Ultrasound-guided continuous median nerve block to facilitate intensive hand rehabilitation

Objectives: Continuous brachial plexus blocks for postoperative analgesia after upper extremity surgery are well described, but they can result in undesirable motor block and lack of specificity for minor hand procedures. We present the use of extended-duration continuous local anesthetic infusion through an ultrasound-guided median nerve catheter inserted at the forearm to facilitate hand physical therapy in a patient who had previously failed rehabilitation due to pain unrelieved by systemic opioids. CASE REPORT:: A 54-year-old man presented with an inability to flex his index finger after proximal phalangeal fracture. He underwent hardware removal and extensive scar release. He had severe postoperative pain that limited his ability to comply with hand therapy, which is required to achieve functional goals after surgery. A perineural catheter was placed under ultrasound guidance adjacent to the median nerve in the proximal forearm; then a continuous infusion of ropivacaine 0.2% was initiated and maintained for 11 days. The patient had focused sensory loss in the median nerve distribution but maintained active flexion of the fingers. He subsequently was able to participate in hand physical therapy and discontinued the use of oral opioid medications. Discussion: Ultrasound-guided perineural catheters targeting terminal branch nerves may have potential benefits beyond the immediate postoperative period and in nonoperative management of patients requiring physical therapy and rehabilitation.