Wide Awake Hand Surgery

Many common hand operations are performed under local anaesthesia alone, with an injection of local anaesthetic numbing the area of surgery to provide pain relief during and after your operation.

Some operations performed under local anaesthesia may also require use of a tourniquet. Tourniquets apply pressure to reduce blood flow at the site of your surgery, and can be applied to the upper arm, forearm or finger. Upper arm tourniquets in particular can become painful if you are awake.

To avoid tourniquet-related pain, Matthew often utilises a ‘wide awake’ local anaesthetic technique, called Wide Awake Local Anaesthetic No Tourniquet (WALANT). The WALANT technique reduces bleeding due to a small volume of adrenaline being injected alongside the local anaesthetic medication. Not all operations are suitable for WALANT and Matthew will discuss the anaesthetic options available for your surgery.

Matthew co-authored the UK national guidance on Wide Awake Hand Surgery for the British Society for Surgery of the Hand (BSSH).

Matthew commonly performs the following operations using ‘wide awake’ or WALANT anaesthesia to avoid the use of a painful arm tourniquet:

If surgery is an option, Matthew will discuss the anaesthetic options for your type of surgery, including WALANT if it is suitable.

  • Local anaesthesia uses an injection of local anaesthetic medication in the region of your surgery to numb a small area of your hand or finger. Local anaesthesia is administered using a small needle, and the numbing effect usually occurs within a few minutes. It helps to avoid the feeling of pain, but the feeling of pressure and movement is usually maintained. You remain awake for the procedure (unless it is combined with other anaesthetic techniques such as sedation or general anaesthesia). You do not need to fast when local anaesthesia is the only type of anaesthetic being used (fasting is when you avoid eating or drinking before your operation).

    Examples of operations that are commonly performed under local anaesthesia include those for carpal tunnel syndrome, trigger finger, De Quervain’s syndrome and some finger operations.

  • A tourniquet is a pressure device that is sometimes used during surgery to reduce blood flow (and bleeding) at the site of surgery. Tourniquets can also help improve the surgeon’s view of the site of surgery.

    The type of tourniquet to be used is chosen according to the site and type of surgery being performed. For example, an elastic ligature or band is the simplest tourniquet and can be used for finger surgery. More complex operations, including bony procedures at the wrist, will usually require a larger tourniquet applied around the upper arm. These tourniquets are inflatable or ‘pneumatic’ and similar to the cuffs used when measuring blood pressure. Inflatable tourniquets can become painful if you are awake during your surgery.

    Some operations performed under local anaesthesia alone may require a tourniquet, but not all. The ‘wide awake’ or WALANT anaesthetic technique can provide a sufficient reduction in blood flow to perform some operations without a tourniquet (see main text).

    Operations performed under general and/or regional anaesthesia will often require use of a tourniquet.

  • Hand surgery can be performed under local anaesthesia, regional anaesthesia or general anaesthesia, or a combination of techniques.

    Matthew will administer a local anaesthetic at the site of your surgery to numb the area. Regional and general anaesthesia are provided by an anaesthetist, a doctor who specialises in anaesthetic techniques.

    Regional anaesthesia

    Regional anaesthesia (also known as a block) uses an injection of local anaesthetic medication further up your arm (variably at the area around your upper arm, shoulder and armpit). It aims to switch off the nerves that transmit pain and often temporarily affects your ability to move or control your arm (requiring a sling). It is reserved for more complex surgeries and requires the expertise of an anaesthetist (a medically trained specialist in anaesthetic techniques). 

    Regional anaesthesia is sometimes combined with sedation or general anaesthesia. Sedation relaxes you to a point where you may sleep, but you can wake up to communicate if needed.

    Examples of operations that can be performed under regional anaesthesia include those for thumb base arthritis (trapeziectomy), cubital tunnel syndrome and some wrist operations.

    You may need to fast before regional anaesthesia, especially if there is a chance it could be combined with sedation or a general anaesthetic. Fasting (sometimes called ‘nil by mouth’) means no food for at least six hours before surgery, and no water for the two hours before. Small sips of water may be allowed, for example to take medication.

    General anaesthesia

    General anaesthesia makes you unconscious and insensitive to pain. It is reserved for more complex surgeries and requires the expertise of an anaesthetist (a medically trained specialist in anaesthetic techniques). It is sometimes combined with regional anaesthesia.

    Examples of operations that can be performed under general anaesthesia include thumb base arthritis surgery, cubital tunnel surgery and most wrist operations.

    You will need to fast if you are having a general anaesthetic. This means no food for at least six hours before surgery, and no water for the two hours before. Small sips of water may be allowed, for example to take medication.

The information contained on this page is for guidance only and should not be considered a substitute for medical assessment and advice by a suitably trained doctor or clinician. External links have been provided for your information and convenience and we are not responsible for their content or accuracy.