Digital Nerve Research Articles

Sensory Neurotization of the Ulnar Nerve, Surgical Techniques and Functional Outcomes: A Review.

When ulnar nerve lesions happen above the wrist level, sensation recovery after acute repair or nerve grafting is often challenging. Distal sensory nerve transfers may be an option for overcoming these sequelae. However, little data has been published on this topic. This study aims to review the surgical procedures currently proposed, along with their functional results. Six donor nerves have been described at the wrist level: the palmar branch of the median nerve, the cutaneous branch of the median nerve to the palm with or without fascicles of the ulnar digital nerve of the index finger, the posterior interosseous nerve, the third palmar digital nerve, the radial branch of the superficial radial nerve, the median nerve, and the fascicule for the third web space. Three donor nerves have been reported at the hand level: the ulnar digital nerves of the index, and the radial or ulnar digital nerves of the long finger. Three target sites were used: the superficial branch of the ulnar nerve, the dorsal branch of the ulnar nerve, and the ulnar digital branch of the fifth digit. All the technical points have been illustrated with anatomical dissection pictures. After assessing sensory recovery using the British Medical Research Council scale, a majority of excellent recoveries scaled S3+ or S4 have been reported in the targeted territory for each technique.

Cold sensitivity, functional disability and predicting factors after a repaired digital nerve injury

To investigate self-reported cold sensitivity and functional disability after a repaired digital nerve injury. We identified 3204 individuals operated with digital nerve repair in the Swedish national quality registry for hand surgery (HAKIR). Patient-reported symptoms, including cold sensitivity and perceived disability, were examined using two questionnaires (HQ-8 and QuickDASH), three and 12 months postoperatively. Patients with diabetes (n = 48; 3%) were identified in the Swedish National Diabetes Register (NDR). Cold sensitivity (scored 0–100) was the most prominent symptom among 1553 included individuals (998 men, 555 women; median age 41 [IQR 27–54] years). In the regression analysis, flexor tendon injury, hand fracture and injury to multiple structures predicted worsened cold sensitivity (6.9, 15.5 and 25.0 points; p = 0.005, 0.046 and < 0.001) at 12 months. Individuals with moderate (30–70) and severe (> 70) cold sensitivity had higher QuickDASH scores at three and 12 months postoperatively than individuals with mild cold sensitivity (6.0 and 5.5; 19.8 and 21.0 points; p = 0.001). Flexor tendon injury, injuries to multiple structures and diabetes had significant effect on QuickDASH scores at three, but not at 12, months postoperatively. Cold sensitivity is common after a digital nerve repair and impacts self-reported disability. A concomitant injury, particularly multiple injuries, predicts postoperative cold sensitivity.

Our 15-year experience of complications of Chow’s technique for endoscopic carpal tunnel releasing

ABSTRACT Purpose Our objective in this study was to summarize our 15-year experience treating carpal tunnel syndrome released with Chow technique, focusing on the complications and how to avoid them. Method We systematically evaluated the postoperative complications in 211 patients who underwent endoscopic carpal tunnel release (ECTR) with Chow technique. We recorded the incidence of complex regional pain syndrome type I (CRPS I), median nerve and digital nerve injury, superficial palmar arch injury, and tendon injury. Result The overall incidence of complications was 5.6%, and involved 10 cases of CRPS I, 1 case of median nerve trunk injury, and 1 case of superficial palmar arch injury. No other complication occurred. We used oral pregabalin and neurotropin to relieve CRPS I symptoms, and performed second operations for the other two complications. Conclusions Our study revealed that ECTR could reduce structural and cutaneous complications, but increase the incidence of nerve injury. we speculated that the incidence of CRPS I may be higher in the Asian population.

Percutaneous hallux valgus surgery: Anatomical study of its safety and effectiveness

Background and hypothesisAlthough percutaneous hallux valgus surgery is increasing in popularity, concerns about safety regarding neurovascular and tendinous structures remain. The first aim of this body-donor study was to evaluate the safety of three common percutaneous portals. Secondly, to evaluate percutaneous surgery effectiveness in completing adductor tendon release and first ray osteotomies. Patients and methodsTwenty body-donor feet were included and underwent three percutaneous procedures, which are commonly performed in combination: distal metatarsal osteotomy, proximal phalanx osteotomy and adductor tendon release. After surgery, the distance between surgical portals and relevant neurovascular structures was measured. Damage to this neurovascular structures, tendons or articular cartilage was noted. Completion of adductor tendon release and osteotomies was verified. ResultsThe medial dorsal digital nerve of the hallux was damaged in two specimens. Mild peritendon damage was observed in two feet. The rest of neurovascular and tendinous structures were intact. No cartilage damage was observed. The distance between the adductor tenotomy portal and the lateral dorsal digital nerve of the hallux and the first dorsal metatarsal artery was 3.3mm (SD 1.4) and 2.4mm (SD 1.8), respectively. Complete adductor tenotomy was achieved in 14 feet. ConclusionsThe structure with the highest risk of damage during percutaneous hallux valgus surgery is the medial dorsal digital nerve. The lateral dorsal digital nerve and the first dorsal metatarsal artery might be at risk due to the small distance to the adductor tendon release portal. A deep anatomical knowledge and a meticulous surgical technique are required to avoid lesions to neurovascular and tendinous structures. Level of evidenceV, Cadaveric study.

Sensorimotor Outcomes of Upper Extremity End-to-Side Nerve Transfers: A Meta-analysis.

End-to-side nerve transfer (ETSNT) for treatment of peripheral nerve injuries is controversial given the myriad anatomic locations, injury types, and indications. Efficacy of ETSNT remains debated. We hypothesized differences in age, sex, transfer location, and time to surgery influence outcomes. We performed a search of the PubMed database for ETSNT in the upper extremity from 1988 to 2018. Age, sex, transfer location, time to surgery, donor and recipient axons, and strength and sensation outcomes as measured by Medical Research Council scale were extracted from articles. Meaningful recovery was classified as Medical Research Council Grade 3 or greater. Association between meaningful recovery and younger (<25) and older (≥25) patients, injury mechanism, sex, transfer location, donor axons, and recipient axons were calculated using a χ 2 or Fisher exact test. A logistic mixed effect model was used with time to surgery, age (categorical), transfer location, and injury type as a fixed effect, and a random paper effect was included to account for correlation among patients from the same paper. One hundred fifteen patients from 11 studies were included. Neither age (continuous variable, P = 0.68) nor time to surgery ( P = 0.28) affected meaningful recovery. Injury mechanism, sex, and younger age (<25 vs ≥25 years) were not associated with meaningful recovery. Within the brachial plexus ETSNT demonstrated median M4 ± 1 postoperative strength, with trunks/cords as the primary axon donor ( P = 0.03). The musculocutaneous nerve demonstrated promising but variable results in 31 patients with median strength M3 ± 4. Digital nerves consistently demonstrated meaningful sensory recovery as both donor and recipient axons (15 of 15, 100%). Logistic regression analysis demonstrated that odds of meaningful recovery after ETSNT are significantly greater for transfers within the brachial plexus compared with the distal arm (odds ratio, 41.9; 95% CI, 1.1-1586.7, P = 0.04), but location does not significantly affect meaningful recovery ( P = 0.22). Patients undergoing ETSNT for digital nerve injury demonstrated meaningful recovery. End-to-side nerve transfer seems to be more efficacious when performed within the brachial plexus. This study did not find sex, injury mechanism, or time to surgery to significantly affect meaningful recovery. Additional study is needed to better evaluate the effectiveness of ETSNT in the upper extremity.

Total, gender- and age-specific incidence rates of upper extremity nerve injuries in Finland.

The aim of this study was to describe the epidemiology of nerve injuries of the upper extremity in the whole population of Finland (1998-2016). Data based on diagnosis codes were obtained from the Care Register for Health Care, including cases of median, radial, ulnar, musculocutaneous, axillary and digital nerves. Age- and gender-specific incidence rates, both crude and standardized (for the European normal population in 2011), were calculated. Our study included 13,440 patients with upper extremity nerve injury. The mean standardized annual incidence rate of any upper extremity nerve injury was 18.18 among men and 8.15 among women per 100,000 person-years over the study period. The incidence peaked among men at working age. Nerve injuries occurred most commonly in the fingers and thumb, with 5532 cases and mean standardized incidence rates per 100,000 person-years of 7.84 among men and 2.95 among women. The annual incidence did not change significantly over the study period.Level of evidence: III.

Palmar approach for fixation of metacarpal fractures.

Between 2018 and 2020, 14 patients with closed metacarpal fractures requiring open reduction were operated on via a palmar approach. Reduction and fixation were done with screws or plates. We assessed range of motion, grip strength, Mayo score, possible nerve damage and cosmesis. The range of motion and grip strength were fully restored by 6months after operation. Transient paraesthesiae in the digital nerve territory occurred in two patients and had resolved by 3months. In selected patients the palmar approach for metacarpal shaft fractures can provide satisfactory cosmesis and function of the hand. This method can be useful in patients with history of hypertrophic scarring or in patients who would prefer to avoid a visible scar on the dorsum of the hand.Level of evidence: IV.

Mirror Foot: Surgical Approach for Esthetic and Functional Improvement.

Mirror foot is a rare congenital anomaly on to the spectrum of complex foot polydactyly. It may occur in isolation or associated with other malformations or genetic syndromes. This is a subject little described in the literature, with few publications on its treatment. We herein report the case of a 4-year-old female patient who presented with a left foot with 8 fingers, without other associated deformities, whose complaints included the impossibility of wearing shoes and social stigma. Radiographically, eight metatarsi with their respective phalanges, five cuneiform bones, and absence of bone deformities in the hindfoot were verified. The surgical approach was chosen in order to promote functional and esthetic improvement, as well as a better adaptation to the use of closed shoes, according to the patient's and family's desire. A dorsal and plantar V incision was performed, with resection of three supranumerary rays, including three central metatarsi with their nine corresponding phalanges, two cuneiform bones, tendons and extra digital nerves, followed by suture of the intermetatarsal ligaments, preserving the fingers with normal appearance, decreasing the width of the foot, and maintaining proper support. The reduction was maintained through transmetatarsal fixation with Kirschner wires. The postoperative period went on with the use of a walking boot and zero load, without complications, with removal o the Kirschner wires and allowing load on the limb after twelve weeks.

Investigation of Predictors of Successful Replantation of Distal Digits at the Nail Bed Level: The Contribution of Digital Nerve Repair to Survival Rate.

Replantation of amputated digits at the nail bed level is surgically challenging and differs from replantation at a more proximal amputation level. This study aimed to determine the predictors influencing the success rate of fingertip replantation. Overall, 239 digits of 226 patients who underwent replantation surgery from August of 2009 to March of 2020 were considered. A total of 15 independent variables (i.e., sex; age; injured hand; digit; history of smoking; history of hypertension or diabetes; injury mechanism; amputation level; ischemia duration; surgeon's expertise; numbers of repaired arteries, veins, and nerves; and the need for a vein graft) were investigated for their effects on the survival of the replanted digits. Of all 239 digits, 190 (79.5 percent) survived. Univariate analysis indicated that non-crush-avulsion injury, expertise and experience of the surgeon, vein repair, and nerve repair contributed to increasing the survival rate. Binary logistic regression analysis demonstrated that injury mechanism, vein repair, and nerve repair were significant predictive factors. In addition, in non-vein-repaired, blunt cut, or Ishikawa subzone II cases, digital nerve repair contributed significantly to promote the success rate relative to vein-repaired, crush-avulsion-type injury, and subzone I cases. Vein repair, nerve repair, non-crush-avulsion injury, and surgeon's expertise and experience were the predictors for successful replantation. Intraoperative vein and nerve repair are recommended to improve the survival rate of fingertip replantation at the nail bed level. Risk, III.

Discussion: Investigation of Predictors of Successful Replantation of Distal Digits at the Nail Bed Level: The Contribution of Digital Nerve Repair to Survival Rate.

Austin, Texas From the Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin. Received for publication April 1, 2021; accepted July 16, 2021. Disclosure:The author has no financial interest to declare in the content of this Discussion. Steven L. Henry, M.D., Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, 1601 Trinity Street, Suite 704D, Austin, Texas 78712, [email protected]

Digital Nerve Management and Neuroma Prevention in Hand Amputations.

Hand and digit amputations represent a relatively common injury affecting an active patient population. Neuroma formation following amputation at the level of the digital nerve can cause significant disability and lead to revision surgery. One method for managing digital nerves in primary and revision partial hand amputations is to perform interdigital end-to-end nerve coaptations to prevent neuroma formation. All patients with an amputation at the level of the common or proper digital nerves that had appropriate follow-up at our institution from 2010 to 2020 were included. Common or proper digital nerves were managed with either traction neurectomy or digital end-to-end neurorrhaphy. The primary outcome was the development of a neuroma. Secondary outcomes included revision surgery, complications, and visual analog pain scores. A total of 289 nerves in 54 patients underwent hand or digital amputation in the study period. Thirteen hands with 78 nerves (27%) underwent direct end-to-end coaptation with a postoperative neuroma incidence of 12.8% compared with 22.7% in the 211 nerves that did not have a coaptation performed. Significantly fewer patients reported persistent pain if an end-to-end coaptation was performed (0% vs. 11.8%, P < .01). The prevalence of depression and workers compensation status was significantly higher in in patients with symptomatic neuromas than in patients without symptomatic neuromas (P < .01). Digital nerve end-to-end neurorrhaphy is a method for neuroma prevention in partial hand amputations that results in decreased residual hand pain without increase complications. Depression and worker's compensations status were significantly associated with symptomatic neuroma formation.

Dexmedetomidine prolongs the duration of action of mepivacaine on anesthesia of the palmar digital nerves of horses

To determine whether palmar digital nerve (PDN) blockade in horses with a combination of dexmedetomidine and mepivacaine would block the response to mechanical force applied to the digit longer than would anesthetizing these nerves with mepivacaine alone or dexmedetomidine alone. 8 mares with no signs of lameness. In a randomized, crossover, blinded, experimental study, both PDNs of the same forelimb of each horse were anesthetized by perineural injection with either 30 mg mepivacaine alone, 250 µg of dexmedetomidine alone, or 30 mg mepivacaine combined with 250 µg of dexmedetomidine. Each horse received each treatment, and treatments were administered ≥ 2 weeks apart. The mechanical nociceptive threshold was measured at a region between the heel bulbs with the use of a digital force gauge before (baseline) and at 15-minute intervals after treatment. The mean duration of sensory blockade of the digit was 2-fold longer when a combination of mepivacaine and dexmedetomidine was administered (371 minutes), compared with when mepivacaine alone was administered (186 minutes). Treatment with dexmedetomidine alone did not change the mechanical nociceptive threshold substantially from baseline and resulted in no clinical signs of sedation. Results indicated that relief from digital pain provided by perineural treatment with mepivacaine for PDN blockade can be extended by adding dexmedetomidine to the injectate.

Techniques to prevent symptomatic neuroma in digital amputations

The occurrence of a symptomatic neuroma on a digital amputation stump, whether traumatic or not, is a frequent complication that affects the patient’s quality of life. The objective of this study was to analyze the complications inherent to the various techniques used to manage the nerves when performing digital amputation. We compared different surgical nerve management techniques to determine if one technique is more effective than another in preventing neuroma occurrence. We reviewed 105 patients over a 5-year period. A DN4 score greater than 4 and the modified Tinel test (percussion) showing a trigger zone allowed us to clinically diagnose symptomatic neuroma-related pain. We found 23 symptomatic neuromas out of 131 digital amputations. Twelve neuromas were found when the nerves had been neglected (12/33), eight were found in nerves treated by stripping (8/60), three when nerves were treated by stripping and thermal ablation (3/18). No neuroma was found in the five cases of centrocentral union of the two proper palmar digital nerves, in the 5 nerves buried in the bone or in the 9 nerves subjected to thermal ablation only. Management of the nerve is essential for the prevention of neuromas in digital amputations. New techniques such as bone burial and centrocentral union of the two stumps appear to be particularly effective.

A Comparison of Blinded versus Ultrasound-Guided Limited-Open Trigger Finger Release Using the Yasunaga Knife

Background: An open approach is the gold standard for trigger finger (TF) release. However, this may be associated with infection and scar tenderness. Percutaneous trigger release is an alternative, but this can sometimes result in incomplete release and digital nerve injury, even with ultrasound (US) guidance. Limited-open TF release is an intermediate technique that uses a specially designed knife via a 2-3 mm incision. The aim of this study is to compare the outcomes of blinded versus US-guided limited-open TF release using the Yasunaga knife (Medical U&A, Inc., Japan). Methods: About 138 fingers in 111 patients underwent limited-open TF release using the Yasunaga knife. Green classification was used to grade the severity of TF. Thirty-one patients had grade 3 TF and 80 patients had grade 4 TF. The TF was released in a blinded fashion in 60 patients and using US guidance in 51 patients. Outcome measures included residual triggering, contracture of the proximal interphalangeal joint, visual analog scale (VAS) for assessment of pain, Quick Disability of the Arm, Shoulder, and Hand (DASH) score, and the Patel and Moradia grading of patient satisfaction. Complications were also recorded. Results: Six patients had residual triggering in the blinded group, whereas it resolved in all patients in the US-guided group. This difference was statistically significant (p = 0.03). Patients in both groups showed significant improvement in VAS and Quick DASH score postoperatively. There were no significant differences between the two groups for these two outcomes. Patient satisfaction was graded as excellent by 20 patients and good by 30 patients in the US-guided group compared to eight excellent and 45 good in the blinded group. Conclusion: The incidence of residual triggering was lower and overall satisfaction higher in patients who underwent US-guided limited-open TF release using the Yasunaga knife. Level of Evidence: Level III (Therapeutic).

Surgical Technique for Concurrent Endoscopic Carpal Tunnel Release and Distal Radius Fracture Fixation Using the Flexor Carpi Radialis Approach: A Case Series

PurposeMultiple prior studies have assessed the results of open approaches for concurrent carpal tunnel release with distal radius fracture fixation; however, less is known regarding the feasibility of endoscopic techniques, especially in the setting of high-energy trauma. In this study, we assessed the feasibility and results of concurrent endoscopic carpal tunnel release and distal radius fracture fixation using the flexor carpi radialis approach after high- and low-energy trauma.MethodsWe performed a retrospective, single-surgeon study of 17 consecutive adult patients (aged >18 years) who underwent open reduction internal fixation of an acute distal radius fracture with concurrent endoscopic carpal tunnel release at a level 1 trauma center between April 2017 and October 2020. Recovery from median nerve dysfunction was assessed from patient charts at routinely scheduled postoperative follow-up visits (at 2 weeks, 4 weeks, 6 weeks, and 12 weeks).ResultsThe transverse carpal ligament could be visualized and released in all patients. All patients had a return of light touch sensibility with or without intermittent paresthesia by 12 weeks after surgery (the median time from surgery to recovery was 19 days [range, 12–82 days]). There were no patient reports or clinical examination evidence of palmar cutaneous branch, recurrent motor branch, or the third common digital nerve injury. Time to recovery was significantly different in the setting of high- versus low-energy trauma (26 days vs 18 days, respectively; P = .02).ConclusionsIn this study, we demonstrated that concurrent endoscopic carpal tunnel release using the flexor carpi radialis approach for distal radius fracture fixation in the settings of high- and low-energy trauma is safe from major complications and effective at releasing the transverse carpal ligament.Type of study/level of evidenceTherapeutic IV.

Intraneural glomus tumor within the digital nerve: a case report

A glomus tumor is a soft tissue tumor that arises from the glomus body, a peripheral organ responsible for regulating skin temperature. It accounts for about 1% to 5% of tumors occurring in the hand, is mainly located in the subungual region, and is less than 1 cm in size. The diagnosis is mainly based on clinical symptoms, and the main symptoms are pain at the site of the glomus tumor, pinpoint tenderness, and cold intolerance. The pain is severe and usually requires surgical resection, and the results of complete resection of the tumor are good. This case report presents a 37-year-old female patient who developed pain in the radial side around the proximal interphalangeal joint of the right second finger without any traumatic history. On physical examination and imaging, a glomus tumor of the digital nerve was diagnosed and resected. After surgery, the symptoms improved and there was no recurrence. A careful examination and accurate diagnosis and treatment are necessary for symptomatic masses.

Selective Fasciectomy in Dupuytren’s Contracture: An Experience of A Specialized Tertiary Hospital in Bangladesh

Background: Dupuytren’s disease is a benign yet disabling, irreversible, progressive fibroproliferative condition affecting the palm and fingers, leading to flection contracture of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints.Objective: To evaluate results of selective fasciectomy to correct the deformity of MCP and PIP joints and observe the complications.Methods: This crosssectional study was done on 30 patients of Dupuytren’s contracture treated by selective fasciectomy, between January 2015 and December 2018, in Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Selective fasciectomy was done under brachial plexus block, tourniquet control and loupe magnification. Brunner zigzag incision was used. Indications for surgery was MCP flection contracture more than 30⁰ and any degree of PIP flection contracture. Postoperatively hand was immobilised in extension of MCP and PIP joints for 2 weeks and then active and passive movements were encouraged and intermittent splinting for 10 weeks (only at night in last 6 weeks).Results: Among 30 patients, 24 (80%) patients were male, 6 (20%) were female; mean age was 62 years (56-74 years). 12 (40%) cases were bilateral, ring and little fingers involvement were seen in most cases (92%). Mean MCP correction was 53⁰ and mean PIP correction was 34⁰ (p&lt;0.001). There were 3 digital nerve injuries peroperatively which were repaired/reconstructed and protective sensation regained in repaired nerve area at 1 year and 3 (10%) marginal skin loss postoperatively which healed secondarily. Superficial wound infection developed in 3 (10%) patients which healed on dressing and antibiotics. Complex regional pain syndrome developed in 2 (6.66%) patients which were mild and resolved on conservative management. 3 (10%) patients developed scar sequilae which were mild and resolved on conservative treatment. Radial digital artery injury was observed in 1 (3.33%); however, no ischaemic insult was observed postoperatively. 2 (6.66%) patients developed recurrence of the disease who were more than 70 years old; however, they declined further intervention.Conclusion: Selective fasciectomy is an easy and effective procedure with less complication to correct the deformities and improve the gripstrength significantly in Dupuytren’s contracture patients.International Journal of Human and Health Sciences Vol. 06 No. 01 January’22 Page: 41-46

Surgical Management of Hollow Hoof Syndrome with Compression Shoeing in a Geriatric Mare

Hollow Hoof Syndrome (HHS) is a condition of equine foot that causes the hoof wall layers to separate. This separation starts at the solar surface of the foot and works its way dorsally (upward) toward the coronary band, though it can be managed with proper medical and surgical care. A mare was presented in Veterinary Clinical Complex, LUVAS, Hisar (India) with a history of lameness in right forelimb since last four months. Clinical examination revealed significant increase in the size of hoof accompanied with hard tissue swelling at fetlock joint and also nodding of head during landing of the affected hoof on the ground. Physical examination of hoof revealed that the epithelium of sole was eroded and 3rd phalanx was present just below the punctured keratinized epithelium at the solar surface of hoof. Radiographic examination revealed increased distance between the hoof wall and 3rd phalanx moving towards the apex of hoof confirming the rotation of pedal bone. Palmer digital nerve neurectomy was done to relieve the pain and use of compressive therapeutic shoe leads to uneventful recovery of animal.

Rubber band anesthesia for periungual procedures

Although local infiltration anesthesia, intralesional steroid injection, cryotherapy, and other periungual procedures are common in dermatology clinics, periungual pain proves bothersome for patients. Topical anesthesia or a digital nerve block can be applied before the procedure, but the former is not sufficient and the latter requires an experienced physician.

Development of Ultrasound-Guided Technique for 4 Points Blockade of Manus in Dromedary Camel: A Cadaveric Investigation

The purposes of this study were to describe the most applicable approach of manus blockade in camel using ultrasound-guided techniques. The study was performed on 40 forelimbs of 20 apparently healthy mature freshly slaughtered camels. Limbs were randomly allocated into 3 phases of the study. Phase-I (n=8 limbs): dissection of both dorsal and palmar aspects to identify the topographical anatomy of the target nerves. Phase-II (n=8 limbs): dissection after US guided needle insertion to confirm the needle insertion position. Phase-III (n=24 limbs): US-guided methylene blue injection using one of three volumes (3, 5, or 7 mL) to establish the ideal injection volume. Our results revealed that the dorsal aspect of manus received its innervation from dorsal common digital nerves II and III (DCDN-II &amp; III) and dorsal common digital nerve IV (DCDN-IV). The palmar aspect of manus was received its innervation from the palmar common digital nerve IV (PCDN-IV) and the median nerve. Under Ultrasonographic guidance, the most applicable approach for blocking the DCDN-II &amp; III is at the dorsomedial aspect at about 8-10 c.m below the carpometacarpal joint (CMJ) and 2 cm medial to CDET. Blocking of the DCDN-IV is performed at the dorsolateral aspect at about 8-10 c.m below the CMJ and 2 cm lateral to CDET. Blocking the PCDN IV was performed at the lateral and palmar aspect at about 10-12 c.m below the accessory carpal bone (ACB) and 5 cm palmar to the imaginary line bisect the forelimb longitudinally from lateral to medial. Blocking the median nerve was performed at the proximal third of medial and palmar aspect of metacarpal bone at about 10-12 c.m below the ACB and about 5 cm palmar to the same imaginary line. In conclusion, four point blockade of the manus region in dromedary cadavers can be achieved by US-guided injection of the DCDN-II, III, DCDN-IV, PCDN-IV, and the median nerve.