Carpal Tunnel Syndrome – Open Carpal Tunnel Release

Anatomy Perioperative management Technique Complications Evidence Total Video

Planning/Skin Incision
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Anatomical orientation by palpation and marking of anatomical landmarks:
- Planning mini-incision with incision line in the extension line middle 3rd/4th finger ray to ulnar insertion of the palmaris longus tendon at the aponeurosis (guiding structure)
- Incision median palm approximately 2-3 cm long (mini-incision) starting approx. 1.0 to 1.5 cm distal to the rascetta
- sharp transection of the subcutis with bipolar coagulation of individual veins
- Exposure of palmar aponeurosis
Tips for Orientation
- Orientation carpal tunnel based on palpable pisiform bone and scaphoid tubercle
- Flexor retinaculum begins at the level of the rascetta
- Orientation course of median nerve between flexor carpi radialis tendons and palmaris longus tendon
Transection of Palmar Aponeurosis
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Transection of palmar aponeurosis with exposure of flexor retinaculum
- sharp transection of the palmar aponeurosis in longitudinal direction
- Exposure of distal portion of the flexor retinaculum with, if applicable, superficial palmar arch (arterial superficial palmar arch)
Transection of Flexor Retinaculum
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Transection of Flexor Retinaculum with Palmar Carpal Ligament
- sharp transection of the distal portion of the flexor retinaculum under direct vision
- exposure of median nerve
Now reposition the operator to the head end of the hand table for better insight into the proximal carpal tunnel
- blunt release of the median nerve from the carpal roof with careful spreading using scissors over the nerve
- completion of the division of the flexor retinaculum proximally with scissors
- division of the palmar carpal ligament with scissors at the ulnar edge of the palmaris longus tendon (guide structure)
Tips
- running the scissors along the carpal roof to check for complete division
- distally, if necessary, exposure of the superficial palmar arch (arterial superficial palmar arch)
Exposure and Inspection of Median Nerve and Flexor Tendons
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Exposure of the median nerve, if applicable thenar branch as well as the flexor tendons
- Exposure and inspection of the median nerve as well as optionally of the thenar branch
- macroscopic description of the median nerve regarding signs of constriction (flattening, coloration, prestenotic dilation)
- Exposure and inspection of the flexor tendons, optionally tenosynovectomy in case of pronounced chronic tenosynovitis
Tip
- in case of pronounced tenosynovitis, a proximal extension incision with ulnar circumincision of the rascetta is possible to perform a complete tenosynovectomy
Digital Carpal Tunnel Test
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Assessment of the carpal tunnel lumen by digital palpation of the carpal tunnel
- Insert the little finger proximally and distally into the carpal tunnel
- Checking the width of the carpal tunnel
Irrigation and skin suture
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Irrigation, if necessary drainage insertion and skin suture
- thorough irrigation of the surgical site with e.g. physiological Ringer's solution with final inspection
- if necessary insertion of a Mini-Redon or an 8-Redon drainage
- everting skin suture (single knot/continuous/intracutaneous, if necessary Omni- or Steri-Strips)
- sterile elastic compressive dressing
- if necessary application of a dorsal wrist splint