Advertisement

Wide-Awake Olecranon Fracture Fixation: Is it Possible?

Open AccessPublished:January 21, 2023DOI:https://doi.org/10.1016/j.jhsg.2022.12.006

      Purpose

      The wide-awake local anesthesia no tourniquet technique has been widely performed in hand and wrist surgery with remarkable results. However, its use on the elbow has rarely been reported. Here we describe the use of wide-awake local anesthesia no tourniquet in olecranon fracture fixation in 4 cases.

      Methods

      Tumescent anesthesia was injected from the proximal ulna to approximately 10 cm distally and into the periosteum and fracture site, approximately 25 minutes before skin incision. The fracture underwent closed reduction and was fixed using a long 6.5-mm cancellous screw with a washer through a small incision. No tourniquet was applied and none or mild sedation was administered. At the end of the operation, patients were asked to perform active elbow flexion-extension and forearm pronosupination movements under an image intensifier to test the range of motion and fracture stability.

      Results

      The surgical procedure was completed in all 4 cases. Two patients reported mild pain during ulnar medullary canal reaming, with pain scores of 3 and 4 on a 10-point scale, respectively. One case was resolved with additional local anesthetic injection. The other case required the administration of intravenous propofol. Both patients were able to actively move the elbow at the end of the operation.

      Conclusions

      The use of wide-awake local anesthesia no tourniquet for olecranon fracture fixation has the advantage of obviating the need for an arm tourniquet, general anesthesia or heavy sedation, preoperative tests, and discontinuing routine medications (including anticoagulants). The stability of the elbow fixation was tested by active motion during surgery. This simple, safe, low-cost, and reproducible technique may be a good option for patients with contraindications or high risk of general or regional nerve block anesthesia.

      Type of study/level of evidence

      Therapeutic IV.

      Key words

      Olecranon fractures account for 10% of all fractures around the elbow.
      • Wiegand L.
      • Bernstein J.
      • Ahn J.
      Fractures in brief: olecranon fractures.
      They usually occur as a result of direct trauma or forceful elbow extension.
      • Amis A.A.
      • Miller J.H.
      The mechanisms of elbow fractures: an investigation using impact tests in vitro.
      Surgical treatment is indicated in displaced fractures to realign the articular surface and restore the extension mechanism of the elbow joint. Depending on the fracture configuration, osteosynthesis can be performed with tension band wiring, intramedullary screw fixation, or plate-and-screw fixation.
      • Wiegand L.
      • Bernstein J.
      • Ahn J.
      Fractures in brief: olecranon fractures.
      ,
      • Baecher N.
      • Edwards S.
      Olecranon fractures.
      • Bosman W.M.P.F.
      • Emmink B.L.
      • Bhashyam A.R.
      • Houwert R.M.
      • Keizer J.
      Intramedullary screw fixation for simple displaced olecranon fractures.
      • Duckworth A.D.
      • Clement N.D.
      • Aitken S.A.
      • Court-Brown C.M.
      • McQueen M.M.
      The epidemiology of fractures of the proximal ulna.
      • Duckworth A.D.
      • Clement N.D.
      • White T.O.
      • Court-Brown C.M.
      • McQueen M.M.
      Plate versus tension-band wire fixation for olecranon fractures: a prospective randomized trial.
      • Matar H.E.
      • Ali A.A.
      • Buckley S.
      • Garlick N.I.
      • Atkinson H.D.
      Surgical interventions for treating fractures of the olecranon in adults.
      • Wood T.
      • Thomas K.
      • Farrokhyar F.
      • Ristevski B.
      • Bhandari M.
      • Petrisor B.
      A survey of current practices and preferences for internal fixation of displaced olecranon fractures.
      The procedure is performed under general anesthesia or regional nerve block and an upper-extremity tourniquet is used to minimize bleeding. The wide-awake local anesthesia no tourniquet (WALANT) technique has been widely used in hand and wrist surgery with remarkable results.
      • Lalonde D.H.
      Conceptual origins, current practice, and views of wide awake hand surgery.
      Local anesthesia with epinephrine is a safe, effective, and cost-saving technique that does not require the use of a tourniquet during the procedure, reducing the risks to the patient.
      • Tang J.B.
      • Xing S.G.
      • Ayhan E.
      • Hediger S.
      • Huang S.
      Impact of wide-awake local anesthesia no tourniquet on departmental settings, cost, patient and surgeon satisfaction, and beyond.
      There is 1 case report of the use of WALANT in elbow fracture surgery for open reduction and plate fixation of an olecranon fracture.
      • Ahmad A.A.
      • Sabari S.S.
      • Ruslan S.R.
      • Abdullah S.
      • Ahmad A.R.
      Wide-awake anesthesia for olecranon fracture fixation.
      We describe the use of WALANT in olecranon fracture fixation in 4 cases.

      Materials and Methods

      Four patients with acute displaced noncomminuted (Mayo type 2A) closed olecranon fractures presented at the clinic and were subsequently operated on by the senior author (C.R.F.) at a mean of 10 days after the related trauma. The patients’ consent was obtained and they understood and accepted the wide-awake technique. They did not exhibit any contraindications, such as compromised peripheral circulation or limb ischemia. The patients were monitored by an anesthetist at all times during the procedure and severe cardiovascular disease was not observed as a contraindication.
      The demographic data of the patients are presented in the Table. The study was approved by the Ethics Committee of our institution and conducted in accordance with the provisions of the Declaration of Helsinki. All patients signed an informed consent form regarding the risks and benefits of the surgical procedure. Besides the routine preoperative explanation regarding elbow fracture fixation surgery, a detailed description of the WALANT procedure was provided. The main objective was to assure patients that they would not feel any pain during the operation, because patients were understandably surprised to know that the operation would be performed under local anesthesia. It was important to clarify that an anesthesiologist would be monitoring the entire procedure. Patients were encouraged to express whether they felt any pain or discomfort. The pain was rated from a range of 1 (very mild) to 10 (very severe). After the surgical procedure, patients remained in the recovery room for approximately 4 hours before discharge.
      TableDemographic Data and Fracture Classification (Mayo)
      Patient NumberAge (y)SexOperative Time (min)
      Operative time (min) was started with the skin incision.
      SideFracture ClassificationF/U (mo)Flexion/ExtensionMayo Elbow Score
      156F50R2A9145/1525
      223M37L2A6145/025
      363F24R2A4145/2020
      483F44L2A12140/1025
      F/U, follow-up.
      Operative time (min) was started with the skin incision.

      Anesthetic technique

      The anesthetic solution was prepared by combining 30 mL of 1% lidocaine with 1:100,000 epinephrine and 30 mL of normal saline, resulting in 60 mL of 0.5% lidocaine with 1:200,000 epinephrine, buffered with 3 mL of 8.4% sodium bicarbonate. Lidocaine was diluted in normal saline to obtain a greater volume of the anesthetic solution as well as staying within the maximum safe dose of 7 mg/kg.
      • Klein J.A.
      • Jeske D.R.
      ,
      • Lalonde D.H.
      • Wong A.
      Dosage of local anesthesia in wide awake hand surgery.
      We planned a 2-cm incision in the proximal ulna to approach the olecranon proximal fragment, but tumescent anesthesia (TA) needed to be injected all the way from the proximal ulna to approximately 10 cm distally because of the intramedullary screw length. The area for TA was demarcated as shown in Figure 1. Moreover, in such fracture cases, we always infiltrate the periosteum and fracture site as well.
      We started by injecting TA into the skin with a 30-gauge needle proximally and then into the subcutaneous layer with a 25-gauge needle (Fig. 2). We filled the entire demarcated area with 30 mL of local anesthesia. Subsequently, the fracture site and the periosteum of the proximal ulna were also infiltrated from the proximal to the distal border of the area that was planned to receive local anesthesia (Fig. 3). Care was taken to hold the needle very close to the bone, especially proximally and medially. We palpated the ulnar nerve to ensure that the needle was away from the nerve. Nevertheless, a transient ulnar nerve block may occur because of this anesthesia was infiltrated medially, and this should be explained to the patient.
      Figure thumbnail gr2
      Figure 2A Starting the operation by injecting TA in the skin with a 30-gauge needle proximally. B Injecting the subcutaneous layer with a 25-gauge needle.
      Figure thumbnail gr3
      Figure 3The periosteum of the proximal ulna is also infiltrated.
      As the ulna has a triangular shape proximally, we infiltrated at least 2 bone surfaces (Figs. 4, 5). Special attention was paid when filling the fracture site with local anesthesia. Approximately 20–30 mL of the anesthetic was injected into the periosteum and fracture site. We then waited for at least 25 minutes to start the operation, as this is the optimal time interval required to achieve maximal vasoconstriction within the limits of TA.
      • Lalonde D.
      Minimally invasive anesthesia in wide awake hand surgery.
      Figure thumbnail gr4
      Figure 4The ulna has a triangular shape proximally. The red arrow indicates the fracture site and the black arrows indicate the periosteum to be infiltrated.
      Figure thumbnail gr5
      Figure 5At least 2 bone surfaces were infiltrated. The different colors represent the different surfaces of the ulna.
      Before starting the operative procedure, pain sensation was tested with Adson forceps by pinching the skin and manually palpating the fracture site. The operation can only be started if there is no pain whatsoever. In our small case series, all 4 patients had intravenous access and were monitored by an anesthesiologist, who was also alert to any complaints of pain or discomfort by the patient throughout the procedure.

      Operative technique

      The fracture underwent closed reduction by distally pushing the proximal fragment with the elbow in extension,

      Folberg CR, Alves JAO, Sirena FM, Silva BV. Minimally invasive olecranon osteosynthesis. Paper presented at: IFSSH, IFSHT, FESSH Combined Congress; June 6, 2022; London, United Kingdom.

      temporarily stabilized with a Kirschner wire, and then fixed using a 6.5-mm cancellous screw with a washer as previously described in the literature,
      • Bosman W.M.P.F.
      • Emmink B.L.
      • Bhashyam A.R.
      • Houwert R.M.
      • Keizer J.
      Intramedullary screw fixation for simple displaced olecranon fractures.
      ,
      • Panchal H.C.
      • Bhabhor P.K.
      6.5 mm cancellous screw with washer vs tension band wiring for fractures of the olecranon.
      except that we used only a 2-cm incision along the proximal olecranon to insert the screw. With the patient in the supine position and the arm resting on the arm table, closed reduction was started with the elbow in extension or slight flexion. Under an image intensifier, we pushed the proximal olecranon fragment distally against the ulnar diaphysis. A towel clamp or Kirschner wire helped reduce and hold fragments together temporarily (Fig. 6). Once the fracture was reduced, a 2.0-mm (0.079 in) Kirschner wire was inserted across the fracture site to help maintain the reduction. A guide wire was inserted in the ulnar medullary canal and a stab incision was performed, followed by blunt dissection and passage of the intramedullary guided reamer. A 6.5-mm cancellous screw with a washer was inserted taking care to avoid soft tissue interposition. The screw length was usually 100–110 mm, which provided enough support distally with good thread purchase in the medullary canal (Fig. 7). The patient was then asked to perform full active elbow flexion-extension and forearm pronosupination under the image intensifier so that the elbow range of motion and fracture stability could be tested.
      Figure thumbnail gr6
      Figure 6A Closed reduction was started with the elbow in extension or slight flexion. B The Kirschner wire helped reduce and temporarily hold the fragments together.
      Figure thumbnail gr7
      Figure 7A Screw length of 100–110 mm was used. B This length allowed for enough support distally and thread purchase to be achieved within the medullary canal.

      Results

      The procedure on all 4 patients was performed successfully under local anesthesia and no tourniquet. Fracture reduction was assessed under fluoroscopy and adequate fracture reduction and fixation was assured with no gap or articular step. When asked, all 4 patients could actively move the elbow in flexion (at least 100°) and extension (at least 30°) and pronosupination without any pain. No intraoperative or postoperative complications were recorded. Patients were discharged with a sling without upper limb immobilization and were encouraged to start active range of motion as soon as it could be tolerated. The Table shows detailed patient data and follow-up with the Mayo elbow functional evaluation score.
      Patients 1 and 2 reported mild pain during canal reaming (with pain scores of 3/10 and 4/10, respectively). We stopped the procedure and injected an additional 6 mL of local anesthetic distal to the fracture site in an attempt to reach the deep borders of the ulna on both sides. This infiltration solved the problem in patient 1. Patient 2, however, continued to report the same pain (score 4/10) after reinfiltration of the periosteum. Propofol was administered intravenously to induce sedation and surgery was resumed. After screw insertion, the patient was alert and could actively move the elbow. Patient 4 was an 83-year-old woman with a history of cardiac arrhythmia, who was waiting for an ablation procedure scheduled in a few days. We decided to administer local anesthesia in the operating room with cardiac monitoring. The anesthesiologist administered 3 mg midazolam intravenously twice, before administering local anesthesia and starting the operation. The patient was alert enough during the procedure to answer questions about pain sensation and actively move the elbow when asked.

      Discussion

      At the beginning of this century, Lalonde et al
      • Lalonde D.
      • Bell M.
      • Benoit P.
      • Sparkes G.
      • Denkler K.
      • Chang P.
      A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase.
      introduced the concept of wide-awake surgery. With a bloodless field, surgery can be performed without an arm tourniquet and the patient does not need sedation. The use of WALANT has already been established in hand surgery,
      • Lalonde D.H.
      Conceptual origins, current practice, and views of wide awake hand surgery.
      ,
      • Lalonde D.
      Minimally invasive anesthesia in wide awake hand surgery.
      recently including distal radius and scaphoid fracture fixation.
      • Folberg C.R.
      • Alves J.A.O.
      • Pereira F.M.S.
      • Pedrozo V.B.
      WALANT technique in percutaneous scaphoid osteosynthesis.
      • Ahmad A.A.
      • Yi L.M.
      • Ahmad A.R.
      Plating of distal radius fracture using the wide-awake anesthesia technique.
      • Orbach H.
      • Rozen N.
      • Rubin G.
      Open reduction and internal fixation of intra-articular distal radius fractures under wide-awake local anesthesia with no tourniquet.
      The additional advantages of WALANT technique–based surgery include no need for preoperative tests, a long fasting period or a recovery room stay, resulting in a shorter and cheaper hospital stay.
      • Lalonde D.H.
      Conceptual origins, current practice, and views of wide awake hand surgery.
      Although WALANT was used for surgical treatment of proximal median nerve entrapment in the elbow in 44 patients,
      • Hagert E.
      Clinical diagnosis and wide-awake surgical treatment of proximal median nerve entrapment at the elbow: a prospective study.
      its use in the surgical treatment of fractures remains to be explored. Ahmad et al
      • Ahmad A.A.
      • Sabari S.S.
      • Ruslan S.R.
      • Abdullah S.
      • Ahmad A.R.
      Wide-awake anesthesia for olecranon fracture fixation.
      described a case of open olecranon fracture fixation with wide-awake anesthesia in which they used the concept of TA in addition to periosteal block, similar to our study, except that we used a greater volume of the anesthetic solution (60 mL vs 40 mL). Although 1% lidocaine was diluted in 0.9% saline (40 mL of 1% lidocaine plus 40 mL of saline) to be within the safe anesthetic dose range, we believe that we were able to fill the subcutaneous area with a larger volume of the anesthetic. The patient in the study by Ahmad et al
      • Ahmad A.A.
      • Sabari S.S.
      • Ruslan S.R.
      • Abdullah S.
      • Ahmad A.R.
      Wide-awake anesthesia for olecranon fracture fixation.
      was placed in the usual lateral decubitus position for surgery, which could be very uncomfortable, as pointed out by the authors. Our patients were placed in the supine position so that if they needed sedation or even general anesthesia for not being able to tolerate the WALANT technique, this position would be convenient for the anesthesiologist. Because we used a minor open technique, this position did not adversely affect fracture reduction and fixation, and 2 of our patients were lightly sedated during part of the procedure. Although not recommended, it would still be possible to operate on the patient in the lateral decubitus position, and, with the patient being awake, they could be asked to change to the supine position during the procedure if needed.
      Local anesthesia has its caveats. The risk factors for systemic toxicity of local anesthesia include the extremes of age, hepatic dysfunction, low cardiac output, cardiac pathology, pregnancy, and the use of β-blockers, digoxin, and calcium antagonists.
      • Ciechanowicz S.
      • Patil V.
      Lipid emulsion for local anesthetic systemic toxicity.
      Lidocaine with epinephrine may be cardiotoxic but lidocaine anaphylaxis is very rare.
      • Dillane D.
      • Finucane B.T.
      Local anesthetic systemic toxicity.
      • Baluga J.C.
      • Casamayou R.
      • Carozzi E.
      • et al.
      Allergy to local anaesthetics in dentistry. Myth or reality?.
      • Speca S.J.
      • Boynes S.G.
      • Cuddy M.A.
      Allergic reactions to local anesthetic formulations.
      Epinephrine in lidocaine can cause transient elevation of the heart rate and blood pressure, but its clinical relevance remains unclear.
      • Dogru K.
      • Duygulu F.
      • Yildiz K.
      • Kotanoglu M.S.
      • Madenoglu H.
      • Boyaci A.
      Hemodynamic and blockade effects of high/low epinephrine doses during axillary brachial plexus blockade with lidocaine 1.5%: a randomized, double-blinded study.
      ,
      • Yamashita K.
      • Kibe T.
      • Shidou R.
      • Kohjitani A.
      • Nakamura N.
      • Sugimura M.
      Difference in the effects of lidocaine with epinephrine and prilocaine with felypressin on the autonomic nervous system during extraction of the impacted mandibular third molar: a randomized controlled trial.
      Olecranon fracture fixation is usually performed with tension band wiring or plate osteosynthesis.
      • Baecher N.
      • Edwards S.
      Olecranon fractures.
      ,
      • Wood T.
      • Thomas K.
      • Farrokhyar F.
      • Ristevski B.
      • Bhandari M.
      • Petrisor B.
      A survey of current practices and preferences for internal fixation of displaced olecranon fractures.
      A few authors have reported satisfactory results with the use of only a 6.5-mm cancellous screw for olecranon fractures and osteotomies.
      • Bosman W.M.P.F.
      • Emmink B.L.
      • Bhashyam A.R.
      • Houwert R.M.
      • Keizer J.
      Intramedullary screw fixation for simple displaced olecranon fractures.
      ,
      • Woods B.I.
      • Rosario B.L.
      • Siska P.A.
      • Gruen G.S.
      • Tarkin I.S.
      • Evans A.R.
      Determining the efficacy of screw and washer fixation as a method for securing olecranon osteotomies used in the surgical management of intraarticular distal humerus fractures.
      Over the past 2 years, our group has routinely used a 6.5-mm cancellous screw inserted through a small incision for olecranon fractures as part of a study, and 4 cases of this series were performed using the WALANT technique as described here. Although it was not needed, we planned to keep the wide-awake anesthesia as an option if we had to change the technique and open the fracture site. This has already been reported in 1 case by Ahmad et al.
      • Ahmad A.A.
      • Sabari S.S.
      • Ruslan S.R.
      • Abdullah S.
      • Ahmad A.R.
      Wide-awake anesthesia for olecranon fracture fixation.
      The fact that patients are wide awake during surgery makes it possible to talk to them about the procedure and postoperative steps. It is important to remember that patients undergoing the procedure using the WALANT technique need to be more cooperative than those under sedation. This requirement should be made very clear before surgery. The patients in our case series had no history of psychiatric illness and were selected after they had expressed full understanding of and agreed with the wide-awake procedure.
      • Lalonde D.
      • Martin A.
      Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia.
      Important limitations of this study are its retrospective design, small sample size, and lack of a control group. Additionally, in this series of patients with olecranon fractures, the WALANT technique was performed with a closed reduction technique that still needs further studies for validation. As a new frontier to be explored, the use of the WALANT technique in elbow fractures still needs further study with more data to draw strong evidence-based conclusions.
      Our study demonstrates a simple, safe, low-cost, and reproducible technique of local anesthesia for the surgical treatment of olecranon fractures. It may be a good option for surgeons who appreciate the advantages of WALANT technique–based surgery and for patients with contraindications or high risk of general or regional nerve block anesthesia.

      References

        • Wiegand L.
        • Bernstein J.
        • Ahn J.
        Fractures in brief: olecranon fractures.
        Clin Orthop Relat Res. 2012; 470: 3637-3641
        • Amis A.A.
        • Miller J.H.
        The mechanisms of elbow fractures: an investigation using impact tests in vitro.
        Injury. 1995; 26: 163-168
        • Baecher N.
        • Edwards S.
        Olecranon fractures.
        J Hand Surg Am. 2013; 38: 593-604
        • Bosman W.M.P.F.
        • Emmink B.L.
        • Bhashyam A.R.
        • Houwert R.M.
        • Keizer J.
        Intramedullary screw fixation for simple displaced olecranon fractures.
        Eur J Trauma Emerg Surg. 2020; 46: 83-89
        • Duckworth A.D.
        • Clement N.D.
        • Aitken S.A.
        • Court-Brown C.M.
        • McQueen M.M.
        The epidemiology of fractures of the proximal ulna.
        Injury. 2012; 43: 343-346
        • Duckworth A.D.
        • Clement N.D.
        • White T.O.
        • Court-Brown C.M.
        • McQueen M.M.
        Plate versus tension-band wire fixation for olecranon fractures: a prospective randomized trial.
        J Bone Joint Surg Am. 2017; 99: 1261-1273
        • Matar H.E.
        • Ali A.A.
        • Buckley S.
        • Garlick N.I.
        • Atkinson H.D.
        Surgical interventions for treating fractures of the olecranon in adults.
        Cochrane Database Syst Rev. 2014; 2014CD010144
        • Wood T.
        • Thomas K.
        • Farrokhyar F.
        • Ristevski B.
        • Bhandari M.
        • Petrisor B.
        A survey of current practices and preferences for internal fixation of displaced olecranon fractures.
        Can J Surg. 2015; 58: 250-256
        • Lalonde D.H.
        Conceptual origins, current practice, and views of wide awake hand surgery.
        J Hand Surg Eur Vol. 2017; 42: 886-895
        • Tang J.B.
        • Xing S.G.
        • Ayhan E.
        • Hediger S.
        • Huang S.
        Impact of wide-awake local anesthesia no tourniquet on departmental settings, cost, patient and surgeon satisfaction, and beyond.
        Hand Clinics. 2019; 35: 29-34
        • Ahmad A.A.
        • Sabari S.S.
        • Ruslan S.R.
        • Abdullah S.
        • Ahmad A.R.
        Wide-awake anesthesia for olecranon fracture fixation.
        Hand (N Y). 2021; 16: 402-406
        • Klein J.A.
        • Jeske D.R.
        Estimated maximal safe dosages of tumescent lidocaine: Anesth Analg. 2016; 122: 1350-1359
        • Lalonde D.H.
        • Wong A.
        Dosage of local anesthesia in wide awake hand surgery.
        J Hand Surg Am. 2013; 38: 2025-2028
        • Lalonde D.
        Minimally invasive anesthesia in wide awake hand surgery.
        Hand Clin. 2014; 30: 1-6
      1. Folberg CR, Alves JAO, Sirena FM, Silva BV. Minimally invasive olecranon osteosynthesis. Paper presented at: IFSSH, IFSHT, FESSH Combined Congress; June 6, 2022; London, United Kingdom.

        • Panchal H.C.
        • Bhabhor P.K.
        6.5 mm cancellous screw with washer vs tension band wiring for fractures of the olecranon.
        Int J Orthop Sci. 2019; 5: 971-975
        • Lalonde D.
        • Bell M.
        • Benoit P.
        • Sparkes G.
        • Denkler K.
        • Chang P.
        A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase.
        J Hand Surg Am. 2005; 30: 1061-1067
        • Folberg C.R.
        • Alves J.A.O.
        • Pereira F.M.S.
        • Pedrozo V.B.
        WALANT technique in percutaneous scaphoid osteosynthesis.
        Rev Bras Ortop (Sao Paulo). 2022; 57: 1070-1073
        • Ahmad A.A.
        • Yi L.M.
        • Ahmad A.R.
        Plating of distal radius fracture using the wide-awake anesthesia technique.
        J Hand Surg Am. 2018; 43: 1045.e1-1045.e5
        • Orbach H.
        • Rozen N.
        • Rubin G.
        Open reduction and internal fixation of intra-articular distal radius fractures under wide-awake local anesthesia with no tourniquet.
        J Int Med Res. 2018; 46: 4269-4276
        • Hagert E.
        Clinical diagnosis and wide-awake surgical treatment of proximal median nerve entrapment at the elbow: a prospective study.
        Hand (N Y). 2013; 8: 41-46
        • Ciechanowicz S.
        • Patil V.
        Lipid emulsion for local anesthetic systemic toxicity.
        Anesthesiol Res Pract. 2012; 2012: 1-11
        • Dillane D.
        • Finucane B.T.
        Local anesthetic systemic toxicity.
        Can J Anesth. 2010; 57: 368-380
        • Baluga J.C.
        • Casamayou R.
        • Carozzi E.
        • et al.
        Allergy to local anaesthetics in dentistry. Myth or reality?.
        Allergol Immunopathol (Madr). 2002; 30: 14-19
        • Speca S.J.
        • Boynes S.G.
        • Cuddy M.A.
        Allergic reactions to local anesthetic formulations.
        Dent Clin North Am. 2010; 54: 655-664
        • Dogru K.
        • Duygulu F.
        • Yildiz K.
        • Kotanoglu M.S.
        • Madenoglu H.
        • Boyaci A.
        Hemodynamic and blockade effects of high/low epinephrine doses during axillary brachial plexus blockade with lidocaine 1.5%: a randomized, double-blinded study.
        Reg Anesth Pain Med. 2003; 28: 401-405
        • Yamashita K.
        • Kibe T.
        • Shidou R.
        • Kohjitani A.
        • Nakamura N.
        • Sugimura M.
        Difference in the effects of lidocaine with epinephrine and prilocaine with felypressin on the autonomic nervous system during extraction of the impacted mandibular third molar: a randomized controlled trial.
        J Oral Maxillofac Surg. 2020; 78: 215.e1-215.e8
        • Woods B.I.
        • Rosario B.L.
        • Siska P.A.
        • Gruen G.S.
        • Tarkin I.S.
        • Evans A.R.
        Determining the efficacy of screw and washer fixation as a method for securing olecranon osteotomies used in the surgical management of intraarticular distal humerus fractures.
        J Orthop Trauma. 2015; 29: 44-49
        • Lalonde D.
        • Martin A.
        Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia.
        J Am Acad Orthop Surg. 2013; 21: 443-447