Carpal Tunnel Repair and Fasciectomy for Carpal Tunnel Syndrome and Dupuytren’s Disease

Carpal Tunnel Syndrome (CTS) and Dupuytren's disease (DD) are two common hand conditions that can significantly impact a patient's quality of life and hand function. CTS affects approximately 1–5% of adults in the general population, with higher prevalence observed among women and individuals over 50 years of age.^1–3

Dupuytren's disease, a progressive fibroproliferative disorder affecting the palmar fascia, exhibits varying prevalence rates depending on age and population.^4,5 Patients with DD may experience progressive finger contractures, leading to difficulties with hand function, such as gripping objects, shaking hands, or performing fine motor tasks.

In cases where both conditions coexist, as demonstrated in this video, a combined surgical approach is adopted in suitable candidates. Combining carpal tunnel release and fasciectomy in a single surgical setting is safe, cost-effective, and efficient, reducing recovery time and healthcare costs while achieving functional outcomes comparable to staged interventions.

The following describes the surgical technique for this combined procedure, demonstrating key operative steps for both conditions.

The surgical intervention was initiated with the application of a tourniquet. A 2-centimeter longitudinal incision was made in the thenar crease, followed by division of the palmar aponeurosis in line with the skin incision. The length of the skin incision may vary depending on the size of the hand and soft tissue pliability. The transverse carpal ligament (TCL) and deep forearm fascia is exposed by careful dissection of superficial tissue which allows safe placement of a right angled retractor. At this point it is essential to look for any anomalous nerve branch which may be in the path of surgical release. Transligamentous branching of the recurrent motor branch of the median nerve has been reported in several studies. There seems to be an association with anomalous branching of the median nerve and hypertrophic muscle overlying the transverse carpal ligament.^6,7 Clear visualization of the entire transverse carpal ligament is a prerequisite to performing its release. The proximal release was performed using saline-moistened dissecting scissors, extended into the distal forearm, while the distal release was performed under protection of a Freer elevator until the characteristic fat pad surrounding the superficial arch was encountered.

At all times the medial nerve is kept under direct visualization to prevent accidental injury. Complete release was confirmed both visually and by palpation. In a primary case it is almost always possible to perform a complete and safe release with the technique as described. In revision cases it is often necessary to extend the incision into the distal forearm in a zigzag fashion. This allows safe and complete visualization of the nerve and its branches.

Following closure of the carpal tunnel release, attention was turned to the small and ring fingers for fasciectomy. A zigzag Bruner incision was made, starting in the hypothenar area and extending into the proximal and middle segments of the small finger. Skin flaps were elevated at the subdermal level taking care to avoid buttonholing the skin flaps. Each neurovascular bundle is identified and protected with vessel loops. This may be done at multiple levels.

Once complete exposure is achieved excision of the diseased fascia is performed with particular attention directed at protecting the neurovascular structures. It should be kept in mind at all times that because of fascial contracture the neurovascular bundle may be displaced from its usual anatomic position. Unless this is recognised, inadvertent injury to the nerve and artery may occur. In this case there was a retrovascular cord that required meticulous dissection of the neurovascular bundle to allow complete fascial excision. Once all the diseased fascia is excised full correction of the flexion deformity is achieved. Additional diseased tissue extending toward the ring finger was then excision by elevating existing skin flaps and using standard technique as described.

The tourniquet was released to assess digital perfusion and achieve hemostasis. A bipolar cautery is used to minimize tissue damage. Brisk capillary refill is confirmed in all digits. Following satisfactory hemostasis, the tourniquet was reinflated for final closure. Local anesthetic was administered, and small silicone drains were placed to prevent hematoma formation. These drains are removed at the first dressing change in 2–3 days. The procedure concluded with appropriate dressing application and plaster splint application keeping the digits in gentle extension.

This video demonstration is particularly valuable for practicing hand surgeons and surgical trainees, offering detailed insights into technical challenges such as neurovascular bundle protection, management of retrovascular cord components, and the precise balance between complete disease excision and preservation of vital structures. The demonstrated solutions, including the use of vessel loops for nerve protection, staged fascia removal, and careful hemostasis management, provide practical guidance for similar cases.

The patient referred to in this video has given their informed consent to be filmed and is aware that information and images will be published online.

We would like to thank the patient, Roland Neibarger, who graciously participated in this study and wanted to be mentioned by name.