The initial treatment for Shoulder Elbow and hand conditions involves oral anti-
inflammatory medications, physiotherapy and local steroid injections failing which
surgery is usually required. Surgery maybe performed under different modalities of
anaesthesia. Pradeep Balasubramanian, Dubai, explores some of the most common
upper limb conditions requiring surgery and how it is safe and effective to treat them
under general anaesthesia even during the covid era.
Pradeep Balasubramanian Dubai explains that there are many upper limb conditions
that may require surgery. Traditionally upper limb procedure were done under a
tourniquet which is an air inflated cuff like a blood pressure cuff, that keeps blood out of
the surgical field. This improves visualization of critical structures during surgery. This is
especially important when performing hand surgery as small nerves, blood vessels and
tendons will have to be visualized and protected. The tourniquet will often need to be
remain inflated from 60 to 90 minutes or deflated and inflated a second time for more
complex and longer upper limb procedures. Inflation of the tourniquet can cause pain in
an unanaesthetised patient.
Elbow and hand surgeries can be done either under regional anaesthesia or under
general anaesthesia. Regional anaesthesia involves infiltrating large volumes of local
anaesthesia into the nerves at the base of the neck or axilla to numb the nerves
supplying the upper limb. General anaesthesia (GA) involves complete sedation and
insertion of an artificial temporary airway such as an Endotracheal tube or Laryngeal
mask (LMA).
Although theoretically regional anaesthesia poses a lower risk to life than general
anaesthesia, the complication rate with general anaesthesia is so low worldwide, that it
has now become the standard of care for day surgery. Moreover with regional
anaesthesia there is small risk that that the regional anaesthesia may not work
completely in the field of surgery and may need conversion to general anaesthesia.
The recovery from regional anaesthesia is usually more prolonged than with GA or LMA.
It is for this reason that many upper limb surgeons prefer to have even complex upper
limb procedures done under LMA so that their patients can go home the same day.
There is a small risk of permanent nerve damage or chronic residual pain with regional
anaesthesia. This is why regional anaesthesia is often contraindicated if the patient is at
risk for a neuropathy or already has nerve damage. Sedation is usually given
concomitantly with regional anaesthesia. If the sedation is inadequate, the patient can
sometimes move during critical steps of repairing important blood vessels, nerves or
tendons. This may lead to suboptimal surgical outcomes.
Many people are apprehensive about any invasive anaesthetic procedure like GA or
LMA. Much of this fear is generated by anecdotes of complications or poor outcomes
from old school techniques. Dr Bala urges anyone who is recommended an upper limb
surgery to read this blog to be aware of benefits and risks involved with GA or LMA.
The last decade or so has seen a surge in the advent of more and more upper limb
procedures being done under WALANT (Wide Awake Local Anaesthesia No
Tourniquet). This is a technique where large volumes of diluted LA with adrenaline is
infiltrated extensively around the field of surgery. There are definite advantages to this
technique especially with tendon repair and tendon transfer surgery, where the patient is
awake and can move his or her hand and fingers and one can fine-tune the technique to
optimize function. This is not possible when the patient is under general anaesthesia.
The down side to this procedure is that infiltration of large volumes of LA can often
distort local anatomy. Dr Bala is trained in WALANT techniques if required. Weighing
benefits and risks Dr Bala believes that risk of damage to vital structures in the hand and
upper limb during inadequate regional anaesthesia or during dissecting edematous
tissue infiltrated during WALANT is far greater than the theoretical risk of GA going
wrong. This is why he prefers GA or LMA over regional blocks or WALANT.
Although in theory general anaesthesia carries a theoretical risk to life Dr Bala has not
seen any such complications in his decade and a half of orthopaedic practice. In the
unlikely event it should happen Dr Bala’s anaesthetic team is well versed in managing
this. It is always a good idea to consult and discuss these options with the anaesthetic
team prior to the procedure. These maybe avoided by adequate patient education prior
to the procedure and adequate ICU backup for resuscitation should it ever be required.
It is now mandated by health regulation authorities for hospitals and operating facilities
to take covid safe precautionary steps during surgery. It is therefore very safe to have
general anaesthesia even during this covid era.
According to Pradeep Balasubramanian Dubai, a shoulder, elbow, and hand surgeon in
Dubai, United Arab Emirates, many people are prone to some upper limb injury or
condition in their lifetime. Pradeep Balasubramanian of Dubai identifies that these
problems may require specialist attention.
After spending over a decade and a half with patients who have suffered from upper
limb conditions, Pradeep Balasubramanian Dubai will offer the best possible treatment
individualized to every persons needs. He understands how proper surgery is critical to
get you back to being active again with the least morbidity. Surgical outcomes rely
largely on team work and the anaesthetic team is a major contributor to good outcomes.
A mindset change is the need of the hour to accept general anaesthesia more readily.
Health is happiness and Dubai is aiming to be the happiest city in the world to live in.
After all there are some things money can’t buy, and orthopaedic upper limb health is
one of them!
More About Pradeep Balasubramanian
Pradeep Balasubramanian Dubai is a globally trained shoulder, elbow, and hand
surgeon. He attended university in India and has completed three fellowships including 2
in Australia. He currently works as a Shoulder Elbow and Hand surgeon in UAE.
