Application of WALANT in Diaphyseal Plating of Forearm Fractures: An Observational Study

Abstract

Purpose: Wide-Awake Local Anesthesia No Tourniquet (WALANT) is a novel anesthesia technique in distal radius and ankle fracture fixation. However, to date, there are limited studies in diaphyseal plating of forearm fractures under WALANT. This research is to study the feasibility of the use of WALANT technique in plating of diaphyseal fractures of the forearm as well as peri-operative outcomes.

Methods: Sixty-one adult patients who underwent diaphyseal plating of the forearm under WALANT between the period of January 2019 and January 2021. It consists of 31 radius fractures, 15 ulna fractures and 15 ipsilateral radius and ulna fractures. Outcomes evaluated were duration of stay, peri-operative numerical pain rating scale, peri-operative blood pressure and heart rate, visual analogue scale for anxiety, blood loss, surgery duration, adverse effect, patient's satisfaction and any complications at 6 months follow up.

Results: Fifty-four patients (88.5%) were male and 7 patients (11.5%) were female with a mean age of 31.7 years (SD = 13.564). Thirty-eight out of 61 patients were totally pain free throughout the surgery. Ten (13%) patients reported pain during muscle dissection, 14 (18%) patients reported pain during bone manipulation and 12 (16%) patients reported pain during bone drilling. There was no significant difference in pain score between radius and ulna bones (P > .05). There was a significant change in blood pressure after LA infiltration (P < .01). The mean estimated blood loss was 27.39 ml (SD = 11.44) and the mean duration of post-surgery hospital stay was 1 day (SD = 1.026). Fifty-six patients (92%) recommended diaphyseal plating of the forearm under WALANT. None of the patients required conversion to general anesthesia and had any adverse events or infection during 6 months follow up.

Conclusions: Diaphyseal plating of the forearm under WALANT is a feasible alternative anesthesia technique and is well tolerated by patients.

Type of study/level of evidence: Therapeutic III.

Keywords: Plating; Radius; Technique; Ulna; WALANT.

Figure 1

WALANT administration technique. A First infiltration at the fracture site (10 ml). This will ease the fracture site pain shortly before positioning the forearm for subcutaneous infiltration. B Infiltration around 10 ml of LA at 3–5 cm proximal to the fracture site. C Infiltration around 10 ml of LA at 3–5 cm distal to the fracture site. D Subcutaneous infiltration along the volar forearm or midaxial ulna incision site (15–20 ml). Tumescent effect on the skin incision site is the desirable result after subcutaneous infiltration.

Figure 2

A A cross-sectional view of the forearm, in which around 10 ml of LA are injected on the bone subperiosteally. First the solution is administered at the lateral cortex (2 ml), then anterior cortex (4 ml) and posterior cortex (4 ml) by angulating the needle from the same entry point without withdrawing the needle. A longer needle is preferable for patients with a large forearm or large muscle bulk to infiltrate the surrounding bone and, more importantly, to reach the corner of the bone, resulting in the entire bone and periosteum being immersed in the solution completely. B Good visualization of the surgical field due to adrenaline. The duration of the scrubbing and draping time of the forearm is equivalent to the waiting time for adrenaline to attain its best hemostatic effect, at around 20 minutes.

Figure 3

A Plain radiographs of plating proximal third of the right radius and midshaft of the right ulna. B Plain radiographs of plating distal third of the right radius.

Figure 4

Blood pressure and heart rates during and after surgery. H, hour.

Figure 5

Preoperative, intraoperative, and postoperative visual analog scale for anxiety of patients (no anxiety: 0; mild anxiety: 1–3; moderate anxiety: 4–6; very anxious: 7–9; most anxiety: 10).