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Carpal Tunnel Syndrome
Updated: Oct 4 2016

Revision Carpal Tunnel Release

Preoperative Patient Care
Operative Techniques

Preoperative Plan


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

Room Preparation


Surgical instrumentation

  • Loupes recommended


Room setup and equipment

  • standard operative table with hand table


Patient positioning

  • supine position

Superficial Dissection


Make incision

  • make an incision through the previous incision and extend it proximally and distally

Expose TCL


Expose the TCL

  • use a scalpel or scissors to dissect through the subcutaneous fat and palmar tissue
  • the palmaris brevis muscle is often seen superficial to the TCL
  • incise and feather the palmaris brevis muscle from the TCL to allow adequate visualization
  • use a mosquito clamp or Carroll elevator into the carpal canal just deep to the TCL
  • this space defines the undersurface of the TCL and the hamate hook


Visualize the superficial surface of the TCL

  • place a right angle retractor
  • this is placed to protect the critical structures that are located between the skin and the ligament

Release TCL


Release the most ulnar aspect of the TCL

  • identify the most ulnar aspect of the TCL in the canal close to the hook of hamate
  • release the TCL under direct visualization
  • make sure to release proximally and distally
  • use scissors, scalpel or mini meniscotome type beaver blade
  • keep the radial leaflet of the TCL over the median nerve


Release the distal forearm fascia proximally

  • this is a common secondary site of compression


Confirm release of the TCL proximally and distally


Release Scarring and Check Integrity of Nerve


Separate the TCL from the median nerve

  • scarring is expected and puts the median nerve at risk during this entire procedure
  • completely release the TCL while protecting the motor branch of the median nerve


Perform external epineurotomy

  • perform an external epineurotomy to expose the bands of the fontana on the surface fascicles on the median nerve

Explore Nerve to Ensure Decompression


Check nerve

  • palpate and visual any signs of compression on the nerve

Hypothenar Fat Pad (optional)


Excise Fat Pad

  • dissect the fat pad to the level of the ulnar nerve and artery
  • advance the radial edge of the fat pad to cover the median nerve


Suture edge of the fat pad to the radial flap of the TCL


Wound Closure


Use 3-0 nylon for skin closure

Postoperative Patient Care
Private Note

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