56 year old female with a previous history of carpal, cubital and radial tunnel release as well as previous trigger finger releases.
Recently undergoes WALANT left hand index, long and ring finger trigger release on May 17th of 2023. Immediately following the procedure, had severe pain and was developing discoloration and swelling of digits. OP note attached.
PC goes to the ER for pain and swelling. A doppler was performed and showed flow up to the DIP joint. The ER physician contacts the surgeon for guidance and the surgeon elects to see PC in office the next day for eval. No admission or further treatment given. Consult note attached.
PC followed up the next day and the surgeon recommended and performed Phentolamine injections to the index and middle finger bases. While monitoring her post injection, PC continued to have extreme pain and ischemic changes to the digits. She was sent back to the emergency room for further evaluation and admission.
During this admission, an angiogram was performed which revealed hyperemia of the second and fourth digit with minimal to no flow at the distal tips. They attempted thrombolysis with no success. She was started on Eliquis and was instructed to follow up with the specialist for arterial duplex in one month.
PC elected to have a second opinion from a different facility in which they diagnosed her with tissue necrosis to the left index and ring finger. They theorize that it could have been due to the digital nerve block. This provider also performed a debridement and burn dressings. 3 days after debridement, PC continued to develop excruciating pain and was taken to the or for excision and kerecis placement.
She was monitored for approximately 1 month and it was determined that the distal phalangeal segment of the index finger was to be amputated. A below DIP joint amputation was performed in June 2023.
In the subsequent year, PC developed hand neuromas, difficulty with range of motion, severe pain. Had additional graft in September of 2023 which appeared to take and heal well. Despite graft healing, multiple specialists have informed her that a more proximal invitation is possible.
Our concern is the original digital block being performed properly. Also the original emergency room visit when the surgeon was contacted, that Phentolamine should not have been given immediately with possibility of digital ischemia? Appropriate to see the next day?
Please see photos, consult and OP note attached. Thank you.
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Do you believe there might have been medical error?
The surgeon's operative note details that 30 cc of lidocaine with epinephrine was administered in a WALANT technique. This works out to 10 cc per digit released, which is a much higher dose than would be typical. Volumes of 1% lidocaine with epinephrine administered for a trigger finger procedure are typically on the order of 2-5 ml for a single digit. WALANT has been shown to be safe and effective, however there are limits to the safety of the technique. A dose of epinephrine that is too high that is administered locally can cause ischemia, which appears to be exactly what happened in this case. This patient did have the risk factor of having more than two digits operated on concurrently for trigger finger, which does seem to correlate with worse outcomes in general. However, when WALANT technique is performed safely and correctly, with an appropriate dose of local anesthesia, even this should be safe, with the avoidance of digit ischemia. The issue was compounded when, during consultation in the ER, the surgeon did not administer phentolamine. A patient who underwent a multiple-digit WALANT procedure using lidocaine with epinephrine should be considered at high risk for digit ischemia, recognition of which could, in theory, have salvaged the digits with phentolamine treatment. The only factor that must be considered is the possibility that this is a self-induced/accidental hot-water burn rather than ischemia. It seems unlikely given the chronology, as well as the arteriogram results, however, hot water burns have been reported to mimic ischemic post-operative changes. Patients sometimes try to "wake up" an anesthetized digit with hot water and due to the numbness, this can result in burns. However, this is considered unlikely.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As described above, there was likely to be medical error, and if present, the medical error directly resulted in injury i.e. ischemia and amputation. It is also important to consider the injury of stiffness and loss of use of the remainder of the hand, not just the amputated digits, as an injury such as this will usually affect function of the entire hand, and not just the amputated areas.
What makes you a good expert for this case?
I am a board-certified fellowship-trained hand surgeon, who regularly performs WALANT cases with local anesthesia with epinephrine.
How often do you encounter cases similar to this one in your practice?
I have thankfully not seen a similar case of digit ischemia in my practice. However, I perform trigger finger releases with lidocaine with epinephrine on a very regular basis, as WALANT is my predominant technique for the procedure. Trigger finger release is one of the two most common procedures I perform in practice.
Do you believe there might have been medical error?
Should have seen in ER and given phentolamine and admitted.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Not in terms of initial treatment but once presented to ER with pain and ischemia.
What makes you a good expert for this case?
Extensive experience as a hand surgeon and performing this procedure.
How often do you encounter cases similar to this one in your practice?
Throughout my 24 year career as a hand surgeon. But never had this complication.
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