Pediatric Digital Nerve Block
Last Published 75 days ago at 10:50AM by  Dan Imler, MD


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Pediatric Digital Nerve Block

Determine approach

Nitrous Oxide Inhalation Analgesic
Inclusion Criteria
  • Clinical need to anesthetize a finger or toe
Exclusion Criteria
  • History of hypersensitivity to local anesthetics of the amide type
  • Soft tissue infection at site of local anesthetic injection
  • Vascular compromise to digit

Withdraw needle and repeat on the other side

Test for adequate analgesia and if lacking, inject more anesthetic or consider other analgesic procedure

Contraindications to midazolam

  • History of adverse event
  • Current disease process causing myocardial depression
  • Patients at risk for hypoventilation

Obtain 25 - 30 gauge needle with 1% lidocaine (buffered and warmed) and consider epinephrine if extensive bleeding expected

Lidocaine 1% injection
Lidocaine 1% with epinephrine injection

Determine approach

Contraindications to midazolam?

Sterilize the puncture site with providone-iodine or chlorhexidine

Contraindications to nitrous oxide?

Patient to require anxiolysis?

Contraindications to nitrous oxide

  • History of adverse event
  • Vomiting
  • Pregnancy
  • Gas within body cavities (SBO, Pneumothorax, Otitis Media, etc)

Wing block

  • Place patient's hand/foot flat with volar side down
  • Insert needle 3 mm at 45 degree angle perpendicular to the digit into the deep intradermal tissue of the dorsum of the digit
  • Inject anesthetic infiltrating the proximal nail fold
  • Redirect needle and infiltrate the intradermal tissue along the lateral nail fold

Intranasal or Oral midazolam 20 min prior to procedure

Midazolam 10mg/mL intranasal solution
Midazolam suspension

Transthecal block

  • Place patient's hand flat with palm-side up
  • Locate distal palmar crease and then palpate for the flexor tendon of affected digit
  • Insert needle distal to palmar crease at 45 degrees and advance to flexor tendon sheath
  • Inject 1 - 2 ml of anesthetic into flexor tendon sheath (should have minimal resistance)

Toe digital block

  • Place patient's foot flat with plantar-side down
  • Insert needle perpendicular into the subcutaneous tissue in the web space at the base of the toe
  • Inject anesthetic into subcutaneous tissues around the nerve (induration should appear)
  • Advance the needle towards the plantar surface and inject more anesthetic
  • Withdraw needle and repeat on the other side

Three-sided great toe block

  • Place patient's foot flat with plantar-side down
  • Insert needle perpendicular subcutaneous tissue in the web space at the base of the toe
  • Inject anesthetic into subcutaneous tissues around the nerve (induration should appear)
  • Advance the needle towards the plantar surface and inject more anesthetic
  • Withdraw needle and repeat on the other side

Partially withdraw needle and redirect over the dorsum of the toe and inject anesthetic

Web space block

  • Place patient's hand flat with palm-side down
  • Insert needle perpendicular into the subcutaneous tissue in the web space at the base of the finger
  • Inject anesthetic into subcutaneous tissues around the nerve (induration should appear)
  • Advance the needle towards the palmar surface and inject more anesthetic