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Three Part Question

In [ED patients requiring anesthesia to the finger] is a [digital nerve block better than local anesthesia] at [minimizing pain during infiltration and achieving adequate anesthesia].

Clinical Scenario

A 4 y/o boy presents to an urgent care setting with a 1 cm laceration across the volar aspect of his index finger just distal to the dip joint? The attending physician is debating whether to numb the laceration locally versus employing a digital block

Search Strategy

Medline 1950-04/09 using OVID interface, Cochrane Library (2009), PubMed clinical queries

[(exp nerve block/ or "nerve block".mp or exp anesthesia or exp anesthesia, local) AND (exp metacarpus/ or "metacarpal".mp. or exp finger injuries/)]. LIMIT to human AND English.

Search Outcome

96 papers were found of which 2 were relevant to the three part question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Chale S. Singer AJ. Marchini S. McBride MJ. Kennedy D 10/06 USA	55 patients presenting to a university-based ED > 8 y/o with finger lacerations. Pts were randomized to digital or local anesthesia w/LET. Pts were then assessed for quality of anesthesia s/p repair.	Single-center, prospective, randomized, clinical-trial design	Pain of needle insertion, anesthetic injection, and suturing. Secondary outcomes included patient satisfaction, time until anesthetic onset, and the presence of wound infection and persistent numbness.	Based on a validated visual analog scale, there was no between-group differences in pain of needle insertion, anesthetic infiltration, or suturing.	-Study size of 55 -Not double-blinded, practitioner and patient knew which arm of the study they were in. -No LET administered to digital block (even if it would provide a placebo effect) -VAS is a subjective form of data collection -1% Lidocaine was neither warmed, buffered, nor had any epi -Topical anesthesia for local group only administered for 15 mins -One study site
Robson AK. Bloom PA. 11/1990 UK	62 patients presenting to the Accident Department of the Bristol Royal Infirmary > 16 y/o w/finger lacerations not involving deep structures or under the influence of drugs/ETOH. Pts were randomized into a group receiving a digital block, the other local infiltration. Pts were then assessed for quality of anesthesia after repair was performed	A single-center, prospective, randomized trial	Primary outcomes included pain of administiring the anesthetic and pain of suturing posed to both physician and patient in the form of a questionaire	In each of the 4 q's posed by the questionairre, digital block was more effective than local infiltration	-study size of 62 -Not double-blinded, both practioner and patient knew which arm of the study they were in -only data presented is "p" values, so it is impossible to determine the clinical significance of the study -VAS used in questionnaire is a subjective form of data acquisition -2% lignocaine (lidocaine) was neither warmed, buffered, nor contained epi -One study site

Comment(s)

The UK study showed that the digital block was a more effective form of anesthesia based on responses from both the patient and the provider. The US study showed no difference in anesthesia between local infiltration and digital block with the only caveat being the administration of LET (lidocaine-epinephrine-tetracaine) in the local group. Digital block takes longer to take effect, but administering LET has the same effect. Unless staff applies LET in triage, there does not seem to be any significant advantage.

Clinical Bottom Line

Until a clinical trial uses LET (lidocaine-epinephrine-tetracaine) in both arms, the effectiveness of analgesia cannot be accurately answered. Both methods are viable options in regards to efficacy and efficiency.

References

1. Chale S. Singer AJ. Marchini S. McBride MJ. Kennedy D Digital versus Local Anesthesia for Finger Lacerations: A Randomized Controlled Trial Academic Emergency Medicine Oct 2006; 13(10):1046-50
2. Robson AK. Bloom PA Suturing of digital lacerations: digital block or local infiltration? Annals of the Royal College of Surgeons of England Nov 1990; 72(6):360-1