Carpal tunnel release

  • Operation: Carpal tunnel release
  • Introduction- Carpal tunnel syndrome is a result of median nerve entrapment as it course underneath the transverse carpal ligament (ie the flexor retinaculum). It is the most common entrapment neuropathy and is more prevalent in women. The most common presenting symptom is dysesthesias in the distribution of the median nerve. Weakness or loss of fine motor skills can also be seen.
  • Positioning and anesthesia
    • Monitored anesthesia care (MAC): Morphine and versed
    • Supine with the affected arm on an arm board
  • Prep and Landmarks
    • Identify
      • Wrist crease- entrapment of the median nerve occurs just distal to the wrist crease
      • Palmaris longus- not present in about 10% of patients but is useful in approximating the location of the median nerve]
      • Recurrent motor branch of the median nerve (ie thenar branch)- takes off superior to the normal incision but can be invested within the transverse carpal ligament
      • Palmar cutaneous branch- takes off proximal to TCL and course superficially
    • Prep
      • Prep the arm in usual fashion
      • Down drape on the arm board
      • Stocking on the arm
      • Extremity drape
      • Cut an opening in the stocking over the incision site
  • Incision and approach
    • Local anesthesia- inject lidocaine c epi around the incision site to limit bleeding/pain
    • Incision: Make a 2-3cm vertical incision within a natural palm crease just distal to the wrist crease and on the ulnar side of the palmaris longus
  • Operative details
    • Extending the incision all the way through the dermis and identify the underlying fat
    • Sharply dissect through the fat to identify the transverse carpal ligament
    • Open the TCL with a 15 blade, use mets to extending the incision
    • Assure the median nerve is adequately decompressed by sliding a Penfield 4 superiorly and inferiorly.
    • Closure
      • Close the skin with vertical mattress nylons
  • Hand wrap
    • Place a fluffed 4×4 over the incision site (with or without xeroform guaze) and pad the fingers. Wrap the wrist with a curlex and then an ace bandage.
  • Postop Orders
    • D/C home with lortab
  • Complications
    • Infection
    • Injury to the median nerve or motor branch
    • Failure to improve
    • hematoma

 

 

Joseph MillerCarpal tunnel release

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