by | Aug 24, 2021


  • Laceration repair
  • Dislocation/fracture reduction
  • Pain control for traumatic injury
  • Paronychia
  • Felon
  • Nail trephination or removal


  • Infection overlying injection site
  • Allergy to local anesthetic


  • 5-10cc of local anesthetic of choice
  • 27G needle
  • Cleansing solution


Approach #1 (Traditional)

  1. Cleanse skin at proximal, dorsal aspect of the digit to be anesthetized, including web space
  2. Introduce the needle at the base of the digit near the MCP joint, lateral to the midline of the digit.
  3. Advance the needle around the bone towards the ventral side of the digit – stop if skin tenting is noted
  4. Inject ~1mL of anesthetic to block ventral digital nerve
  5. As needle is withdrawn, inject additional ~1mL of anesthetic to block dorsal digital nerve
  6. Repeat on opposite side of digit

Approach #2 (Transthecal)

  1. With hand supinated, locate flexor tendon of finger to be anesthetized
  2. Cleanse skin over the distal palmar crease and proximal digital crease
  3. Insert needle at 90° to the skin at the proximal digital crease
  4. Advance until needle hits bone, then withdraw 2-3mm
  5. Redirect needle 45 degrees to the skin with needle pointing distally (towards finger tip)
  6. Slowly inject anesthetic – initially no resistance, progressive resistance felt as tendon sheath fills (~1.5-3mL)


  1. WikEM