What if you could fix hand fractures without sedation, tourniquet pain, or costly OR time? Welcome to the era of wide-awake, local anesthesia, no tourniquet (WALANT) surgery.
In this episode, we unpack the principles, technique, and rehab pearls behind wide-awake surgical management of hand fractures. WALANT challenges long-held beliefs about epinephrine use in the finger and empowers surgeons to treat metacarpal and phalangeal fractures safely and effectively — with patients awake, engaged, and moving intraoperatively.
Key Takeaways:
Why WALANT? Lower cost, no fasting or pre-op clearance, minimal perioperative anxiety, and high patient satisfaction .
Intraoperative advantage: Surgeons can confirm fixation stability and detect tendon gapping by asking patients to actively move .
Technique pearls: Buffered lidocaine with epinephrine, periosteal blocks, and the “hole-in-one” anesthesia strategy improve comfort and hemostasis .
Fracture fixation: K-wire configurations for metacarpal, phalangeal, and mallet injuries, with intraop fluoroscopy to confirm alignment .
Rehab protocols: Early protected motion (Modified St. John Protocol) minimizes stiffness and speeds recovery .
Complications: Rare cases of finger necrosis underscore the importance of knowing contraindications and phentolamine rescue .
Whether you’re a resident learning fracture fixation or an attending rethinking anesthesia strategy, WALANT offers a powerful, patient-centered approach that’s reshaping hand surgery.
References:
Hyatt BT, Rhee PC. Wide-Awake Surgical Management of Hand Fractures: Technical Pearls and Advanced Rehabilitation. Plast Reconstr Surg. 2019;143(3):800–810. doi:10.1097/PRS.0000000000005379
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