Open Carpal Tunnel Release

Contributors: Theresa O. Wyrick

This video shows the open surgical release of the carpal tunnel for relief of compressive median neuropathy at the wrist or carpal tunnel syndrome (CTS).

DOI: https://doi.org/10.17797/2ddezhnxdf

After exsanguination of the upper extremity, a tourniquet is inflated to prevent bleeding. An incision is made in the skin just proximal to Kaplans line and approximately along the radial border of the ring finger with preference for location within a skin crease. The incision is extended proximally and stopped just distal to the volar wrist crease. The palmar fascia is released, followed by the transverse carpal ligament. Care is taken to avoid injury to the thenar motor branch and the median nerve. Complete release of the transverse carpal ligament and the distal antebrachial fascia of the forearm are confirmed by inspection and palpation. The skin is then closed with nylon suture and sterile soft dressings are applied.
Carpal tunnel syndrome is the most common entrapment peripheral neuropathy, affecting up to 3% of the population. Patients present with pain, numbness, and parasthesias in the thumb, the index and middle fingers, and the radial half of the ring finger. Thenar wasting can be seen in advanced disease. Surgery is indicated after failed non-operative treatment consisting of rest, activity modifications, wrist splinting, and corticosteroid injections. Carpal dislocation, especially of the lunate, distal radial fracture or other severe hand or wrist trauma may cause an acute carpal tunnel syndrome. Urgent carpal tunnel release with reduction of the fracture or dislocation is indicated in this instance and a more extensile approach may be warranted.
No specific contraindications for this procedure exist. This procedure is elective except in the case of acute carpal tunnel syndrome associated with acute trauma, so general contraindications for routine surgery apply. Advanced chronological age is not a contraindication to surgical treatment.
We perform carpal tunnel release under sedation with the patient supine with an attached arm board. The skin near the incision is injected with local anesthesia by the surgeon just before skin preparation.
Proper diagnostic testing for CTS remains somewhat controversial. A clinical diagnosis can often be made, but some patients may have atypical symptoms. Nerve conduction studies and electromyography can be useful in confirming and quantifying the clinical diagnosis of CTS and to differentiate CTS from cervical radiculopathy and other compressive neuropathies of the upper extremity. Radiographs should be obtained if a history of trauma is present or in the case of acute symptom onset.
The carpal tunnel is defined by the pisiform and hook of the hamate ulnarly and the scaphoid and trapezium radially. The floor of the tunnel is formed by the bones of the proximal carpal row, with the roof of the tunnel being the flexor retinaculum or transverse carpal ligament. The contents of the carpal tunnel are the median nerve and nine tendons including the flexor digitorum superficialis (4), flexor digitorum profundus (4) and flexor pollicus longus tendons. The transverse carpal ligament is the thick central band of the flexor retinaculum. The vascular superficial palmar arch marks the distal extent of the tunnel. The recurrent motor branch of the median nerve must be protected and variations in it�s normal anatomy should be recognized to prevent injury.
Endoscopic release is an alternative, but is historically associated with more complications, requires longer surgical time, and has a steeper learning curve. Open release allows for faster surgical times in most cases but may cause more soft-tissue damage and may be associated with a longer recovery postoperatively.
Persistent symptoms may occur after surgery and are typically associated with incomplete release of the transverse carpal ligament. Other risks include recurrence of symptoms, tenderness over the surgical incision, infection, wound dehiscence, hematoma formation and nerve injury.
Persistent symptoms may occur after surgery and are typically associated with incomplete release of the transverse carpal ligament. Other risks include recurrence of symptoms, tenderness over the surgical incision, infection, wound dehiscence, hematoma formation and nerve injury.
Ghasemi-Rad M. A handy review of carpal tunnel syndrome: From anatomy to diagnosis and treatment. World Journal of Radiology WJR. 2014;6(6):284. doi:10.4329/wjr.v6.i6.284. Hu K, Zhang T, Xu W. Intraindividual comparison between open and endoscopic release in bilateral carpal tunnel syndrome: a meta-analysis of randomized controlled trials. Brain Behav Brain and Behavior. 2016;6(3). doi:10.1002/brb3.439. Kim P-T, Lee H-J, Kim T-G, Jeon I-H. Current approaches for carpal tunnel syndrome. Clinics in Orthopedic Surgery. 2014;6(3):253. doi:10.4055/cios.2014.6.3.253. Louie D, Earp B, Blazar P. Long-term outcomes of carpal tunnel release: a critical review of the literature. Hand. 2012;7(3):242-246. doi:10.1007/s11552-012-9429-x. Mack GR, Mcpherson SA, Lutz RB. The Role of Emergent Carpal Tunnel Release. Clinical Orthopaedics and Related Research. 1994;&NA;(300). doi:10.1097/00003086-199403000-00018. Newington L, Harris EC, Walker-Bone K. Carpal tunnel syndrome and work. Best Practice & Research Clinical Rheumatology. 2015;29(3):440-453. doi:10.1016/j.berh.2015.04.026. Vasiliadis HS, Nikolakopoulou A, Shrier I, et al. Endoscopic and Open Release Similarly Safe for the Treatment of Carpal Tunnel Syndrome. A Systematic Review and Meta-Analysis. PLOS ONE PLoS ONE. 2015;10(12). doi:10.1371/journal.pone.0143683.

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