A 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<br /> B Advanced Evaluation and Patient Management 1 Complex postop management worsening numbness worsening pain additional radiating symptoms C 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
E 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 F Room Preparation 1 Surgical instrumentation Loupes recommended 2 Room setup and equipment standard operative table and hand table 3 Patient positioning supine position G 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 H 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 I 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 J 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 K 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 L 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 N 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
O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds wound care outpatient PT schedule follow up in 2 weeks