Application of Regional Anesthesia in Hand Surgery for Pediatric Patients: Two Effective Approaches - Case Report

Abstract

Introduction

Pediatric regional anesthesia has advanced significantly in the last two decades, providing safe and effective techniques for managing perioperative pain in children. Upper limb blocks, such as those of the brachial plexus, are fundamental in pediatric surgery, offering adequate analgesia and reducing the need for opioids. The incorporation of ultrasound has improved the precision and safety of these techniques, facilitating the identification of anatomical structures and the administration of local anesthetics, creating a calmer surgical environment.

Case 

LMCGR is a 4-year-old preschool boy, born at term on December 13, 2020. At birth, he weighed 3.5 kg and measured 50 cm, being considered eutrophic. His neurodevelopment is appropriate, and he exhibits right-handedness. Currently, he weighs 16.5 kg and measures 102 cm.

On May 5, 2025, while playing, he had an accident attempting to lift a block that fell on his right hand, presenting pain, edema, and inflammation. He was admitted with a diagnosis of compartment syndrome and fractures of the 3rd, 4th, and 5th metacarpals, as well as a fracture of the proximal phalanx of the 2nd finger of the right hand.

On May 6, a fasciotomy of the right hand, closed reduction, and percutaneous fixation of the fractures were performed. The anesthetic technique consisted of intravenous sedation and brachial plexus block via a costoclavicular approach. Premedication included 2 mg of Midazolam IV, and during the procedure, spontaneous ventilation was maintained, administering oxygen via nasal cannula at 3 l/min. The sedation included Midazolam, Fentanyl, Lidocaine, and Dexmedetomidine. For the block, a linear transducer and a 50 mm needle were used, administering 30 mg of Ropivacaine at 0.375% in a total volume of 8 ml (1.8 mg/kg). The procedure was carried out without complications.

The clinical evolution was adequate, and on May 13, the closure of the fasciotomies and repositioning of the fixation nail of the 4th metacarpal were scheduled. This time, combined anesthesia was used, consisting of balanced general anesthesia and brachial plexus block. Induction was initially performed via inhalation with Sevoflurane using an ascending technique. After achieving venous access, Midazolam, Fentanyl, and Propofol were continued. A type 2 Ambu laryngeal mask was placed, and the block was performed under ultrasound guidance, administering 22 mg of Ropivacaine at 0.36% in a volume of 6 ml (1.3 mg/kg). At the end of the procedure, emergence was carried out, and the patient was discharged without adverse events.

LMCGR was discharged home on May 15, 2025, with antibiotic and analgesic treatment, and adequate color and perfusion of the fingers were observed.

Conclusions

This clinical case demonstrates the effectiveness of anesthetic management in two distinct interventions, highlighting the flexibility in the choice of anesthetic techniques. The inclusion of the brachial plexus block significantly improved pain control, allowing for a reduction in opioid use and optimizing the perioperative experience for the patient.