Surgical Release of the Carpal Tunnel
This chapter details the steps in surgical release of the carpel tunnel. From the palmar side, the transverse carpal ligament is reached, and it is slowly released until full opening of the carpal tunnel. Indications, essential steps, postoperative care,
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Tuan Anh Tran and Robert M. Szabo
Indications
Essential Steps
1. Diagnosis of carpal tunnel syndrome with intermittent pain and paresthesias in the median nerve distribution of the hand. 2. No improvement with conservative management with activity modification, wrist splinting, NSAIDs, or corticosteroid injections for 3–6 months. 3. Electrodiagnostic testing shows delays of motor and sensory latencies across the wrist, decreased sensory and motor amplitudes, and in advanced cases positive fibrillations in the abductor pollicis brevis muscle on EMGs consistent with median neuropathy across the carpal tunnel.
Preoperative Markings 1. Mark a longitudinal line parallel to the thenar crease beginning at intersection of the radial border of the ring finger and Kaplan’s cardinal line that extends 3–4 cm proximally toward the transverse palmar crease just distal to the hook of the hamate. 2. Incision design should avoid injury to deep and superficial arches, recurrent motor branch, palmar cutaneous branch of the median nerve, and the ulnar neurovascular bundle.
Intraoperative Details T.A. Tran, M.D., M.B.A. Division of Plastic Surgery, Department of General Surgery, University of Miami/Jackson Memorial Hospital, 1120 NW 14th Street, 4th floor, Miami, FL 33136, USA Division of Hand Surgery, Department of Orthopedic Surgery, University of California at Davis Medical Center, 4860 Y Street, Suite 3800, Sacramento, CA, USA R.M. Szabo, M.D., M.P.H. (*) Orthopaedic and Plastic Surgery, Hand & Upper Extremity, Orthopaedics, University of California, Davis Health Care Systems, Sacramento, CA, USA e-mail: [email protected]
1. Place in supine position with forearm supinated and arm outstretched, on a hand table. 2. Axillary block or intravenous regional block or local anesthesia with or without sedation. Preferred technique is to use wide-awake local anesthesia no tourniquet (WALANT). Before surgery, in the recovery room, after an appropriate surgical pause and a sterile prep, block the right palm along the thenar crease and proximal to the wrist crease using a solution of 9 mL 1 % Xylocaine with epinephrine mixed with 1 mL of 8.4 % sodium bicarbonate.
© Springer International Publishing Switzerland 2017 T.A. Tran et al. (eds.), Operative Dictations in Plastic and Reconstructive Surgery, DOI 10.1007/978-3-319-40631-2_122
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T.A. Tran and R.M. Szabo
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3. Place well-padded pneumatic tourniquet, inflated to 250 mmHg on upper arm if not using WALANT. 4. Incise the skin 3–4 cm in the thenar crease from the proximal wrist crease just ulnar to the palmaris longus tendon. Carry the incision down to the subcutaneous tissues and raise flaps proximally and distally. 5. Incise the palmar fascia longitudinally. 6. Incise the antebrachial fascia proximally and identify the median nerve. Incise the transverse carpal ligament from proximal to distal until the fat pad of the superficial palmar arch is reached. Incise about 1 cm into the antebrachial fascia. 7. Close the incision with buried subcuticular 4-0 Monocryl sutures.
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