Orthopaedic Surgery Residents

Contributing authors: Joshua Rozell, MD; Jonathan Dattilo, MD; Matthew Winterton, MD; David Steinberg, MD

Surgical Steps

Steinberg Carpal Tunnel Release

Review consent with patient in pre-op holding area; mark site

Positioning/Prep:

• Rotate stretcher 90 degrees
• Attach armboard to bed
• 18” tourniquet over webril at the proximal arm (no 10-10 used)
• Chuck --> Weebie
• Chlorhexidine prep --> Wait 3 minutes
• Stockinette over hand/arm
• Down sheet
• Sticky U drape
• Extremity drape
• Cut stockinette to expose hand/arm
• 2 green towels under the wrist

Incision:

• Mark Kaplans cardinal line, the pisiform, and the hamate
• Incision will be longitudinal, radial to the hook of the hamate, biased slightly more radial than the radial border of the ring finger
• Injection 10cc lidocaine; first 7-8cc infiltrated just in subcutaneous tissue from proximal to distal (ensure that entry point is just proximal to the glabrous skin); remaining 5cc infiltrated into the wrist crease and proximally in the subcutaneous tissue only (avoid injecting the nerve)
• Roll stockinette over hand to cover marking --> Esmarch --> Inflate tourniquet to 250mmHg
• Check sensation with adson forceps to ensure analgesia
• Incision through dermis with 15 blade
• Use Bora to spread perpendicular to the skin to expose the palmar fascia
• Use 2 Heis retractors distally and proximally and then small right angle retractors to retract
• May encounter wisps of the palmaris brevis muscle
• While spreading, see if you can identify the palmar cutaneous branch of the median nerve crossing the field
• Continue to break up the palmar fascia (can do with Bora or beaver blade) until you reach the transverse carpal ligament
• Take beaver blade and very delicately incise the TCL proximally; use the blade to spread the fibers radially and ulnarly
• Continue to release the TCL distally until you reach the fat around the superficial palmar arch
• Make sure you are radial to the hook of the hamate and between the thenar and hypothenar musculature as you march distally
• Insert right angle retractors proximally; adjust lights so you can see up to the forearm fascia
• Use the bora to spread above and below the TCL; then release the remaining TCL by cutting with the scissor proximally; stop at the level of the screw on the bora scissors
• Use a freer inserted proximally and pull back to see if there are any bands of tissue left to be released
• Irrigation
• Tourniquet down
• Bipolar for hemostasis
• 3-0 Nylon horizontal mattress sutures
• Wet/Dry
• Adaptic --> 4x4 --> Fluffs --> Kerlix --> Ace --> 2” silk tape

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