet
pressure has yet to be demonstrated.
Digital tourniquets are well tolerated, pro-
vided that the skin is anesthetized.37 Safe use of
digital tourniquets has been described, as acidosis
and hyperkalemia systemically are not noticed be-
cause of dilution factors.18,20,38 – 45 However, cases of
tourniquets mistakenly being left on at the con-
clusion of surgical procedures with resultant isch-
emia and necrosis have been described.46 – 49
Hot soaks have been implicated in finger gan-
grene following digital blocks with both epineph-
rine-enhanced anesthetic and plain anesthetic.
Kaufman30 and McLaughlin32 reported two pa-
tients with finger gangrene after digital blocks
with epinephrine. However, these patients suf-
fered scald burns to their anesthetized fingers
from hot solutions of boric acid. These patients
did not feel the burn until the solution had passed
the anesthetized areas and reached their palms.
The epinephrine may have contributed to the gan-
grene only through prolonging the anesthetic ef-
No. fect and thereby facilitating the burn injuries.
O’Neill and Byrne34 had similar results of burn
96
120 injuries from hot soaks with the use of digital
132 blocks. As a result, they condemned the use of hot
117 soaks after digital block anesthesia.
86
117 The ring technique has also been implicated
109 in finger gangrene with digital blocks. Bradfield
140 reported one case of finger gangrene after the
101
93 patient received a digital block of 15 ml of plain
1111 anesthetic through one injection into the lateral
aspect of the finger in a ring block fashion.33
Burnham31 reported success using digital blocks
with epinephrine in 1958. He had no complica-
tions in 93 patients who received digital blocks of
2% procaine and 1:200,000 epinephrine. He pos-
tulated that his lack of complications stemmed
from his technique of injecting the epinephrine
proximal to the metacarpal heads.
Sylaidis and Logan reported their prospective
study in which 100 patients underwent digital block
anesthesia of 2% lidocaine with 1:80,000 adrenaline.
Their study demonstrated temporarily reduced dig-
ital flow with persistent digital perfusion.50
In 2005, Lalonde et al. demonstrated their use
of epinephrine in hand and finger surgery in a
multicenter study that involved 3110 cases, with no
complications related to ischemia and infarction
secondary to epinephrine use.51 Lalonde et al.
described their findings with the use of epineph-
rine in hand and finger surgery, with the majority
in the hand. The current study aims to add to these
findings by providing further supporting evidence
to challenge the accepted practice of not using
epinephrine in digital block anesthesia.
CONCLUSIONS
After reviewing 1111 cases, there were no com-
plications associated with the use of epinephrine in
digital blocks. The added benefits of using epineph-
rine in conjunction with local anesthetics include
decreasing the amount of local anesthetic, decreas-
ing the need for a tourniquet, providing hemostasis,
and prolonging the anesthetic effect.14,26,27,35,52,53 By
enhancing and prolonging the effects of the local
anesthetic, the use of epinephrine may also re-
duce the need for additional injections and
thereby reduce the potential for neurovascular
injury. The pillars of medical education are
founded on not using vasoconstrictive agents in
the vicinity of end arteries. As such, the use of
epinephrine in digital blocks has been con-
demned by traditional medical theory without
supporting clinical evidence. We suggest that cor-
2033
 Plastic and Reconstructive Surgery • December 2010
rect clinical application of epinephrine in digital
blocks is appropriate, and defend its use.
Saeed Chowdhry, M.D.
Mt. Sinai Medical Center
777 North Michigan Avenue, Unit 2503
Chicago, Ill. 60611
sachowdhry22@gmail.com
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