Carpal Tunnel Release
My name is Asif Ilyas. I'm a professor of orthopedic surgery and the program director of hand surgery at the Rothman Institute at Thomas Jefferson University in Philadelphia. We're going to be doing a carpal tunnel release procedure today. Carpal tunnel release is the most common hand surgery performed and amongst the most common orthopedic & plastic surgery performed. The indication for a carpal tunnel release is carpal tunnel syndrome or a median nerve compression at the wrist where you develop paresthesias into the hand - very common phenomenon - and when it fails nonoperative treatment or it becomes recalcitrant to nonoperative treatment, and nonoperative treatment being splinting and injections primarily, and/or the disease is fairly advanced by exam or electrodiagnostic testing, then a carpal tunnel release surgery is indicated.
Now broadly speaking, a carpal tunnel release surgery can be performed in two ways: one in an open way, and one in an endoscopic way. Each of those general techniques have several subcategories as to how it can be performed. Today, we'll be performing it using an open technique - specifically the mini-open technique - but as we go through the procedure, I'll show you some of the variations in terms of the approach and techniques and nuances. Also during the surgery, I'll sh - show you some tips and perils and pitfalls in terms of how to manage carpal tunnel release intraoperatively.
We are going to start with a carpal tunnel release. So a carpal tunnel release involves placing an incision directly over the - the carpal tunnel as well when you're doing an open technique. So there's a couple ways to tell where to place the incision; you've got three broad ways you can tell. First is by placing the incision directly in line with the third web space, so the incision goes about like so. Another way is to use the ring finger and - and see if it lines up. Now I find this technique to be a little bit less sensitive because some people rotate a lot, but it's a common technique people say is to bring the ring finger down and where it hits the palm is where the distal extent of the transverse carpal ligament is. I'm not so sure about that, but it's a - it's a common technique. Another is to use the palmaris longus if it's evident in line with that. And the third thing is if they have a good inner thenar valley, you can use that. I think - I find the most reliable one is just using the third web space, like so, from about there to there.
So the mini open technique is about a 1 inch or two centimeter incision at the base of palm, like so. Now if you're doing an extensile release, your incision will go a little bit further proximal and distal; you'll go across the wrist crease and oblique angle and go forward as well. But again, we're going to be doing what's called the mini open technique. Now if you're doing endoscopic technique, there's typically an incision placed at the wrist crease and, depending on your technique, a second one distal to the transverse carpal ligament, but again, we'll - we'll - we'll proceed with the mini open technique. So this is just a small incision, and we take this through the subcutaneous tissue.
And the first layer you're going to come across is the trans - is the superficial palmar fascia. So I'm going to - I'll place the self retainer here to show us some of that. So I'm still just going through the superficial tissue. Now you may have noticed on this patient that she's hollowed-out right here - that's called thenar atrophy - so that tells me right away that she has fairly advanced disease.
Alright, so we're going to proceed, and the next layer we're going to find is the superficial palmar fascia. It's right below the fat. It's this softer layer below. It's relatively wispy. A longitudinal cut through that layer will - will free that layer up quite readily. It has very little resistance to that unlike the transverse carpal ligament that has a good amount of resistance to it. So I'm going to change this. I'm going to drop the self retainer a little bit deeper. I'll make sure we have adequate release of the superficial layer. The - the better that's released, the more evident the ligament will be. So if we put in a retractor now, we'll have a direct view of the ligament right there.
Alright, so once you get through the superficial palmar fascial layer, you'll come down to the transverse carpal ligament. Very often there's muscle over top of the ligament covering it. You can bust through it or cut through it or sweep it to the side. Here I'm going to do a - a sweep technique where I just sweep it to the side, and I would further expose the ligament. So once you're - once you are exposed, it's just a release. Again, release in line with the - with the third web space, and there's a couple ways to do the release. I like to just push through gently 'til you get a give. I'll show you this in just a moment, and you'll see the tendons and/or the nerve itself - the flexor origins or the - the median nerve itself - and you just go longitudinally.
I'll put back in a second so you can see a little better; it's a small field obviously. So I'm going to come in. The distal part has been released, and what you'll find is the median nerve and the flexor tendons - is that the carpal tunnel contains the median nerve most superficially as well as the FPL, which is a flexor tendon to the thumb, the four FDS tendons, and the four FDP tendons. So this is the release of the distal aspect, and the question often comes up, how far distal to take the release, and the - the rule of thumb is you go to when the ligament loose - the - the tautness of the ligament is gone or until you see this yellowy fat distal to it. People will refer to it as an essential pad of fat, and what that represents is the perivascular fat of the ark - the vascular arch of the hand. Okay, so we're at that level now, but I find that it's quite evident when you're at the end of it. And moreover, most of the tension of the - of the carpal tunnel is really more proximal anyways. So I'm - I'm going to change this retractor, and I'm going to switch hands.
And now I'm going to actually do the proximal release. Alright, so this is the proximal part right here. This is - I find this area to be quite tight, typically, and surprisingly thick. So now we have a couple options. I'm going to retract here to - so you can appreciate it a little bit better. At this level here, you want to do a release to about this level. So you can do that in one of two ways; you can do that with your knife the whole way, you can do it with the fasciatome, you can do it with the scissor - all those techniques are perfectly fine. The one thing I would tell you is just be a little bit careful with indiscriminate sliding of any sharp instruments proximally. I like to use a regular scissor, a Metz or a tenotomy, and I create a path first above and below the ligaments.
So I'm above right now - I have a nice path - and then I check below as well. Make sure I have no resistance, and I'm hugging the tendon - I'm sorry, I'm hugging the ligament above, and the tendons are below me. Once I'm satisfied that I'm there, I'll do it in one motion, like so, and if you have resistance - so that's one technique - and if you have resistance, you can also just go with your scissors as well. Again, showing you the different ways to do this. And release that as well. I guess I'm going to cover ya for just one second just so I can get in here for this part, and it's hard to do without seeing it. And now it's released. And now if you look here, when I spread there, you'll see no resistance whatsoever, and you have a clear view of the contents of the carpal tunnel. You'll see the retracted leaflet of the transverse carpal ligament. The contents of the carpal tunnel I can show you by moving the fingers. You'll see the tendons move as I move the fingers back and forth like so. So in terms of closure for this - it's a very routine closure.
So once you're satisfied with the release, you wash the wound. Then you close the incision. I use a simple nylon suture. I use inner - interrupted mattresses - typically three will do the trick. I typically will leave these sutures in for 10 days, plus or minus a couple days. The dressings: I place just a soft dressing on - no splints or anything. They're allowed to use your - their hands right away. I tell them writing, typing, eating, driving - all allowed and encouraged - and I ask them to leave my dressing on for two days, and after two days they can take the dressing off. And then they can shower and wash normally. The way that I ask them to take care of the incision is - besides bathing normally - after 2 days, they clean the incision twice a day with some rubbing alcohol at least and - and just apply either a soft dressing of their choice or a Band-Aid. Have them return to the office then in - in 10 days approximately to have the sutures removed. I do not typically recommend any formal physical therapy. Occasionally, if a patient feels very weak or sore or stiff, then therapy can be initiated. I also do not routinely recommend any kind of splinting afterwards, and they're welcome to if they would like - but not required.