WEBVTT 00:00:00.000 --> 00:00:02.660 Welcome to the Deep Dive. Today we're diving 00:00:02.660 --> 00:00:04.719 into something really intricate, the world of 00:00:04.719 --> 00:00:07.219 surgical approaches to the hand, wrist, and forearm. 00:00:07.309 --> 00:00:10.990 Yeah, it's an area packed with tiny vital structures, 00:00:11.369 --> 00:00:14.089 really fascinating stuff. Absolutely. And for 00:00:14.089 --> 00:00:16.269 you listening, if you want to grasp the complexities 00:00:16.269 --> 00:00:18.429 here without getting totally bogged down in medical 00:00:18.429 --> 00:00:20.530 speak, well, that's our goal today. Exactly. 00:00:20.789 --> 00:00:23.850 We're basing this on a couple of key sources. 00:00:23.929 --> 00:00:26.929 One's a very detailed medical text on the anatomy 00:00:26.929 --> 00:00:28.969 and surgical technique, sort of the surgeon's 00:00:28.969 --> 00:00:31.769 map, you could say. OK. And the other is a chapter 00:00:31.769 --> 00:00:34.649 focusing specifically on anesthesia for these 00:00:34.649 --> 00:00:37.530 upper limb surgeries. which is, you know, just 00:00:37.530 --> 00:00:40.310 as crucial. Right. So the mission today. Basically 00:00:40.310 --> 00:00:43.170 to pull out the most critical anatomical ideas, 00:00:43.729 --> 00:00:46.409 the things surgeons absolutely need to know for 00:00:46.409 --> 00:00:50.030 safe procedures in this very delicate zone, and 00:00:50.030 --> 00:00:52.950 also to touch on how anesthesia makes it all 00:00:52.950 --> 00:00:55.770 work for the patient. OK, let's get into it. 00:00:56.210 --> 00:00:58.310 First up, something that seems obvious, but is 00:00:58.310 --> 00:01:01.590 fundamental, anatomical knowledge. Our source 00:01:01.590 --> 00:01:04.150 really hammers this home, doesn't it? Yeah. It 00:01:04.150 --> 00:01:06.170 really does. It's not just about knowing names. 00:01:06.349 --> 00:01:09.230 It's about having this like 3D picture in your 00:01:09.230 --> 00:01:11.430 head of how everything fits and works together. 00:01:11.769 --> 00:01:14.510 It's paramount for safe dissection. And there's 00:01:14.510 --> 00:01:16.609 this concept they highlight inner nervous planes. 00:01:16.689 --> 00:01:20.829 What's that about? Ah, yes. Think of them as... 00:01:20.650 --> 00:01:23.890 Well, natural corridors, they're the spaces between 00:01:23.890 --> 00:01:26.090 muscle groups that happen to be supplied by different 00:01:26.090 --> 00:01:28.870 nerves. OK, so like a seam. Exactly, like a seam 00:01:28.870 --> 00:01:31.310 in the fabric. By going through these seams, 00:01:31.590 --> 00:01:33.650 surgeons can get to deeper structures, bones, 00:01:33.849 --> 00:01:35.709 joints, you name it, without cutting through 00:01:35.709 --> 00:01:37.890 or damaging the nerves supplying the muscles 00:01:37.890 --> 00:01:40.689 they're moving aside. Which avoids causing weakness 00:01:40.689 --> 00:01:43.810 or paralysis later on. Precisely. Avoiding muscle 00:01:43.810 --> 00:01:47.549 denervation is huge. So finding and using these 00:01:47.549 --> 00:01:49.909 planes, it's a core principle for minimizing 00:01:49.909 --> 00:01:52.489 harm. during extensive exposure. Makes total 00:01:52.489 --> 00:01:54.469 sense. It's like taking the path of least resistance, 00:01:54.750 --> 00:01:57.930 but for nerves. And this whole area, hand, wrist, 00:01:58.250 --> 00:02:00.189 forearm, it's uniquely challenging because everything's 00:02:00.189 --> 00:02:03.010 so crowded, right? Oh, absolutely. You've got... 00:02:02.840 --> 00:02:06.840 muscles, tendons gliding smoothly, vital blood 00:02:06.840 --> 00:02:09.460 vessels, and all those nerves controlling movement 00:02:09.460 --> 00:02:12.539 and feeling all packed into a really tight space. 00:02:13.080 --> 00:02:15.900 It's a delicate balance. A small mistake could 00:02:15.900 --> 00:02:17.919 have big consequences. Definitely. That's why 00:02:17.919 --> 00:02:20.719 the detailed knowledge is so vital. So, to manage 00:02:20.719 --> 00:02:23.280 this complexity, the anatomy is often discussed 00:02:23.280 --> 00:02:26.000 in terms of compartments. Our source mentions 00:02:26.000 --> 00:02:28.680 this for both the hand and forearm. Yeah, thinking 00:02:28.680 --> 00:02:30.919 in compartments is really helpful. It gives structure. 00:02:31.319 --> 00:02:33.599 In the hand, for example, you've got the thonara 00:02:33.599 --> 00:02:35.840 compartment, that fleshy bit at the base of your 00:02:35.840 --> 00:02:38.400 thumb. Right, thumb muscles. Mostly median nerve 00:02:38.400 --> 00:02:41.099 territory. Then the hypothenar on the pinky side, 00:02:41.520 --> 00:02:44.460 mostly ulnar nerve. You have the interosseous 00:02:44.460 --> 00:02:46.919 muscles between the hand bones. Also ulnar nerve, 00:02:47.020 --> 00:02:50.740 mostly. Largely, yes. And then the famous carpal 00:02:50.740 --> 00:02:53.250 tunnel. critical channel for the median nerve 00:02:53.250 --> 00:02:55.629 and tendons heading into the hand. Thinking about 00:02:55.629 --> 00:02:58.189 these zones helps surgeons plan their approach. 00:02:58.729 --> 00:03:00.969 And our source goes into the specific muscles, 00:03:01.310 --> 00:03:03.090 their attachments, their nerve supply within 00:03:03.090 --> 00:03:05.270 each compartment. We're just skimming the surface, 00:03:05.569 --> 00:03:08.069 but it shows the detail needed. It really does. 00:03:08.250 --> 00:03:11.810 And similarly, in the forearm, you have compartments 00:03:11.810 --> 00:03:15.030 too. Superficial volar that's palm facing. Like 00:03:15.030 --> 00:03:17.469 the wrist flexors? Yeah, things like pronator 00:03:17.469 --> 00:03:20.990 teres, flexor carpe radialis, mostly median nerve 00:03:20.990 --> 00:03:23.430 again. Then there's a deep volar compartment 00:03:23.430 --> 00:03:25.969 and a dorsal compartment on the back. Knowing 00:03:25.969 --> 00:03:28.310 which compartment you're in tells you what structures 00:03:28.310 --> 00:03:30.870 to expect. It's like a roadmap. OK, so moving 00:03:30.870 --> 00:03:33.409 from the map, the anatomy to the actual journey, 00:03:33.509 --> 00:03:36.419 the surgery. The source talks about principles 00:03:36.419 --> 00:03:40.159 of surgical management. Planning seems key. Non 00:03:40.159 --> 00:03:43.159 -negotiable. The text stresses that every single 00:03:43.159 --> 00:03:46.240 approach needs that solid understanding of anatomy 00:03:46.240 --> 00:03:48.800 surface and deeps, plus those inner nervous planes 00:03:48.800 --> 00:03:50.979 we talked about, and of course, good surgical 00:03:50.979 --> 00:03:52.919 technique. And it's not just knowing the steps 00:03:52.919 --> 00:03:55.280 right. There's a lot of prep work. A huge amount. 00:03:55.460 --> 00:03:56.979 Making sure you have all the right instruments, 00:03:57.120 --> 00:03:58.960 the right sutures, imaging available if needed. 00:03:59.020 --> 00:04:01.379 If you're putting in plates or screws, they have 00:04:01.379 --> 00:04:04.900 to be ready. Exactly, using x -rays or scans 00:04:04.900 --> 00:04:07.860 to plan implant sizes and positions beforehand. 00:04:08.419 --> 00:04:10.780 The whole team reviews the anatomy, the approach, 00:04:11.020 --> 00:04:13.520 the procedure itself, and even discusses alternatives, 00:04:13.919 --> 00:04:17.019 what if Plan A doesn't work? And the OR setup. 00:04:17.560 --> 00:04:19.899 Seems like small details matter. They really 00:04:19.899 --> 00:04:23.019 do. Patient positioning is usually supine, lying 00:04:23.019 --> 00:04:25.360 on their back with the arm out on a special hand 00:04:25.360 --> 00:04:28.100 table. That table needs to be rock solid. For 00:04:28.100 --> 00:04:30.699 precision. Absolutely. And the surgeon needs 00:04:30.699 --> 00:04:33.790 a stable stool, good lighting. really good lighting, 00:04:34.209 --> 00:04:37.209 angled properly to avoid shadows. It all contributes. 00:04:37.430 --> 00:04:39.769 And the tourniquet. That's standard for a bloodless 00:04:39.769 --> 00:04:42.029 field. Almost always in hand and wrist surgery, 00:04:42.269 --> 00:04:44.250 yes. A pneumatic tourniquet on the upper arm. 00:04:44.430 --> 00:04:46.430 It gives you that clear view which is just essential 00:04:46.430 --> 00:04:49.029 when you're working around nerves and tiny vessels 00:04:49.029 --> 00:04:51.509 like working on a delicate machine. Right. Now 00:04:51.509 --> 00:04:54.110 let's talk incisions. Making the cut in the hands 00:04:54.110 --> 00:04:56.680 specifically. Are there general rules? There 00:04:56.680 --> 00:04:59.180 are. The source says you can technically make 00:04:59.180 --> 00:05:01.620 an incision almost anywhere, but you have to 00:05:01.620 --> 00:05:04.199 respect certain principles for good healing and 00:05:04.199 --> 00:05:07.779 function. Avoid areas that stay damp, like deep 00:05:07.779 --> 00:05:10.480 creases sometimes, and plan so the skin edges 00:05:10.480 --> 00:05:12.959 come together nicely without tension. And they 00:05:12.959 --> 00:05:16.220 mark the incision beforehand, with a sterile 00:05:16.220 --> 00:05:19.199 marker. Always. Standard practice lets you visualize 00:05:19.199 --> 00:05:21.560 it, check placement, make sure you leave enough 00:05:21.560 --> 00:05:24.199 skin between cuts if you need multiple incisions. 00:05:24.459 --> 00:05:27.720 It's a guide. Okay, and differences between palm 00:05:27.720 --> 00:05:30.920 side volar and Back of hand dorsal incisions. 00:05:31.019 --> 00:05:33.779 Yeah, that's important on the palm The subcutaneous 00:05:33.779 --> 00:05:36.259 tissue can be thin and incisions right in the 00:05:36.259 --> 00:05:38.839 deep creases might not heal quite as well And 00:05:38.839 --> 00:05:41.120 a big don't is making straight incisions across 00:05:41.120 --> 00:05:43.699 the flexion creases. Why is that? scar contracture. 00:05:43.939 --> 00:05:46.579 Exactly. It can lead to tight scars that limit 00:05:46.579 --> 00:05:48.959 bending later on. The skin on the back of the 00:05:48.959 --> 00:05:51.279 hand is generally looser, more mobile, so sometimes 00:05:51.279 --> 00:05:53.279 you can get away with a slightly smaller incision 00:05:53.279 --> 00:05:55.019 there. And the shape of the incision can vary 00:05:55.019 --> 00:05:58.680 too, like zigzags. Definitely. Zigzag incisions 00:05:58.680 --> 00:06:01.600 are common on the volar side of fingers. They 00:06:01.600 --> 00:06:04.699 break up the line across the creases. On the 00:06:04.699 --> 00:06:06.680 back, you might see straight lines or gentle 00:06:06.680 --> 00:06:09.720 curves. Medaxial incisions along the side of 00:06:09.720 --> 00:06:12.420 the finger need extra care because of the neurovascular 00:06:12.420 --> 00:06:14.500 bundles running there. Okay, let's get more specific. 00:06:15.000 --> 00:06:18.040 Approaching the finger joints, the interphalangel 00:06:18.040 --> 00:06:20.399 joints. Right, the hinge joints in your fingers. 00:06:21.100 --> 00:06:23.399 Surgeons often use dorsal incisions straight, 00:06:23.800 --> 00:06:27.279 S -shaped, maybe chevron. A common way in is 00:06:27.279 --> 00:06:29.519 from the side, carefully lifting and retracting 00:06:29.519 --> 00:06:32.079 the lateral bands of the extensor tendon mechanism. 00:06:32.360 --> 00:06:34.959 Any specific precautions depending on which joint? 00:06:36.040 --> 00:06:39.980 DIP versus PIP. Yes. At the DIP joint near the 00:06:39.980 --> 00:06:41.819 nail, you have to be super careful of the geminal 00:06:41.819 --> 00:06:43.660 matrix where the nail grows from. It's right 00:06:43.660 --> 00:06:46.060 near the tendon insertion. At the PIP joint, 00:06:46.199 --> 00:06:48.360 the middle one, the extensor mechanism is right 00:06:48.360 --> 00:06:50.180 there under the skin. No inner nervous plane 00:06:50.180 --> 00:06:52.899 there. Correct. For more exposure at the PIP, 00:06:53.160 --> 00:06:55.579 they might carefully release and repair those 00:06:55.579 --> 00:06:58.920 lateral bands, or even create a V -shaped flap 00:06:58.920 --> 00:07:01.759 in the extensor tendon itself, which gets meticulously 00:07:01.759 --> 00:07:04.379 repaired. But the absolute key is presuming the 00:07:04.379 --> 00:07:07.100 central slip of that extensor tendon. That's 00:07:07.100 --> 00:07:08.699 vital for straightening the middle part of the 00:07:08.699 --> 00:07:11.540 finger. Got it. What about the knuckles where 00:07:11.540 --> 00:07:14.959 fingers meet the hand, the MCP joints? Metacarpal 00:07:14.959 --> 00:07:18.399 phalangeal joints, yeah. Usually a straight dorsal 00:07:18.399 --> 00:07:20.620 incision over the knuckle, maybe transverse if 00:07:20.620 --> 00:07:23.139 doing multiple fingers. Again, no real inner 00:07:23.139 --> 00:07:25.579 nervous plane extensor mechanism is right there. 00:07:25.879 --> 00:07:28.220 Need to watch for little sensory nerve branches. 00:07:28.379 --> 00:07:30.680 And getting into the joint itself, different 00:07:30.680 --> 00:07:33.180 options. Several ways. You can retract the sagittal 00:07:33.180 --> 00:07:35.540 band, that little sling holding the tendon centered. 00:07:35.709 --> 00:07:38.610 or carefully split the extensor tendon lengthwise, 00:07:38.949 --> 00:07:40.750 but you have to be careful not to go too far 00:07:40.750 --> 00:07:43.910 down and damage that crucial central slip insertion 00:07:43.910 --> 00:07:45.930 at the PIP joint. You mentioned that central 00:07:45.930 --> 00:07:48.730 slip is key. It really is. Another option is 00:07:48.730 --> 00:07:50.889 incising along the ulnar side sagittal band, 00:07:51.250 --> 00:07:53.370 but they try to avoid releasing the radial one 00:07:53.370 --> 00:07:55.310 on the thumb side to prevent the tendon from 00:07:55.310 --> 00:07:58.050 slipping off track. OK, how about accessing the 00:07:58.050 --> 00:08:00.490 long bones in the hand, the metacarpals? You 00:08:00.490 --> 00:08:03.209 feel for the bone, identify the extensor tendons 00:08:03.209 --> 00:08:06.389 running over it, then usually a straight dorsal 00:08:06.389 --> 00:08:08.790 incision right over that bone, sometimes between 00:08:08.790 --> 00:08:11.550 two metacarpals if needed. Still no inner nervous 00:08:11.550 --> 00:08:14.730 plane. Not really a true one there. So it's about 00:08:14.730 --> 00:08:18.009 carefully identifying and protecting those extensor 00:08:18.009 --> 00:08:20.649 tendons and the little cross connections between 00:08:20.649 --> 00:08:23.680 them, the juncture. Then you make an incision 00:08:23.680 --> 00:08:26.339 in the periosteum, the bone's outer layer, and 00:08:26.339 --> 00:08:28.920 gently lift the interosseous muscles off the 00:08:28.920 --> 00:08:32.019 bone. Superior steel elevation. Let's move to 00:08:32.019 --> 00:08:33.960 the wrist now. Carpal tunnel, everyone's heard 00:08:33.960 --> 00:08:36.080 of that. How does it approach? Right. So the 00:08:36.080 --> 00:08:38.279 carpal tunnel itself, narrow passage, median 00:08:38.279 --> 00:08:42.019 nerve, nine tendons. Roof is the thick transverse 00:08:42.019 --> 00:08:44.379 carpal ligament. Floor and sides are the carpal 00:08:44.379 --> 00:08:46.740 bones. Extends up to the wrist crease. Lamp marks. 00:08:47.000 --> 00:08:49.200 Surgeons use the interthinar depression, that 00:08:49.200 --> 00:08:50.940 little dip near the thumb base. They can feel 00:08:50.940 --> 00:08:53.519 the pisiform bone, maybe the hook of the hemat. 00:08:54.019 --> 00:08:56.320 And there's Kaplan's cardinal line, an imaginary 00:08:56.320 --> 00:08:58.799 line helping locate structures. And the incision 00:08:58.799 --> 00:09:00.700 has to be super careful because of the median 00:09:00.700 --> 00:09:03.759 nerve. Extremely careful, usually centered in 00:09:03.759 --> 00:09:06.559 that interthinar depression, aiming towards the 00:09:06.559 --> 00:09:09.460 space between the third and fourth fingers. This 00:09:09.460 --> 00:09:12.340 helps avoid the palmar cutaneous branches of 00:09:12.340 --> 00:09:15.460 both the median and ulnar nerves. That's essentially 00:09:15.460 --> 00:09:17.899 the inner nervous plane there. You cut through 00:09:17.899 --> 00:09:20.620 fat, the superficial palmar fascia, then carefully 00:09:20.620 --> 00:09:23.299 divide the transverse carpal ligament itself, 00:09:23.700 --> 00:09:26.220 always watching for the median nerve right underneath, 00:09:26.340 --> 00:09:28.500 and especially its recurrent motor branch to 00:09:28.500 --> 00:09:31.379 the thumb muscles, which can sometimes have unusual 00:09:31.379 --> 00:09:33.440 anatomy. And there's a sign when you're fully 00:09:33.440 --> 00:09:35.860 released? Yeah. Distally, you look for this little 00:09:35.860 --> 00:09:38.750 pad of fat, the sentinel fat pad. that confirms 00:09:38.750 --> 00:09:40.610 you've cut the ligament all the way. What about 00:09:40.610 --> 00:09:42.750 the canalogion, the other tunnel on the pinky 00:09:42.750 --> 00:09:45.049 side? Right, ulnar nerve and artery pass through 00:09:45.049 --> 00:09:48.210 there. Borders involve the volar carpal ligament, 00:09:48.529 --> 00:09:51.090 transverse carpal ligament, pisiform bone, hook 00:09:51.090 --> 00:09:54.549 of hamate. You palpate the pisiform, try to find 00:09:54.549 --> 00:09:58.159 the hook. Tricky to feel sometimes. Can be. The 00:09:58.159 --> 00:10:00.700 incision is usually zigzag or curved between 00:10:00.700 --> 00:10:02.919 those points, extending up the forearm a bit, 00:10:03.159 --> 00:10:04.740 but again, avoiding crossing the wrist crease 00:10:04.740 --> 00:10:07.940 straight on. You find the flexor carpi ulnaris 00:10:07.940 --> 00:10:11.100 tendon. Move it aside gently. The ulnar, nerve, 00:10:11.179 --> 00:10:13.179 and artery are right there. And then release 00:10:13.179 --> 00:10:15.200 the ligament. Release the volar carpal ligament 00:10:15.200 --> 00:10:17.179 to decompress the nerve and artery. Important 00:10:17.179 --> 00:10:19.600 to remember, the ulnar nerve splits here into 00:10:19.600 --> 00:10:21.779 motor and sensory branches, and the motor branch 00:10:21.779 --> 00:10:24.899 often ducks under a little fibrous arch. Anatomy 00:10:24.899 --> 00:10:27.220 varies a lot here, the source notes. OK, moving 00:10:27.220 --> 00:10:29.960 up the forearm. The radius thumb side bone. Yeah. 00:10:30.039 --> 00:10:31.879 Volar approach first from the palm side. Right. 00:10:32.139 --> 00:10:35.110 Key landmarks. Feel for the flexor carpe radialis 00:10:35.110 --> 00:10:38.450 tendon, the brachioradialis muscle belly, biceps 00:10:38.450 --> 00:10:41.409 tendon higher up, radial artery pulse, the inner 00:10:41.409 --> 00:10:44.470 nervous plane changes a bit. Distally, it's between 00:10:44.470 --> 00:10:48.080 flexor carpe radialis, median nerve. and brachioradialis, 00:10:48.179 --> 00:10:50.299 radial nerve. Ah, you're up. Proximally, it's 00:10:50.299 --> 00:10:54.039 between pronator teres, median nerve, and brachioradialis, 00:10:54.139 --> 00:10:56.679 radial nerve. The incision is usually just above 00:10:56.679 --> 00:10:58.679 the wrist crease, thumb side of the FCR tendon 00:10:58.679 --> 00:11:01.759 going upwards. You dissect down between FCR and 00:11:01.759 --> 00:11:04.320 brachioradialis. Watch out for it. Radial artery, 00:11:04.600 --> 00:11:07.419 definitely. Median nerve is a bit deeper. And 00:11:07.419 --> 00:11:09.759 the superficial radial sensory nerve can be in 00:11:09.759 --> 00:11:11.700 the way lower down. Sometimes they go through 00:11:11.700 --> 00:11:14.279 the FCR sheath instead. To get to the bone itself, 00:11:14.279 --> 00:11:16.419 you often have to lift overlying muscles like 00:11:16.419 --> 00:11:18.840 pronator quadratus or flexor pollicis longus 00:11:18.840 --> 00:11:21.259 off the radius. Now the dorsal approach to the 00:11:21.259 --> 00:11:24.220 radius from the back. OK. Land works here. Lister's 00:11:24.220 --> 00:11:26.360 tubercle on the wrist end of the razeus, lateral 00:11:26.360 --> 00:11:28.639 epicondyle at the elbow, and that group of muscles 00:11:28.639 --> 00:11:31.720 called the mobile wad of three. Incision runs 00:11:31.720 --> 00:11:34.519 from Lister's tubercle towards the lateral epicondyle 00:11:34.519 --> 00:11:37.059 along the inner edge of that mobile wad. Inner 00:11:37.059 --> 00:11:39.559 nervous plane here. Can it shifts? Distally, 00:11:39.879 --> 00:11:42.220 it's between extensor carpi radialis brevis. 00:11:43.120 --> 00:11:46.120 ECRB, often radial or pin supplied, and extensor 00:11:46.120 --> 00:11:50.039 pollicis longus, EPL, PM supplied. Proximally, 00:11:50.139 --> 00:11:52.980 it's between ECRB, radial nerve, and extensor 00:11:52.980 --> 00:11:56.600 digitorum communus, EDC, PI supplied, the finger 00:11:56.600 --> 00:11:58.840 expansion. Duct dissection. You open the extensor 00:11:58.840 --> 00:12:01.620 retinaculum over the EPL tendon, move tendons 00:12:01.620 --> 00:12:04.840 aside. Higher up, you detach muscles like abductor 00:12:04.840 --> 00:12:07.460 pollicis longus. The really crucial structure 00:12:07.460 --> 00:12:09.559 in the upper third is the supinator muscle. What 00:12:09.559 --> 00:12:12.350 is that? Because the posterior interosseous nerve, 00:12:12.610 --> 00:12:15.450 PI, a branch of the radial actually runs through 00:12:15.450 --> 00:12:18.490 the supinator. You absolutely have to find and 00:12:18.490 --> 00:12:20.889 protect that nerve before you release the muscle 00:12:20.889 --> 00:12:23.129 from the bone to see the radius underneath. Very 00:12:23.129 --> 00:12:25.490 important point. Okay, finally, the ulna. Pinky 00:12:25.490 --> 00:12:27.669 side bone. Accessing the ulna is often a bit 00:12:27.669 --> 00:12:29.570 more straightforward because much of its border 00:12:29.570 --> 00:12:32.750 is right under the skin subcutaneous. You identify 00:12:32.750 --> 00:12:35.330 the head and styloid at the wrist, feel that 00:12:35.330 --> 00:12:37.429 border along the forearm up to the ola crana 00:12:37.429 --> 00:12:40.549 on the elbow point. Incision follows that border. 00:12:40.789 --> 00:12:43.169 Inner nervous plane for the ulna. Distally, it's 00:12:43.169 --> 00:12:46.549 between flexor carpial nervous, FCU ulnar nerve, 00:12:47.149 --> 00:12:50.750 and extensor carpial nervous, ECU, PIN supplied. 00:12:51.789 --> 00:12:54.830 Proximally near the elbow, it's between FCU ulnar 00:12:54.830 --> 00:12:57.990 nerve and the inconeus muscle radial nerve. You 00:12:57.990 --> 00:12:59.950 also have to be mindful of the dorsal sensory 00:12:59.950 --> 00:13:01.929 branch of the ulnar nerve wrapping around. And 00:13:01.929 --> 00:13:04.190 then lift the muscles. Gently elevate the muscles 00:13:04.190 --> 00:13:07.049 off the bone superior stele. Protect the ulnar 00:13:07.049 --> 00:13:09.049 artery and nerve, especially near the wrist. 00:13:09.570 --> 00:13:11.809 Proximally, you note the triceps insertion in 00:13:11.809 --> 00:13:13.870 the path of the ulnar nerve going behind the 00:13:13.870 --> 00:13:16.629 medial epicondyle, the funny bone spot. Wow, 00:13:16.690 --> 00:13:18.730 that covers a huge amount of surgical anatomy. 00:13:19.350 --> 00:13:22.740 So detailed. Now, let's shift gears to our other 00:13:22.740 --> 00:13:25.120 sorts anesthesia, equally vital. Right, absolutely 00:13:25.120 --> 00:13:27.519 critical. And the landscape has changed, you 00:13:27.519 --> 00:13:30.700 know. More outpatient surgery, so managing pain 00:13:30.700 --> 00:13:33.139 after the patient goes home is a huge focus. 00:13:33.360 --> 00:13:35.679 And regional anesthesia nerve blocks plays a 00:13:35.679 --> 00:13:38.049 big role. I'm Massive Roll. Blocking the specific 00:13:38.049 --> 00:13:40.269 nerve supplying the surgical area often gives 00:13:40.269 --> 00:13:42.669 much better pain relief than general anesthesia 00:13:42.669 --> 00:13:46.190 alone. Plus, less nausea, less vomiting, patients 00:13:46.190 --> 00:13:48.710 generally feel better and recover faster. And 00:13:48.710 --> 00:13:51.049 the blocks can last longer now, even continuous 00:13:51.049 --> 00:13:54.309 relief. Exactly. Long -acting local anesthetics 00:13:54.309 --> 00:13:56.759 help. But for really sustained relief, they can 00:13:56.759 --> 00:13:59.360 place a tiny catheter near the nerve. An indwelling 00:13:59.360 --> 00:14:02.320 catheter. Right. And a small pump infuses local 00:14:02.320 --> 00:14:04.320 anesthetic continuously, sometimes for days, 00:14:04.360 --> 00:14:07.299 even at home. This bridges that gap when a single 00:14:07.299 --> 00:14:09.940 shot block would wear off, which can be a really 00:14:09.940 --> 00:14:12.120 rough period pain -wise. So how do they decide? 00:14:12.740 --> 00:14:15.500 General anesthesia, regional, or both? What goes 00:14:15.500 --> 00:14:18.299 into that choice? Several things. How long is 00:14:18.299 --> 00:14:21.419 the surgery? Very long ones might favor general 00:14:21.419 --> 00:14:23.990 for patient comfort. Does the surgeon need to 00:14:23.990 --> 00:14:26.029 check nerve function right away? A block would 00:14:26.029 --> 00:14:27.990 interfere with that initially. Equation factors 00:14:27.990 --> 00:14:31.350 too? Of course. Patients' overall health, anxiety 00:14:31.350 --> 00:14:34.169 levels, any specific medical conditions like 00:14:34.169 --> 00:14:36.309 lung problems if you're considering certain neck 00:14:36.309 --> 00:14:40.230 blocks, and patient preference, naturally. But 00:14:40.230 --> 00:14:42.169 regional seems to have a lot going for it based 00:14:42.169 --> 00:14:44.759 on our source. It really does. Potential benefits 00:14:44.759 --> 00:14:47.120 include smoother or r -flow blocks can often 00:14:47.120 --> 00:14:50.259 be placed beforehand. Easier management for patients 00:14:50.259 --> 00:14:53.539 with certain conditions. That combo of anesthesia 00:14:53.539 --> 00:14:55.820 and post -op cane control from one technique. 00:14:56.320 --> 00:14:58.960 Less nausea, quicker recovery, maybe even less 00:14:58.960 --> 00:15:01.759 post -op confusion or cognitive issues, especially 00:15:01.759 --> 00:15:03.720 in older patients. In different blocks for different 00:15:03.720 --> 00:15:06.799 areas. Yep. Shoulder surgery often uses interscaling 00:15:06.799 --> 00:15:09.679 blocks near the neck. Elbow might be interscaling, 00:15:09.919 --> 00:15:12.120 supraclavicular, or infraclavicular below the 00:15:12.120 --> 00:15:14.450 collarbone. Down in the forearm and hand, you 00:15:14.450 --> 00:15:16.830 might use infraclavicular, axillary in the armpit, 00:15:16.990 --> 00:15:19.929 or even IV regional for shorter things. IV regional. 00:15:20.309 --> 00:15:23.289 Yeah, beer block. Inject anesthetic into an arm 00:15:23.289 --> 00:15:25.409 vein while a tourniquet keeps it in the limb. 00:15:25.870 --> 00:15:28.289 Good for shorter procedures. But regional isn't 00:15:28.289 --> 00:15:30.950 always an option, is it? Contraindications. Right. 00:15:31.269 --> 00:15:33.730 Definite no -go's include acute nerve injury 00:15:33.730 --> 00:15:36.690 in that limb, progressive neuropathy, infection 00:15:36.690 --> 00:15:39.210 right where you'd stick the needle, patient refusal, 00:15:39.450 --> 00:15:42.470 or serious bleeding problems. Then there are 00:15:42.470 --> 00:15:45.789 relative ones, maybe stable nerve issues, severe 00:15:45.789 --> 00:15:48.389 lung disease for high blocks, active infections 00:15:48.389 --> 00:15:50.750 elsewhere. And managing pain isn't just about 00:15:50.750 --> 00:15:53.029 the block, is it? This idea of preemptive and 00:15:53.029 --> 00:15:56.059 multimodal analgesia. Good point. Preemptive 00:15:56.059 --> 00:15:58.980 means starting pain meds before the pain really 00:15:58.980 --> 00:16:02.700 kicks in, even before surgery sometimes. Multimodal 00:16:02.700 --> 00:16:05.200 means using different types of pain relief together. 00:16:05.320 --> 00:16:07.700 Like combining things. Exactly. Maybe an NSA 00:16:07.700 --> 00:16:10.899 WEI plus acetaminophen, maybe something like 00:16:10.899 --> 00:16:13.500 gabapentin for nerve pain alongside the regional 00:16:13.500 --> 00:16:16.240 block. The idea is to attack pain from multiple 00:16:16.240 --> 00:16:18.500 angles, often meaning you need lower doses of 00:16:18.500 --> 00:16:20.840 each drug, reducing side effects, especially 00:16:20.840 --> 00:16:23.080 from opioids if they're needed at all. And like 00:16:23.080 --> 00:16:25.840 with surgery, consent for anesthesia Absolutely. 00:16:26.539 --> 00:16:28.740 The anesthesiologist has to explain the options 00:16:28.740 --> 00:16:31.679 general, regional, the specific block, along 00:16:31.679 --> 00:16:34.720 with the risks and benefits of each. It's a shared 00:16:34.720 --> 00:16:37.059 decision informed by the patient's choice and 00:16:37.059 --> 00:16:39.159 the medical team's recommendation for the safest 00:16:39.159 --> 00:16:41.360 outcome. Finally, let's touch on complications. 00:16:41.919 --> 00:16:44.100 Both general and regional have potential risks, 00:16:44.139 --> 00:16:46.960 right? It's not risk -free either way. No medical 00:16:46.960 --> 00:16:49.879 procedure is entirely risk -free. General anesthesia 00:16:49.879 --> 00:16:52.480 can have post -op nausea, urinary retention, 00:16:53.039 --> 00:16:55.240 rarely things like corneal abrasion or nerve 00:16:55.240 --> 00:16:58.240 injuries from positioning. Interestingly, the 00:16:58.240 --> 00:17:00.360 source notes ulnar nerve injury at the elbow 00:17:00.360 --> 00:17:02.720 is statistically more common with general anesthesia 00:17:02.720 --> 00:17:05.099 than regional. That is interesting. And regional 00:17:05.099 --> 00:17:07.799 risks. Potential risks include nerve injury from 00:17:07.799 --> 00:17:10.299 the needle or catheter, infection, bleeding, 00:17:10.420 --> 00:17:13.740 or hematoma at the site, and rarely local anesthetic 00:17:13.740 --> 00:17:16.289 toxicity if the drug gets into the bloodstream 00:17:16.289 --> 00:17:18.890 accidentally. But, you know, with ultrasound 00:17:18.890 --> 00:17:21.349 guidance now widely used and careful technique, 00:17:21.789 --> 00:17:24.230 these risks are generally quite low. So overall, 00:17:24.490 --> 00:17:26.349 regional seems to be increasingly favored for 00:17:26.349 --> 00:17:29.490 upper limb surgery. For many patients, yes. The 00:17:29.490 --> 00:17:32.289 potential for superior pain control and a smoother 00:17:32.289 --> 00:17:34.549 overall experience makes it a very attractive 00:17:34.549 --> 00:17:36.910 option. This has been incredibly insightful. 00:17:37.329 --> 00:17:40.890 It really drives home the sheer complexity and 00:17:40.890 --> 00:17:43.500 elegance of the hand, wrist, and forearm. and 00:17:43.500 --> 00:17:46.660 the level of precision needed by surgeons supported 00:17:46.660 --> 00:17:49.519 by sophisticated anesthesia. It really is a team 00:17:49.519 --> 00:17:52.059 effort, isn't it? Surgical skill and anesthetic 00:17:52.059 --> 00:17:54.119 management working hand -in -hand for the patient. 00:17:54.640 --> 00:17:56.740 Definitely. And thinking about this intricate 00:17:56.740 --> 00:17:59.200 network we've discussed, it makes you wonder, 00:17:59.279 --> 00:18:01.799 doesn't it, what other seemingly small, compact 00:18:01.799 --> 00:18:04.359 areas of the human body hold similar levels of 00:18:04.359 --> 00:18:06.960 anatomical challenge and fascination for doctors? 00:18:07.420 --> 00:18:09.799 Maybe something for you, our listener, to ponder. 00:18:10.000 --> 00:18:11.279 Thanks for joining us on The Deep Side.