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Primary Endoscopic Carpal Tunnel Release

Planning

B

Preoperative Plan

1

Execute surgical walkthrough

  • describe the steps verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • Loupes recommended

2

Room setup and equipment

  • standard operative table and hand table

3

Patient positioning

  • supine position

Technique

D

Transverse Incision

1

Identify anatomic landmarks

  • draw out the palmaris longus, flexor carpi radialis and the flexor carpi ulnaris

2

Make incision

  • make a 1 to 2 cm transverse incision in the wrist flexion crease centered over or just ulnar to the palmaris longus
  • if the palmaris longus is not present make the incision half way between the FCR and the FCU
E

Deep Dissection

1

Expose the palmaris longus and retract it radially with a Ragnell retractor

2

Identify and divide the flexor retinaculum

  • create a U shaped flap that is 1 cm wide

3

Retract the flap

  • use a mosquito clamp to retract the flap
F

Prepare Carpal Tunnel

1

Place Hamate finders

  • pass small and large hamate finders down the carpal tunnel to evaluate the space and location of the hamate

2

Ensure proper location of instruments

  • palpate the instruments distal to the TCL at the Kaplan cardinal line
  • if the instruments are palpable proximally then the instruments are not properly placed
  • this could indicate that the insruments are in Guyons canal

3

Separate synovium from the TCL

  • pass the tenosynovial elevator proximally and distally a dozen times along the axis of the fourth ray to dissect the synovium from the undersurface of the TCL
G

Device Insertion

1

Insert the assembled endoscopic device into the carpal tunnel

  • direct the endoscope palmarly.

2

Visual the the undersurface of the TCL

  • TCL has transverse striations

3

Advance the instrument until the distal edge of the TCL is identified

  • the distal edge is identified by a white transverse fiber of the TCL with a yellow amorphous midpalmar fat
  • this fat can contain vessels and nerves
H

Identify Anatomy with Scope

1

Perform a ballotment maneuver with the non dominant hand

  • this is done to distinguish the transition between the midpalmar fat and the distal edge of the TCL

2

Palpate the distal edge of the scope as it emerges into the into the subcutaneous space just distal to the TCL

  • place device in the dominant hand
  • look for a change in the transillumination pattern as the device is moved from underneath the TCL to the transpalmar fat
I

TCL release

1

Divide the TCL

  • elevate the blade of the device while withdrawing device slowly
  • this cuts the TCL from distally to proximally
  • keep the device pressed against the undersurface of the TCL so that no structures come between the TCL and the blade to ensure no other structures are cut
  • only cut the TCL when visualization is excellent
  • repeat this step until the TCL is completely released
  • make sure that there is release from the radial and ulnar flaps from a proximal to distal direction
  • this is ensured by pressing the device against the palmar tissue and being able to seen only one flap at a time
  • also place the device in the trough between the radial and ulnar leaflets
  • visualization of the leaflets should not be possible with the device in this position

2

Divide the antebrachial fascia

  • withdraw the endoscopic device and place hamate finders
  • divide the antebrachial fascia with long tenotomy scissors under direct visualization
J

Wound Closure

1

Irrigation, hemostasis, and drain

  • ensure hemostasis

2

Closure

  • use 3-0 nylon to close skin

3

Dressing and immediate immobilization

  • place in a soft dressing

Patient Care

K

Preoperative H & P

1

Perform basic history and physical exam

  • check neurovascular status
  • identify medical co-morbidities that might impact surgical treatment
  • screen medical studies to identify and contraindications for surgery

2

Perform operative consent

  • describe complications of surgery including
  • incomplete release
  • median nerve damage or scarring
  • ulnar nerve or ulnar artery damage
  • palmer arterial arch damage
  • RSD
L

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • wound care
  • outpatient PT
  • schedule follow up in 2 weeks
M

Intermediate Evaluation and Management

1

Obtain focused history and performs focused orhtopedic exam

  • night pain, paresthesias
  • Median nerve motor/ sensory evaluation
  • MN numbness
  • thumb abduction
  • provocative maneuvers
  • Tinel
  • tap the median nerve over the volar carpal tunnel
  • Phalen
  • wrist flexed with elbow extended for ~60 sec produces symptoms
  • less sensitive than Durkin compression test
  • Durkins compression test
  • is the most sensitive test to diagnose carpal tunnels syndrome
  • press thumbs over the carpal tunnel and hold pressure for 30 seconds.
  • onset of pain or paresthesia in the median nerve distribution within 30 seconds is a positive result.
  • Evaluate other sites of MN compression
  • pronator syndrome
  • cervical radiculopathy

2

Orders and interprets required diagnostic studies

  • EMG and NCV
  • often the only objective evidence of a compressive neuropathy (valuable in work comp patients with secondary gain issues)
  • not needed to establish diagnosis (diagnosis is clinical)
  • NCV
  • increase latencies (slowing) of NCV
  • distal sensory latency of > 3.2 ms
  • motor latencies > 4.3 ms
  • decreased conduction velocities less specific than latencies
  • velocity of < 52 m/sec is abnormal
  • EMG
  • test the electrical activity of individual muscle fibers and motor units
  • detail insertional and spontaneous activity
  • potential pathologic findings
  • increased insertional activity
  • sharp waves
  • fibrillations
  • fasciculations
  • complex repetitive discharges

3

Prescribes and manages nonoperative treatment

  • night splints
  • steroid injections
  • attempts trial of physical therapy

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides simple post operative management and rehabilitation

  • postop: 2-3 Week postoperative visit
  • wound check
  • remove sutures
  • start hand therapy
  • diagnose and management of early complications
N

Advanced Evaluation and Patient Management

1

Complex postop management

  • worsening numbness
  • worsening pain
  • additional radiating symptoms
 

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