By R.D. Beckenbaugh, MD

Hand surgeons in general have the knowledge to properly administer injections of lidocaine and/or medications for treatment of minor surgical procedures or inflammation of tendons in the hand and upper extremity. Unfortunately, many are not skilled in performing these injections with the least amount of discomfort possible. To achieve a minimally painful injection, always do the following:

• Allow a drop or so of local anesthetic to land on the point of planned skin penetration for a minute and gently massage it on the skin under sterile precautions.
• Mix any combined medication with the anesthetic to dilute the medication (usually steroid), three parts anesthetic to one part medication.
• Utilize a 27-, 25-, or, rarely, a 22-gauge needle for the injection.
• Place traction on the skin and pass the needle quickly to just under the  skin and inject ½ to 1 cc of medication slowly beneath the skin into a small wheel.

You may now advance the needle to the desired spot by always injecting a small amount of the anesthetic fluid just ahead of the advancing needle to the desired end point (e.g. joint, tendon sheath, cyst, etc.) and then completing the injection slowly with the remaining mixture.

Note: Diluting the steroid medication 3/1 and using soluble steroid type (Celestine) will prevent any later skin discoloration or atrophy.

The key to this nearly painless technique is the advancement of the local anesthetic ahead of the needle passage and the skin traction prior to injection. Try it: you’ll like it and be known as the surgeon with the “golden needle.”