2002, Vol. 7, Issues 2, Techniques in Carpal Tunnel Surgery

Atlas of the Hand Clinics
Copyright © 2006 Saunders, An Imprint of Elsevier
Volume 7, Issue 2 (September 2002)

Issue Contents: (Pages ix-316)
ix-ix
1 Techniques in carpal tunnel surgery
Osterman A
xi-xi
2 Techniques in carpal tunnel surgery
Katzman B
181-189
3 Open carpal tunnel release
Bozentka DJ
191-198
Limited-open carpal tunnel release using the “Safeguard” system
4 Baratz ME
199-210
5 Carpal tunnel release using the carpal tunnel tome
Higgins JP
211-222
6 Endoscopic carpal tunnel release: Chow technique
Chow JC
223-228
7 Single distal portal endoscopic carpal tunnel release
Murphy MS
229-241
Single-portal endoscopic carpal tunnel release
8 Kozin SH
243-249
The benefit of transverse carpal ligament reconstruction following open carpal
9 tunnel release
Netscher DT
251-258
Carpal tunnel syndrome in rheumatoid or inflammatory arthritic patients
10 Terrono AL
259-272
Median nerve injuries associated with distal radius fractures: current concepts
11 in management
Raskin KB
273-276
Combined carpal tunnel and ulnar nerve release
12 Dell PC
277-286
Secondary carpal tunnel surgery
13 Ting J
287-293
Vein wrapping with autologous graft for recalcitrant median nerve
14 compression
Sarris IK
295-307
Local and distant flaps in recalcitrant carpal tunnel surgery
15 Fletcher JW
309-316
Management of complications of carpal tunnel release
16 Forseth M
Atlas Hand Clin 7 (2002) ix
Foreword
Techniques in carpal tunnel surgery
A. Lee Osterman, MD
Consulting Editor
What more is there to say about the treatment of the most common upper extremity com-
pression neuropathy, carpal tunnel syndrome?
As it turns out, quite a lot. Dr. Akelman and Dr. Katzman have organized a volume that
examines the technique of median nerve decompression in all its permutations: endoscopic, mini
release, standard open, combined with Guyon decompression, and in specific settings such as
rheumatoid arthritis or the distal radius fracture.
Most importantly, the book guides us on how to avoid and salvage complications. These lat-
ter four chapters are riddled with practical bullets of knowledge.
Kudos to all the authors for this classic update and a job well done.
A. Lee Osterman, MD
Consulting Editor
The Philadelphia Hand Center
901 Walnut Street
Philadelphia, PA 19107
1082-3131/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved.
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Atlas Hand Clin 7 (2002) xi
Preface
Techniques in carpal tunnel surgery
Barry Katzman, MD Edward Akelman, MD

Guest Editors
Carpal tunnel syndrome is the most common peripheral compression neuropathy, with ap-
proximately 200,000 procedures performed annually in the United States. Sir James Paget is
often credited with the first description of posttraumatic carpal tunnel syndrome in 1854, and
in 1933 Sir James Learmonth performed the first carpal tunnel release for a patient with post-
traumatic carpal tunnel syndrome.
The open technique of carpal tunnel release has yielded consistently good results over the
years and should be considered the gold standard by which future innovative techniques are
judged. As technology has developed, it has allowed for the use of smaller incisions and less
painful scars to the patient. Further advances will undoubtedly lead to safer release of the trans-
verse carpal ligament and less morbidity to patients.
This issue of the Atlas of the Hand Clinics is dedicated to the treatment of both carpal tunnel
and its complications. This text is inclusive, giving the basic and innovative ways to treat carpal
tunnel syndrome. Readers will gain insights into the treatment of patients who have developed
carpal tunnel secondary to rheumatoid arthritis, those who have developed carpal tunnel from
trauma, and those with recurrence.
We are grateful to all the authors who have devoted much time and effort to assemble this issue.
Thank you to Dr. Arnold-Peter C. Weiss, who was helpful in the early conceptual phases of this
book, and to Dr. Osterman for giving us the opportunity to edit this edition. On a personal note,
we would like to thank our wives, Debbie Katzman and Vickie Akelman, and our children, David
and Jennifer Katzman and Christopher and Matthew Akelman, for their continued support.
Barry Katzman, MD
Guest Editor
Orthopedic Care and Surgery, PC
300 Old Country Road
Mineola, NY 11051, USA
Edward Akelman, MD
Guest Editor
University Orthopedics
Medical Ofice Center
2nd Floor, Two Dudley Street
Providence, RI 02905, USA
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Atlas Hand Clin 7 (2002) 181–189
Open carpal tunnel release

David J. Bozentka, MDa,*, Barry Katzman, MDb
a
Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 8th Floor,
Penn Tower, 34th and Civic Center Blvd., Philadelphia, PA 19104, USA
b
Orthopaedic Care and Surgery, 300 Old Country Rd., Suite 151, Mineola, NY 11501, USA
Carpal tunnel syndrome is the most common peripheral compression neuropathy. Sir James
Paget is often acknowledged with the first description of posttraumatic carpal tunnel syndrome
in 1854 [29]. It was not until 1933 that Sir James Learmonth performed the first carpal tunnel
release for a patient with posttraumatic carpal tunnel syndrome [23]. Phalen further popularized
the diagnosis after a series of articles in 1950. Up to this time only 12 patients had been reported
to have had a surgical release for idiopathic carpal tunnel syndrome. Currently carpal tunnel
release is the most commonly performed procedure of the upper extremity, with over 200,000
procedures performed annually in the United States. This article will review the anatomy in
the region of the carpal canal, the technical aspects of open carpal tunnel release, as well as
the results and complications of the procedure.
Anatomy
In an effort to decrease the risk for injury to the palmar cutaneous branches of the median
and ulnar nerves, the incision for the open carpal tunnel release is made along the ring finger
axis. The palmar cutaneous branch of the median nerve (PCBMN) arises from the volar radial
aspect of the median nerve 5 cm proximal to the volar wrist crease [1].
The PCBMN passes within a short tunnel of the transverse carpal ligament (TCL) and divides
into radial and ulnar branches at the distal end of this tunnel (Fig. 1). The larger radial branch is
directed toward the thenar area whereas one or more smaller ulnar branches enter the subcuta-
neous tissues in the midpalmar skin. Few of these fibers lie ulnar to the line along the axis of the
ray of the ring finger [2]. The classic palmar cutaneous branch of the ulnar nerve (PCBUN)
occurs in less than 10% of cases. When present it runs superficial to the palmaris brevis muscle
in the subcutaneous tissue ulnar to the ring finger axis, although branches have been found to
extend radial to this line. When the classic PCBUN is not present, small branches from the super-
ficial and dorsal sensory branches of the ulnar nerve provide sensation to the hypothenar
eminence [3]. Although there is not a true internervous zone between the PCBMN and the
PCBUN, an incision in the ring finger axis should result in injury to fewer nerve fibers [4].
The TCL runs from the distal pole of the scaphoid and the tubercle of the trapezium radially
to the hook of the hamate and pisiform ulnarly (Fig. 2). Proximally the TCL blends with the
antebrachial fascia in the region of the volar carpal ligament. The antebrachial fascia is released
in addition to the TCL during the open release. The volar carpal ligament and palmaris brevis
muscles that are components of the roof of Guyon’s canal are often encountered during the sur-
gery (Fig. 3). The ulnar neurovascular bundle that lies in Guyon’s canal is at risk for injury with
dissection directed too ulnarly.
The median nerve lies along the radial aspect of the carpal tunnel, and the flexor pollicis
longus tendon is the only tendon that lies radial to the nerve within the canal.
* Corresponding author.
E-mail address: david.bozentka@uphs.upenn.edu (D.J. Bozentka).
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Fig. 1. Diagram of the palmar cutaneous branch of the median nerve as it traverses through a short tunnel in the
transverse carpal ligament. (From Eversmann WW Jr. Entrapment and compression neuropathies. In: Operative hand
surgery, 3rd edition. New York: Churchhill Livingstone; 1993. p. 1341–85.)
During a carpal tunnel release the TCL is typically incised about the ulnar aspect of the liga-
ment because the motor branch of the median nerve most commonly arises radially, with the
motor branch arising from the ulnar aspect of the median nerve in only 1% of cases [5–7].
Lanz has classified the anatomic variations of the median nerve into variations of the thenar
branch, accessory branches, and high divisions of the nerve [8]. The motor branch of the median
nerve most commonly arises distal to the TCL before innervating the thenar musculature,
termed an extraligamentous course (Fig. 4A). The second most common type is termed subliga-
mentous, in which the motor branch arises from the median nerve beneath the TCL before ex-
iting the canal distal to the ligament (Fig. 4B). The motor branch may also travel through the
Fig. 2. Diagram of the transverse carpal ligament and volar carpal ligament. (From Eversmann WW Jr. Entrapment and
compression neuropathies. In: Operative hand surgery, 3rd edition. New York: Churchhill Livingstone; 1993. p. 1341–85.)
D.J. Bozentka, B. Katzman / Atlas Hand Clin 7 (2002) 181–189 183
Fig. 3. Cross section of the wrist at the level of the hook of the hamate. The open arrow represents the transverse carpal
ligament and the solid curved arrow represents Guyon’s canal. (From Seiler JG, et al. Endoscopic carpal tunnel release:
an anatomic study of the two-incision method in human cadavers. J Hand Surg 1992;17A: 996–1002.)
TCL, termed a transligamentous course, in which the motor branch would be at greater risk for
injury during carpal tunnel release (Fig. 4C). The transligamentous variation has been reported
to occur in up to 23% of cases [8]. Kozin, however, found a transligamentous motor branch in
only 7% of cadaveric specimens dissected. He noted that the branch most often passed distal to
the TCL through separate obliquely-oriented fascia that originated on the TCL and inserted on
the undersurface of the palmar aponeurosis [5].
Indications
Nonoperative treatment for carpal tunnel syndrome includes the use of volar wrist splints,
nonsteroidal anti-inflammatory medication, activity modification, and corticosteroid injec-
tions. Those patients unresponsive to nonoperative treatment are considered candidates for
surgical release. There are several indications for expeditious release, including an acute pro-
gressive carpal tunnel syndrome or a symptomatic severe carpal tunnel syndrome. Patients
with a severe median neuropathy at the wrist will less likely have significant improvement
of symptoms with nonoperative modalities and are considered for early release. These patients
will have signs of muscle atrophy and sensory loss on physical examination. In addition,
markedly delayed nerve conduction velocities and muscle denervation on electrodiagnostic
studies are often noted [9].
Surgical technique
Multiple incisions have been described for an open carpal tunnel release [10–15]. Learmonth
initially used a transverse incision at the wrist and subcutaneously incised the transverse carpal
ligament with scissors [12]. This incision was popular because of its small length and the fact it
did not extend into the glabrous skin of the palm. The limited visualization with this incision
likely led to a higher complication rate. Blind sectioning of the ligament has been discouraged
because of the risk for neurovascular injury and incomplete sectioning of the ligament.
Phalen described an incision that extended from the distal palm to the proximal forearm.
This S-shaped incision allowed full exposure of the median nerve at the wrist and forearm.
The extension of the incision into the forearm had been recommended to fully release the
Fig. 4. Diagrammatic representation of an (A) extraligamentous motor branch of the median nerve. (B) Subligamentous
branch of the median nerve. (C) Transligamentous branch of the median nerve. (From Lanz U. Anatomical variations of
the median nerve in the carpal tunnel. J Hand Surg 1977;2:44–53.)
median nerve, including the volar forearm fascia. Currently an incision along the ulnar border
of the ring finger to the distal wrist crease is most popular. The volar forearm fascia is sectioned
subcutaneously under visualization at the proximal aspect of this incision.
The procedure is performed with the patient supine and the extremity on a hand table. A
local anesthetic combined with intravenous sedation is most commonly used although a general
or regional anesthesia is occasionally required. The local anesthetic is a mixture of 1% xylocaine
and 0.5% marcaine, both without epinephrine. Sodium bicarbonate (7.5%) may be added just
before use to decrease the discomfort associated with the injection. Alkalinization of the local
anesthetic with bicarbonate also will increase spread and duration of the sensory blockade and
lessen the time to onset of anesthesia [16,17]. One ml of 7.5% sodium bicarbonate is added for
each 10 ml of solution when xylocaine is used solely. Less bicarbonate is added when marcaine
is used in the local anesthetic mixture to prevent precipitation of the solution.
The extremity is exsanguinated and the tourniquet is elevated to 250 mm Hg. A curvilinear
incision is made along the ring finger axis between the thenar and hypothenar eminences. The
incision extends from Kaplan’s cardinal line (Fig. 5) to the distal wrist crease on the ulnar side
Fig. 5. A diagram of Kaplan’s cardinal line. (Elizabeth Roselius, Allentown, NJ, Ó1991, with permission.)
of palmaris longus (Fig. 6A, B, C). The incision is curved proximally such that if extension into
the volar forearm were required it could be performed at a 45° angle to the proximal wrist crease
(Fig. 6D). If a palmaris longus tendon is not present, the incision is taken proximally ulnar to
the expected location of the PCBMN.
The dissection is taken through the subcutaneous tissues bluntly, taking care to protect the
superficial cutaneous nerve branches [18] (Fig. 7). The palmar fascia is split. The superficial arch
is identified distally (Fig. 8). The subcutaneous tissue below the palmar fascia is bluntly dissected
to expose the TCL. This will limit risk for injury to the ulnar neurovascular bundle if the dis-
section was taken too ulnarly. In addition, blunt dissection in the region will limit risk for injury
to a transligamentous motor branch of the median nerve (Fig. 9). The hook of the hamate is
Fig. 6. (A) The palmaris longus tendon is identified by having the patient oppose the thumb and small finger.
(B) Kaplan’s cardinal line is drawn parallel to the border of the abducted thumb and through the hook of the hamate.
(C) The palmar incision is drawn from Kaplan’s cardinal line to the volar wrist crease just ulnar to the palmaris longus
tendon. (D) An extended incision when required is made at 45 degrees to the volar wrist crease.
Fig. 6 (continued )
palpated and the ligament is incised along its ulnar aspect to prevent injury to the motor branch
of the median nerve. A cuff of ligament is left along the hook of the hamate to prevent symp-
tomatic subluxation of the canal contents postoperatively [19]. Small right-angle retractors are
placed on the skin proximally and the volar forearm fascia is incised in a subcutaneous fashion
for 2 to 3 centimeters under visualization. The median nerve is inspected and motor branch
identified although not routinely released. The median nerve may be adherent to the under-
surface of the TCL and care must be taken during this dissection to prevent injury. One of
the benefits of performing the procedure under a local anesthetic is that the patient will often
note discomfort with trauma to neurovascular structures. The area is inspected for masses
and bony spicules. The digital flexor tendons, which are encased in the ulnar bursa, are retracted
radially from the area of the hook of the hamate to visualize the floor of the canal. A full teno-
synovectomy is not routinely performed unless indicated. Several specific indications include a
flexor tenosynovitis caused by an inflammatory arthritis unresponsive to nonoperative modal-
ities, flexor tendon rupture or imminent rupture caused by invasive tenosynovitis, and in the
treatment of a septic flexor tenosynovitis.
Fig. 7. The palmar cutaneous branches of the median nerve (under the freer elevator) may be encountered during the
dissection in the subcutaneous tissues.
Fig. 8. The superficial arch is identified distal to the transverse carpal ligament after dissecting through the palmar
fascia.
The tourniquet is let down and hemostasis is obtained. The skin edges are approximated with
5-0 nylon sutures. A plaster short arm volar wrist splint is applied and left in place until the first
postoperative visit. After the sutures are removed a scar management program is instituted. The
wrist is protected from full wrist flexion for approximately three weeks to prevent volar subluxa-
tion of the flexor tendons, and a strengthening program is progressed as tolerated [9].
There are several indications to extend the incision proximally into the volar forearm. One
common indication involves difficulty in visualizing the median nerve. This may occur with a lim-
ited open incision particularly if there is abundant subcutaneous tissue preventing safe sectioning
of the volar forearm fascia subcutaneously. On examining the carpal canal, if a mass is noted,
extension of the incision is often required to fully evaluate the process. In treating a compartment
syndrome requiring carpal tunnel release, the incision may be extended proximally into the volar
forearm [20]. On revision carpal tunnel release, the dissection is taken further proximally to
ensure full release and evaluation of the palmar cutaneous branch of the median nerve.
Excellent results have been reported in several studies evaluating open carpal tunnel release.
Overall relief of pain and paresthesias is good although the outcome is related to multiple
Fig. 9. Intraoperative photograph of the transverse carpal ligament cut distally to proximally.
factors, including the severity of the neuropathy. The series by Brown et al. reported 98% of
patients with relief of numbness and paresthesias [21]. Phalen reported normal sensation in
77% of patients postoperatively [22]. Semple and Cargill reviewed 150 cases and found that
75% of hands were asymptomatic at 2 to 7 years postoperatively [23]. Kulick et al. evaluated
100 patients who had undergone carpal tunnel release with an average follow-up of 4 years.
They reported a failure rate of 19%. This high failure rate is believed to be related to several
factors, including their strict criteria of success as complete resolution of symptoms. In addition,
their length of follow-up was long, and there was a large number of patients who had a severe
neuropathy with muscle involvement [24]. Others, including Semple and Cargill [23] and
Graham [25], have documented a direct correlation between the duration of symptoms and
failure rate. Improvement of neurologic symptoms is comparable with open and endoscopic car-
pal tunnel release. The multicenter study of Brown et al. prospectively randomized 145 patients
to either open or two portal endoscopic release. Ninety percent or more of patients in both
groups were noted to have relief of paresthesias [21]. Agee et al. evaluated 122 patients who were
randomized to the open or one portal endoscopic technique in a multicenter study. They noted a
high rate of improvement in the sensory and motor results in both groups [26].
Grip strength is a reliable evaluation method in assessing a patient’s outcome. Gellman et al.
found that patients undergoing open carpal tunnel release on average had a grip strength 28% of
preoperative levels as measured by Jamar Dynamometer (Asimow Engineering, Los Angeles).
Return to preoperative levels was not found until 3 months postoperatively [27]. Several stud-
ies have shown quicker return of grip strength and earlier return to work and daily living activ-
ities after endoscopic release compared with open release, although these advantages are evident
in the early postoperative period [21,26].
Complications
Pain around the thenar and hypothenar eminence that occurs after carpal tunnel release is
termed pillar pain. This discomfort may prolong return of grip strength and may persist for
up to 2 years in one-third of patients [7,27,28]. The etiology of pillar pain is not well defined,
although there are several possible factors. An injury to the small superficial sensory nerve
branches or an alteration of the thenar and hypothenar muscle origin has been implicated. A
widening of the carpal arch and a periostitis of the scaphoid and hamate are also considered
factors [7,29].
Damage to the PCBMN may lead to loss of sensation on the thenar eminence or a painful
scar caused by neuroma formation. This complication likely occurs when the incision extends
radial to the palmaris longus tendon. Masear et al. reviewed 117 employees at a meat packing
plant who had undergone carpal tunnel release, and noted the most common complication was
grip-strength weakness [30]. Scar tenderness is also a common complaint, occurring in 43% of
patients in this series and 36% of patients reported by Cseuz et al [10,30].
MacDonald et al. retrospectively reviewed 186 cases and reported that if symptoms persisted
postoperatively the most common cause was incomplete release of the TCL [31]. Langloh and
Linscheid also reported a high incidence of incomplete release in patients requiring re-explora-
tion [32]. Eason noted a high incidence of incorrect diagnosis in patients who were considered to
have suboptimal results [19].
Conclusion
Open carpal tunnel release is technically straightforward and the required instruments are
readily available in most operating rooms. When performed using the described techniques
the surgeon can have confidence that full release of the median nerve has been performed. Over-
all one can expect good relief of neurologic symptoms, although grip-strength weakness and pil-
lar pain has led to a search for alternative procedures. Despite this search, open carpal tunnel
release is a procedure that has withstood the test of time and is the standard to which all other
procedures for treatment of carpal tunnel syndrome must be compared.
References
[1] Gelberman R, North E. Carpal tunnel release. In: Gelberman R, editor. Operative nerve repair and reconstruction.
1st ed, Vol. II. Philadelphia: J.B. Lippincott Co.; 1991. p. 899–912.
[2] Taleisnik J. The palmar cutaneous branch of the median nerve and the approach to the carpal tunnel: an anatomical
study. J Bone Joint Surg 1973;55A:1212–7.
[3] Engber W, Gmeiner J. Palmar cutaneous branch of the ulnar nerve. J Hand Surg 1980;16A:269–71.
[4] Ruch D, Marr A, Holden M, James P, Challa V, Smith B. Innervation density of the base of the palm. J Hand Surg
1999;24A:392–7.
[5] Kozin S. The anatomy of the recurrent branch of the median nerve. J Hand Surg 1998;23A(5):852–8.
[6] Pfeffer G, Gelberman R, Boyes J, et al. The history of carpal tunnel syndrome. J Hand Surg 1988;13B:28–34.
[7] Gartsman G, Kovach J, Cround C, et al. Carpal arch alteration after carpal tunnel release. J Hand Surg
1986;11A:372–4.
[8] Lanz U. Anatomical variations of the median nerve in the carpal tunnel. J Hand Surg 1977;2A:44–53.
[9] Duncan K, Lewis R, Foreman K. Treatment of carpal tunnel syndrome by members of the American Society for
Surgery of the Hand: results of a questionnaire. J Hand Surg 1987;12A:384–91.
[10] Cseuz K, Thomas J, Lambert E, et al. Long-term results of an operation for carpal tunnel syndrome. Mayo Clin
Proc 1966;41:232–41.
[11] Biyani A, Downes E. An open twin incision technique of carpal tunnel with reduced incidence of scar tenderness.
J Hand Surg 1993;18B:331–4.
[12] Ariyan S, Watson H. The palmar approach for the visualization and release of the carpal tunnel: an analysis of 429
cases. Plast Reconst Surg 1977;60:539–47.
[13] Eboh N, Wilson D. Surgery of the carpal tunnel: a technical note. J Neurosurg 1978;49:316–8.
[14] Crow R. Treatment of the carpal tunnel syndrome. BMJ 1960;1:1611–5.
[15] Milford L. Carpal tunnel and ulnar tunnel syndromes and stenosing tenosynovitis. In: Edmondson A, Crenshaw A,
editors. Campbell’s Operative Orthopaedics. St. Louis: Mosby; 1987. p. 459–61.
[16] Quinlan J, Oleksey K, Murphy FL. Alkalinization of mepivacaine for axillary block. Anesth Analg 1992;74:371–4.
[17] Mckay W, Morris R, Mushlin P. Sodium bicarbonate attenuates pain on skin infiltration with lidocaine, with or
without epinephrine. Anesth Analg 1987;66:572–4.
[18] Tomaino M, Plakseychuk A. Identification and preservation of palmar cutaneous nerves during open carpal tunnel
release. J Hand Surg 1998;23B(5):607–8.
[19] Eason S, Belsole R, Greene T. Carpal tunnel release: analysis of suboptimal results. J Hand Surg 1985;10B:365–9.
[20] Gelberman R. Acute carpal tunnel syndrome. In: Gelberman R, editor. Operative nerve repair and reconstruction.
1st ed. Vol. II. Philadelphia: J.B. Lippincott Co.; 1991. p. 939–48.
[21] Brown R, Gelberman R, Seiler J, et al. Carpal tunnel release: a prospective, randomized assessment of open and
endoscopic methods. J Bone Joint Surg 1993;75A:1265–75.
[22] Phalen G. The carpal-tunnel syndrome: seventeen years experience in diagnosis and treatment of six hundred fifty-
four hands. J Bone Joint Surg 1966;48A:211–28.
[23] Semple J, Cargill A. Carpal tunnel syndrome: results of surgical decompression. Lancet 1969;1:918–9.
[24] Kulick M, Gordillo G, Javidi T, et al. Long-term analysis of patients having surgical treatment of carpal tunnel
syndrome. J Hand Surg 1986;11A:59–66.
[25] Graham R. Carpal tunnel syndrome: a statistical analysis of 214 cases. Orthopedics 1983;6:1283.
[26] Agee J, McCarroll H, Tortosa R. Endoscopic release of the carpal tunnel: a randomized prospective multicenter
study. J Hand Surg 1992;17A:987–95.
[27] Gellman H, Kan D, Gee V. Analysis of pinch and grip strength after carpal tunnel release. J Hand Surg
1989;14A:863–4.
[28] Chow J. The Chow technique of endoscopic release of the carpal ligament for carpal tunnel syndrome: four years of
clinical results. Arthroscopy 1993;9:301–14.
[29] Viegas S, Pollard A, Kaminksi K. Carpal arch alteration and related clinical status after endoscopic carpal tunnel
release. J Hand Surg 1992;17A:1012–6.
[30] Masear V, Hayes J, Hyde A. An industrial cause of carpal tunnel syndrome. J Hand Surg 1986;11A:222–7.
[31] MacDonald R, Lichtman D, Hanlon J, et al. Complications of surgical release for carpal tunnel syndrome. J Hand
Surg 1978;3:70–6.
[32] Langloh N, Linscheid R. Recurrent and unrelieved carpal tunnel syndrome. Clin Orthop 1972;83:41–7.
Limited-open carpal tunnel release using

the ‘‘Safeguard’’ system
Mark E. Baratz, MDa,b,*, Gwynne Bragdon, MSa
a
Medical College of Pennsylvania and Hahnemann University, 2900 Queen Lane, Philadelphia, PA 19129, USA
b
Department of Orthopedic Surgery, Allegheny General Hospital, 490 E. North Avenue,
Suite 500, Pittsburgh, PA 15212, USA
A method to reproducibly perform limited-open carpal tunnel release is vital to avoid injury
to nerves, vessels, or tendons. The ‘‘Safeguard’’ system (Kinetikos Medical Inc, San Diego, CA),
designed for limited-open release, consists of a knife and a protective guide. The authors review
the indications, technique, results of an anatomical study, and clinical results using this system
for limited-open carpal tunnel release.
Indications
The indications for limited-open carpal tunnel release are the same as for any other form
of surgical treatment for carpal tunnel syndrome. The surgeon should rely on a history of
numbness in a median nerve distribution, particularly with extremes of wrist position and on
awakening. Loss of dexterity is characteristic of patients with long-standing median nerve
compression. The Phalen’s, Tinel’s, and carpal compression tests alone or together help confirm
the diagnosis. This confirmation is present in most patients except elderly patients who have ad-
vanced carpal tunnel syndrome. In these patients these provocative maneuvers often produce no
change in symptoms. The necessity of nerve conduction studies has been questioned, however;
this test is often helpful in instances of suspected concurrent cervical radiculopathy, diabetic
neuropathy, and in the patient whose symptoms or examination are atypical. Caution should
be exercised in offering surgical treatment to the patient with abnormal nerve conduction studies
and an atypical presentation. Particularly worrisome is the patient with wrist pain following re-
petitive use, little numbness, and an abnormal nerve study. Carpal tunnel syndrome is a clinical
diagnosis in which nerve conduction studies serve a secondary role.
The ideal patient for limited-open carpal tunnel release (from a purely technical standpoint) is
the patient with a broad, flat palm. This is frequently seen in older individuals, particularly those
with thenar atrophy. Limited-open release is more difficult in patients with very small hands and
workers with thick palms. The authors do not recommend this procedure in patients with altered
anatomy due to previous wrist trauma, particularly those patients with a prior wrist fracture.
The importance of well-documented informed consent prior to performing this procedure
cannot be overemphasized. The consent should include, but not necessarily be limited to, the
risk of anesthesia, infection, nerve damage, vessel damage, tendon damage, reflex sympathetic
dystrophy, persistent numbness, pillar pain, and recurrent numbness.
Technique
A local anesthetic with sedation is used in most cases. Several milliliters are injected into
the subcutaneous tissues between the palmaris longus and the flexor carpi ulnaris. One to
E-mail address: mbaratz@wpahs.org (M.E. Baratz).
1082-3131/02/$ - see front matter 2002, Elsevier Science (USA). All rights reserved.
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192 M.E. Baratz, G. Bragdon / Atlas Hand Clin 7 (2002) 191–198
two milliliters are injected into the carpal canal. Several milliliters more are injected into the skin
and subcutaneous tissue about the pillar region. A transverse line is drawn from the proximal
edge of the first web space across the palm. A second line is drawn proximally and longitudinally
from the radial border of the ring finger. A point 0.5 to 1.0 cm proximal to the junction of these
lines represents the distal point of the surgical incision. From this point a 2.0 cm longitudinal
incision is made (Fig. 1). The dissection is carried through the palmar fascia to the distal edge
of the flexor retinaculum. Retractors are placed and the flexor retinaculum is inspected to ensure
that there is not a transligamentous motor branch of the median nerve (Fig. 2). Special care
must be taken when excess adipose or a palmaris brevis muscle covers the flexor retinaculum.
Just distal to the fibers of the flexor retinaculum is a thin sheet of translucent fascia (Fig. 3).
Fat surrounding the superficial arch, third common digital nerve, and the distal edge of the flexor
retinaculum is found beneath this fascial layer. This fat is more abundant in certain individuals,
especially younger patients. Once the distal portion of the flexor retinaculum is exposed, it is
incised from distal to proximal until the median nerve is clearly visible directly beneath the
incision in the flexor retinaculum (Fig. 4). Sharp dissection directly over the nerve can be per-
formed safely as long as tension is applied to the flexor retinaculum through firm retraction.
Once the nerve is identified, the knife guide is passed under the remaining portion of the flexor
retinaculum. A gentle back and forth motion is used to ensure that the curved tip of the guide
remains in contact with the undersurface of the flexor retinaculum structure. The tip of the guide
is advanced 2.0 cm proximal to the distal wrist crease (Fig. 5). If there is difficulty advancing the
guide, the limited-open technique should be abandoned and converted to an open carpal tunnel
release. Once the guide is in place, it is held snugly against the flexor retinaculum and remains pal-
mar to the bursal compartment of the carpal canal. The carpal tunnel knife is engaged into the
guide’s groove and passed proximally to release the remaining flexor retinaculum and the distal
portion of the palmar forearm fascia (Fig. 6). The knife is withdrawn and the guide is used as a
probe to verify that the flexor retinaculum has been completely released. With wrist flexion and
retractors in the proximal portion of the wound, the median nerve can be visualized throughout
the length of the carpal canal (Fig. 7). It is also possible to explore the distal aspect of the wound
to confirm the position of the superficial arch, third common branch of the median nerve, and
the recurrent motor branch of the median nerve. The wound is irrigated and closed with two or
three interrupted mattress sutures. The hand is wrapped in a non-constrictive soft dressing. Pa-
tients are encouraged to make a fist 20· each hour and to use the hand liberally for all activities
except lifting.
Fig. 1. Typical incision for limited-open carpal tunnel release using the ‘‘Safeguard’’ system.
M.E. Baratz, G. Bragdon / Atlas Hand Clin 7 (2002) 191–198 193
Fig. 2. Exposed transverse carpal ligament.
Anatomical study
Limited-open carpal tunnel releases were performed in 10 cadaver specimens using the ‘‘Safe-
guard’’ system according to the technique described above, with one exception: the guide was
intentionally misaligned in either a radial or ulnar direction [1]. In six specimens the guide
was advanced from distal to proximal on a line directed 15 off of the longitudinal axis between
the middle and ring finger rays toward the radial side of the carpal canal. In three specimens the
guide was advanced along a line directed 15 off the longitudinal axis toward the ulnar side of
the carpal canal. In one specimen the flexor retinaculum was exposed and attempts were made
to place the guide in a position that would place a nerve, vessel, or tendon at risk. Four of the
carpal tunnel releases were performed by a hand surgeon, three by a hand fellow, and three by a
second-year orthopedic resident. In nine specimens, limited-open carpal tunnel release was
safely performed by the three surgeons of varying experience despite intentional errant align-
ment of the ‘‘Safeguard’’ guide. In the final ‘‘open’’ specimen it was impossible to find an unsafe
position for the guide as long as the guide was inserted directly palmar to the median nerve.
In a second stage of the study, the distance between the middle/ring finger axis and the me-
dian nerve, the motor branch of the median nerve, the superficial palmar arch, the ulnar nerve,
Fig. 3. Distal retractor exposes translucent fascia covering fat surrounding the superficial arch.
Fig. 4. The distal edge of the transverse carpal ligament has been released; forceps point to the median nerve.
and the palmar cutaneous branch of the median nerve was measured. The middle/ring longitu-
dinal axis crossed the superficial palmer arch and lay directly over the third common digital
nerve. The axis was a mean of 1.5 cm from the recurrent motor branch of the median nerve,
1.0 cm from the ulnar nerve, 0.5 cm from the median nerve, and 1.2 cm from the palmer cuta-
neous branch of the median nerve. These measurements provided the data necessary for estimat-
ing the ‘‘safe-zone’’ for carpal tunnel release (Fig. 8). In Fig. 8A and Fig. 8C the radial limb of
the ‘‘safe-zone’’ is the median nerve and the ulnar limb is the ulnar wall of the carpal canal. The
apex of the ‘‘safe-zone’’ is represented by the convergence of the superficial arch, the third com-
mon digital nerve, and the distal edge of the flexor retinaculum. The base of the ‘‘safe-zone’’ is
the proximal edge of the flexor retinaculum. The area in the two figures is intended to be iden-
tical, but Fig. 8A has an arrow pointing distal to proximal and Fig. 8C has an arrow pointing
proximal to distal. The arrows show the direction of surgical dissection during limited-open or
endoscopic carpal tunnel release. Figure 8A is designed to depict the ‘‘safe-zone’’ during endo-
scopic carpal tunnel release or limited-open carpal tunnel release performed from distal to prox-
imal without a guard. The ‘‘safe-zone’’ is narrow at the point where the dissection begins
because the superficial arch and third common digital nerve converge at this location in the
Fig. 5. The ‘‘Safeguard’’ guide has been passed between the transverse carpal ligament and the median nerve. The tip
can be palpated proximal to the wrist flexion crease.
Fig. 6. The ‘‘Safeguard knife’’ has released the transverse carpal ligament. The tip of the knife can be palpated proximal
to the wrist flexion crease.
palm. As the surgeon passes instrumentation proximally, the ‘‘safe-zone’’ expands but remains
confined on the radial margin by the median nerve. Figure 8C is designed to depict the
‘‘safe-zone’’ when the surgical dissection is performed working from proximal to distal. The
‘‘safe-zone’’ is widest at the start of the procedure and narrows as the dissection progresses.
Figure 8B illustrates the ‘‘safe-zone’’ when a guard is placed between the median nerve and
the flexor retinaculum and the dissection is performed from distal to proximal. In this case,
the area of the ‘‘safe-zone’’ expands to the full width of the carpal canal.
Clinical results
Wolf, Akelman, and Weiss conducted chart reviews and telephone follow-ups to evaluate 501
patients who underwent 682 mini-open carpal tunnel releases during the period from August
1998 through March 2000. The group studied included 265 females and 173 males, with an aver-
age age of 50 years (range 19 to 97 years). The average follow-up was 3.9 months (range 1 to
Fig. 7. Retractors are placed so as to clearly visualize the decompressed median nerve.
Fig. 8. (A) ‘‘Safe-zone’’ when carpal tunnel release is performed distal to proximal without guide. (B) ‘‘Safe-zone’’ when
carpal tunnel release is performed distal to proximal with ‘‘Safeguard’’ guide. (C) Carpal tunnel release performed
proximal to distal through a progressively narrowing ‘‘safe-zone.’’
17 months). Fifteen patients had a recurrence of symptoms post-operatively, a rate of 1.9%.

Thirteen patients were felt to have chronic pain post-operatively (13/682 surgeries or 2.1%).
There were two wound problems and no infections (unpublished results).
Bragdon and Baratz performed a retrospective review of the outcome following limited-open
carpal tunnel surgery with the ‘‘Safeguard’’ system for patients >65 years of age (unpublished
results). Thirty-two releases were performed in 29 patients with an average age of 74 years
(range 65 to 91). At an average follow-up of 62 days all patients had a significant reduction
in their carpal tunnel symptoms and all were satisfied with the procedure. Seventy-seven percent
of patients had complete resolution of their symptoms.
Discussion
Any procedure used for nerve decompression must be evaluated on the basis of the relative
risks and benefits. The anticipated benefits of endoscopic or limited-open carpal tunnel release
are a small incision, less pillar pain, and a more rapid return to work and recreational activities.
Erdmann conducted a randomized, prospective study on two groups of patients with carpal tun-
nel syndrome [2]. The first group included 25 patients with bilateral carpal tunnel syndrome who
underwent simultaneous open and endoscopic carpal tunnel releases. The second group con-
sisted of 46 patients with unilateral carpal tunnel syndrome who were randomly assigned to
undergo either open or endoscopic carpal tunnel release. In both groups, individuals who were
treated with endoscopic carpal tunnel release had a more rapid return of strength and returned
to work 25 days earlier.
Agee et al [3], Brown et al [4], and Jacobson and Rahme [5] compared time to return-to-
work after open and endoscopic carpal tunnel releases in worker’s compensation and non-
compensation populations. In most instances, return to work was accelerated in the
non-compensation population by endoscopic carpal tunnel release, while there was little differ-
ence between the two techniques in the compensation group.
It is important to recognize that carpal tunnel surgery is not a trivial operation. Whether it is
done by an open, limited-open, or endoscopic technique, there is the risk that tendons, nerves,
or vessels will be injured. A retrospective study by Palmer et al found complications following
both open and endoscopic carpal tunnel releases [6]. Complications associated with endoscopic
carpal tunnel release include incomplete release of the flexor retinaculum, nerve injury (median,
ulnar, digital, palmer cutaneous branch of the median nerve), arterial injury (ulnar, superficial
palmer arch), wound hematoma, flexor tendon injury, reflex sympathetic dystrophy, and inci-
dental Guyon’s canal release [7]. The technique has a learning curve and requires practice on
cadaver specimens under the supervision of surgeons experienced in endoscopic carpal tunnel
surgery.
‘‘Limited-open’’ carpal tunnel release has been performed in various forms for many years.
Early reports describe a release through a transverse incision at the wrist with release of the flexor
retinaculum from proximal to distal. Hallock and Lutz compared the effectiveness of carpal
tunnel release through a small incision in the palm using a scalpel and scissors versus a two-
portal endoscopic release [8]. They found no significant difference in outcome between the
two techniques. Serra et al safely performed limited-open carpal tunnel release using a blunt-tipped
probe/guide and a scalpel [9]. Gutow assessed the risk of iatrogenic injury to the median nerve
using a device called the ‘‘Indiana Tome’’ (Biomet, Warsaw, USA) [10]. Release with this device
is performed through a small incision in the palm in a distal to proximal direction. Gutow re-
ported that there was a 50% risk of median nerve laceration if the knife was directed 15 off the
ring/middle finger longitudinal axis in a radial direction. Lee and Strickland published their ex-
perience with this device in a series of 694 hands in 525 patients [11]. Early in their series they
had two patients who sustained median nerve injuries; one partial and one complete laceration.
One patient had altered anatomy as a result of a previous distal radius fracture. In both cases
the surgeon had ‘‘attempted a second pass of the tome.’’ They report that since eliminating sec-
ond passes of the tome, there have been no nerve injuries.
The ‘‘Safeguard’’ system is designed to help perform limited-open carpal tunnel release and
allowed the three surgeons in the anatomical study to perform carpal tunnel releases success-
fully, even with intentional, errant placement of the knife guide [1]. The safety of this device
is easy to understand in light of the measurements made to design the ‘‘safe-zone.’’ Many of
the structures at risk of injury are located in the palm near the intersection of the middle/ring
finger axis and a transverse line drawn from the proximal edge of the first web space across
the palm. This point is in close proximity to the superficial palmer arch, the third common dig-
ital nerve, and the site of aberrant transligamentous motor branches of the median nerve. Thus,
limited-open releases done proximal to distal must be performed in an ever-narrowing zone of
safety. Similarly, endoscopic devices inserted proximal to distal rely on limited visualization in
this narrow distal zone of safety. In contrast, limited-open techniques that work from distal to
proximal allow accurate identification of many of the structures at risk and enhance the safety of
carpal tunnel release.
When using a device without a guide such as the original version of the Indiana Tome, the
‘‘safe-zone’’ increases as the release is carried proximally, but the radial margin of the ‘‘safe-
zone’’ does not expand, and the knife must remain on the middle/ring axis to avoid injury to
the median nerve. Using the ‘‘Safeguard’’ device the guide is placed between the median nerve
and the flexor retinaculum, which expands the ‘‘safe-zone’’ providing a greater margin of safety.
Atik et al demonstrated this in the study where intentional, errant placement of the guide still
permitted safe carpal tunnel release [1]. Safe carpal tunnel release is possible as long as the guide
hugs the undersurface of the flexor retinaculum and remains palmar to the median nerve. Weiss
and Akelman have safely performed carpal tunnel release in over 1000 patients using the ‘‘Safe-
guard’’ device (A. Peter Weiss, MD, personal communication, August 2001). However, the au-
thors know of one instance in which a patient sustained partial median nerve injuries using this
system of guide and knife. This involved a woman with a very small hand and previous distal
radius fracture. The combination of a small canal and altered anatomy from a previous fracture
might have contributed to her injury. In over 6000 cases using the ‘‘Safeguard’’ system there
have been no nerve injuries in patients who had anatomy that was unaltered by wrist trauma.
Carpal tunnel surgery is the toughest ‘‘simple’’ operation in an upper extremity practice. Ex-
pectations for an excellent outcome are high both on the part of patient and surgeon. These
expectations are realized when the surgeon maintains stringent indications and meticulous tech-
nique. Limited-open and endoscopic techniques raise expectations by offering an expeditious re-
covery. Studies have shown a more rapid return to work and recreation with endoscopic and
limited-open techniques, with the implicit message that these techniques are as safe as open sur-
gery. Experienced hand surgeons know better, however. Direct visualization of the median
nerve throughout the procedure remains the safest way to perform carpal tunnel surgery. Why
should any other method to decompress the median nerve be considered? After 2 years of per-
sonal experience with the ‘‘Safeguard’’ system, it is the authors’ opinion that it is a safe and pre-
dictable technique, with several caveats. Limited-open surgery with the ‘‘Safeguard’’ system
requires greater care in the patient with a small hand, common in petite women. This technique
requires greater attention in a patient with a thick palm, typical of the construction worker. Pa-
tients with altered dimensions of the carpal canal due to previous wrist fracture seem to be at
higher risk of nerve injury with a variety of limited-open techniques; in the authors’ opinion
these patients are best treated with open carpal tunnel release. The authors also recommend
open release in any patient who requires a concomitant tenosynovectomy.
As mentioned earlier, there are several key technical points to using the ‘‘Safeguard’’ system.
The median nerve must be clearly identified. The guide must be placed directly over the median
nerve and maintained in this position throughout the procedure. After the transverse carpal
ligament is released, the wound should be inspected to ensure that the release is complete. By
adhering to these principles the authors have found limited-open carpal tunnel release with
the ‘‘Safeguard’’ system to be a safe and effective technique for treating carpal tunnel syndrome.
Acknowledgments
The authors would like to acknowledge the contributions of Kim Avolio and Cynthia Gayle.
References
[1] Atik TL, Smith B, Baratz ME. Risk of neurovascular injury with limited-open carpal tunnel release: defining the
‘‘safe-zone.’’ J Hand Surg–Brit Eur 2001;5:484–7.
[2] Erdmann MW. Endoscopic carpal tunnel decompression. J Hand Surg 1994;19B:5–13.
[3] Agee JM, McCarroll HR, Tortosa RD, et al. Endoscopic release of the carpal tunnel: a randomized prospective
multicenter study. J Hand Surg 1992;17A:987–95.
[4] Brown RA, Gelberman RH, Seiler JG, et al. Carpal tunnel release: a prospective, randomized assessment of open
and endoscopic methods. J Bone Joint Surg 1993;75A:1265–75.
[5] Jacobson MB, Rahme H. A prospective, randomized study with an independent observer comparing open carpal
tunnel release with endoscopic carpal tunnel release. J Hand Surg 1996;21B:202–4.
[6] Palmer DH, Paulson JC, Lane-Larsen CL, et al. Endoscopic carpal tunnel release: a comparison of two techniques
with open release. Arthroscopy 1993;9:498–508.
[7] Kelly CP, Pulisetti D, Jamieson AM. Early experience with endoscopic carpal tunnel release. J Hand Surg 1994;
19B:18–21.
[8] Hallock GG, Lutz DA. Prospective comparison of minimal incision ‘‘open’’ and two-portal endoscopic carpal
tunnel release. Plast Reconstr Surg 1995;96:941–7.
[9] Serra JM, Benito JR, Monner J. Carpal tunnel release with short incision. Plast Reconstr Surg 1997;99:129–35.
[10] Gutow AP. Cadaveric evaluation of minimal incision carpal tunnel release using the Biomet Indiana Tome carpal
tunnel release system. American Society for Surgery of the Hand, 1998 Annual Meeting, Minneapolis, MN.
[11] Lee WP, Strickland JW. Safe carpal tunnel release via a limited palmar incision. Plast Reconstr Surg 1998;101:
418–24.
Carpal tunnel release using the carpal tunnel tome

James P. Higgins, MD*, Thomas J. Graham, MD
The Curtis National Hand Center, The Union Memorial Hospital, 3333 North Calvert Street,
Baltimore, MD 21218-3333, USA
Since the first application of endoscopic technology to carpal tunnel surgery in 1989 [1], hand
surgeons have deliberated over the safest and most effective way to decompress the median nerve
at the wrist. Advocates of the conventional open technique prefer its simplicity, safety, and mini-
mal expense. Surgeons favoring the endoscopic techniques describe reduced tissue trauma and
postoperative morbidity. In an attempt to combine the benefits of both procedures, the lim-
ited-incision carpal tunnel release was developed utilizing a carpal tunnel tome system (Biomet,
Inc., Warsaw, IN) [2]. This description is intended to serve as a 5-year perspective on the evolu-
tion of this technique, noting the recent contributions of our colleagues as well as the experience
of the senior author (TJG) using this technique nearly exclusively since its inception in 1992.
Background
Relative advantages of endoscopic carpal tunnel release (ECTR) techniques were established
primarily by the two earliest prospective randomized studies [3,4]. These investigations revealed
efficacy equal to that of the conventional open technique in the resolution of symptoms of pain
and numbness, and found greater incidence of scar tenderness and pillar pain as well as longer
periods before return to work among open carpal tunnel release (OCTR) patients. These find-
ings were supported by a large nonrandomized prospective study [5], and, more recently, by the
largest prospective randomized trial to date [6].
The last 5 years have shed further light on the controversy surrounding the relative advan-
tages of open and ECTR techniques with regard to efficacy, complications, recurrence rates,
and costs [7–11]. The debate and investigation promises to continue, bringing us closer to pro-
viding the safest, most reliable, and most cost-effective means of surgical decompression of the
median nerve at the wrist. Such a method would most ideally offer the decreased postoperative
scar/pillar pain and rapid return to work and grip strength associated with small incision and
intact palmar fascia and palmaris brevis muscle. It would offer the safety of direct visualization
of the contents of the carpal tunnel, decreasing the risk of permanent injuries and neuropraxia,
while permitting inspection of the median nerve, surrounding tenosynovium, and space-occupy-
ing lesions. The ideal procedure would minimize the risk of recurrence by ensuring complete re-
lease of the traverse carpal ligament (TCL) in a manner similar to the conventional open release.
Finally, such a procedure would be maximally cost-effective, with lower instrumentation costs
than for endoscopy, lower outcome-adjusted costs by demonstrating more rapid return to work
than with OCTR, and minimal catastrophic complications in terms of nerve injuries.
These advantages are incorporated in the limited-incision carpal tunnel release using a carpal
tunnel tome. Here, we provide a description of the procedure and its technical aspects, followed
by a discussion of the available data illustrating its safety, efficacy, and cost-effectiveness.
* Corresponding author. c/o Lyn Camire.

E-mail address: lync@helix.org (L. Camire).
PII: S 1 0 8 2 - 3 1 3 1 ( 0 1 ) 0 0 0 0 5 - X
200 J.P. Higgins, T.J. Graham / Atlas Hand Clin 7 (2002) 199–210
Fig. 1. The single pilot, palmar stripper, and double pilot.
Carpal tunnel release using the carpal tunnel tome
Limited-incision carpal tunnel release using the carpal tunnel tome is performed with much
the same methodology and instrumentation as that described by Lee and colleagues in 1996 [2].
The following provides pertinent observations and techniques utilized to maximize safety and
ease. The approach, exposure, and three instruments serially introduced into the dissection all
play a preparatory role for the safe passage of the cutting tome (Fig. 1). The tome itself houses
a vertically oriented blade designed to engage the transverse carpal ligament (TCL). Its super-
ficial and deep edges are protected by a smooth protective skids.
The longitudinal incision (2.5 cm to 3.0 cm) is designed along a line extending from the radial
border of the ring finger centered over the distal edge of the thenar musculature. Care is taken to
ensure that the pressure-bearing region of the carpal arch is not violated (Fig. 2).
Fig. 2. Operative markings of limited palmar incision and distal border of the thenar/hypothenar arch. Note the
pressure-bearing area of the carpal arch is not violated with incision of the skin.
J.P. Higgins, T.J. Graham / Atlas Hand Clin 7 (2002) 199–210 201
Fig. 3. Cross-sectional drawing of the carpal canal. H ¼ hamate; C ¼ capitate; Tz ¼ trapezoid; Tm ¼ trapezium;
UN ¼ ulnar nerve; PF ¼ palmar fascia; M ¼ median nerve; FPL ¼ flexor pollicis longus; S2–5 ¼ flexor digitorum
superficialis to digits 2–5; P2–5 ¼ flexor digitorum profundus to digits 2–5. Large arrow is the pathway of dissection
approaching the carpal canal.
The dissection progresses deeper and more radial through the palmar fascia and subcuta-
neous fat to the TCL. This orientation staggers the alignment of the healing skin and ligament
wounds. The TCL is entered ulnar to the midline of the wrist to minimize the chance of entering
immediately adjacent to the underlying median nerve. The nerve and tendons lie radial of the
midline of the wrist, making this ulnar point of entry particularly safe (Fig. 3).
A Heiss self-retaining retractor is used to retract the subcutaneous contents and provide clear
visualization of the TCL. A Ragnell retractor is placed in the proximal axilla of the skin incision
to provide clear visualization of the most distal edge of the TCL (Fig. 4).
Care should be taken by the surgeon in proceeding with the dissection of the TCL and its
surrounding structures. Surgical anatomy and dissection is often conceptualized from a proxi-
mal vantage point progressing distally. In contrast, the limited-incision carpal tunnel release
proceeds in a distal to proximal direction. Unlike both single- and dual-portal endoscopic tech-
niques, instrumentation is never introduced into the dissection in a proximal to distal orienta-
tion. When the surgeon visualizes and approaches the anatomic landmarks surrounding the
Fig. 4. Heiss retractor with Ragnell retractor in proximal axilla of the wound. *Distal edge of TCL.
Fig. 5. After initial incision of the distal edge of the TCL, contents of the carpal canal are directly visualized.
FDS ¼ flexor digitorum superficialis. (Photo taken with endoscope for picture clarity.)
carpal tunnel in a distal to proximal manner, vulnerable structures oriented transversely (the
superficial palmar arch and communicating digital nerve branches) remain safely behind the
field of dissection.
The clearly visualized distal edge of the TCL is incised with a scalpel for a distance of ap-
proximately 1 cm. This defines the line of dissection of the TCL. This starting incision permits
direct visualization of the median nerve and flexor tendons deep and radial to the point of entry
(Fig. 5). Correct positioning and orientation should be easily confirmed at this point. The se-
quential maneuvers that follow serve to prepare the passageway of the cutting tome and mini-
mize the risk of specific complications.
Before introducing instruments to the planes surrounding the TCL, the adjacent structures
are examined. The line of TCL dissection is ulnar to the position of the median nerve, and thus
the surgeon need only to determine the presence or absence of a transligamentous position of
the motor branch of the median nerve before safely proceeding with the proximal dissection.
When the origin of the thenar muscles is particularly ulnar and encroaching upon the line of
dissection, care should be taken to identify or exclude the presence of a transligamentous branch
using blunt scissors dissection. Once this has been addressed, the normal sequence of maneuvers
can be resumed.
The blunt pilot
The blunt pilot (Fig. 6) is introduced beneath the TCL longitudinally to the axis of the arm,
always maintaining the proximal tip oriented superficially (Fig. 7). This ensures that the proximally
Fig. 6. The blunt pilot.

Fig. 7. Passage of the blunt pilot proximally deep to the TCL maintaining the proximal tip oriented superficially.
advancing tip will slide along the dorsal surface of the TCL, avoiding the contents of the carpal
tunnel. No aggressive dissection is performed with this instrument. The goal is to create a pathway
and establish an orientation for the instruments to follow. Once proximal to the TCL, the upward
pointing tip of the pilot is palpable subcutaneously in the distal forearm. A surgical pen is used to
mark the position of the pilot tip on the skin surface approximately two fingerbreadths proximal
to the wrist crease. This visible goal for the passage of the instruments serves to prevent the infre-
quent complications encountered in carpal tunnel surgery associated with poor orientation of in-
strumentation during moments of distraction or haste (Fig. 8).
The palmar stripper
The palmar stripper (Fig. 9) has a blunt skid that is introduced under the TCL along the same
pathway of the blunt pilot. Its second blade is a 15-mm sharp blade for passage superficial to the
TCL. This serves to free the TCL from its dense connections with the overlying palmar fascia
(Fig. 10). Note that the palmaris brevis and the palmar fascia are not bisected during this pro-
cedure. This preservation of the supporting arch of the palm may account for the infrequent in-
cidence of pillar pain encountered postoperatively in these patients.
The double pilot
The double pilot instrument (Fig. 11) has two blunt skids that straddle the TCL, passing
above and below the ligament. These skids are slightly wider than the skids of the cutting tome,
ensuring that the tome may pass without any contact with important structures. This is intro-
duced in the same proximal and superficial direction as the preceding instruments, oriented to-
ward the marked goal on the distal forearm. After passage of the double pilot, a clear pathway
can be directly visualized above and below the TCL (Fig. 12).
The cutting tome
The disposable cutting tome (Fig. 13) houses a vertically oriented central blade protected by
transverse blunt skids above and below its edges. The tome is introduced into the axilla of the
Fig. 8. Marking the position of the blunt pilot tip to create a goal for orientation for subsequent instrumentation.
open end of the TCL, engaging the blade in the ‘‘V’’ incision in the ligament and orienting the
skids proximally and superficially toward the mark on the distal forearm. The skids are designed
much wider than the blade housing to prevent tissue from sliding above the deep skid and ap-
proaching the blade (Fig. 14). The tome is passed proximally, smoothly bisecting the TCL and
distal aspect of the volar antebrachial fascia (VABF). The tome should never require forceful
passage, and should never be passed multiple times to achieve or complete the release of the
TCL. Multiple or forceful passes with the tome may indicate that the orientation of the tome
is incorrect or has strayed from the pathway of the preceding instruments. This should be a
warning sign that the anatomic position or landmarks need to be reassessed prior to any further
attempt at release.
Fig. 9. The palmar stripper.

Fig. 10. The TCL is dissected free of its dense connections with the overlying fascia using the palmar stripper.
Fig. 11. The double pilot.
Fig. 12. After passage of the double pilot structures above and below, the TCL can easily be visualized. (Photo taken
with endoscope for picture clarity.) CT ¼ carpal tunnel; SQ ¼ subcutaneous plane.
Fig. 13. The carpal tunnel tome.
Once the TCL and distal VABF are successfully bisected, a protective hub on the shaft of the
instrument will prevent passage of the tome after the hub impacts the wound margins. This per-
mits transection of only the remaining 3 cm of intact ligament and distal VABF, preventing in-
advertent advancement of the instrument farther into the distal forearm (Fig. 15).
Fig. 14. Closeup of blade housing of the cutting tome.

Fig. 15. Inadvertent overinsertion of the cutting tome is prevented by protective hub on the shaft of the instrument.
The carpal tunnel tome system (Biomet, Inc., Warsaw, IN) includes an alternative method of
transecting the TCL after the dissection has been prepared by the first three instruments. Rather
than using the final cutting tome as described, the surgeon may choose to employ the separate
security clip device (Fig. 16). The clip is introduced to the TCL, displacing the metal obturator
as the TCL enters the plane between the two firm edges of the clip. When applied to the TCL,
this device tightly adheres to the ligament’s superficial and deep surfaces (Fig. 17). The clip
houses a small central canal for passage of a security clip blade. Use of this clip and blade device
may further ensure safe division of the TCL, preventing any encroachment from surrounding
structures (such as the median nerve) into the blade’s pathway.
After the cutting tome or security clip/blade is withdrawn, the TCL is directly inspected to guar-
antee complete release. The contents of the carpal tunnel can easily be inspected to assess for
masses, tenosynovial proliferation, and the condition of the median nerve (Fig. 18). The skin is
Fig. 16. The security clip device (above), security clip blade (below).
Fig. 17. The security clip firmly applied to the TCL. (Photo taken with endoscope for picture clarity.) R ¼ Ragnell
retractor; FDS ¼ flexor digitorum superficialis; SC ¼ security clip.
closed with one or two nylon sutures. A soft dressing is applied to the hand and wrist. No splint is
required. The patient is encouraged to begin active range of motion immediately after surgery.
Discussion
The limited-incision carpal tunnel release is a technique developed during the early years of
endoscopic carpal tunnel surgery as debate arose between advocates of the conventional OCTR
and the newer ECTR techniques. Advantages were attributed to each method with regard to
efficacy, safety, recovery time, cost, and ease. Lee and co-workers [2] described this limited-
incision cutting tome technique, suggesting that this method would possess the best aspects
of both the ECTR and the OCTR.
Data supporting this claim has begun to emerge in the last 5 years. Two uncontrolled studies
of limited-incision methods of carpal tunnel release [6,12] provide results to compare with the
published ECTR series [1,4]. Frequency of resolution of symptoms is similar between the two
groups (92% and 95% versus 99%, respectively) [4,12,13]. Grip strength and key pinch at 2
and 8 weeks postoperatively are also similar in the two techniques [3,12]. Mean values for post-
operative days until return to work were also similar when comparing the two techniques (21
days for limited-incision release versus 25–28 days for ECTR) [3,4,13].
Fig. 18. After release of the TCL, contents of the carpal tunnel can easily be visualized. (Photo taken with endoscope for
picture clarity.) MN ¼ median nerve; FDS ¼ flexor digitorum superficialis. Note the alignment of the TCL division is
ulnar to the underlying median nerve.
These findings are supported by the only prospective controlled trial to date, which compares
71 limited-incision carpal tunnel releases with 66 double portal ECTRs [14]. The series demon-
strated no significant differences in the scar or pillar pain, duration of time to return to work, or
relief of symptoms. Complication rate was statistically similar when grouped to include scar sen-
sitivity, pillar pain, incomplete symptoms relief, infection, and iatrogenic injury. Of note, the
only two neurologic complications (one neuropraxia, one suspected digital nerve injury) oc-
curred in the CTR group.
The expense of ECTR has been regarded as a tradeoff between more rapid recovery and re-
turn to work in exchange for higher operative costs. Studies comparing conventional OCTR and
ECTR have closely examined and extrapolated these immediate and long-term costs to society.
These studies concluded that ECTR would be more cost-efficient than OCTR if ECTR demon-
strated more rapid return to work (particularly if the difference in convalescence was more than
21 days) and a lower complication rate than the conventional technique [15]. The development
of the limited-incision carpal tunnel release has made these data obsolete. Periods of recovery
and resumption of work are now the same, and the limited-incision carpal tunnel release com-
plication rates are the same as or lower than the ECTR rates. The debate of expense has become
one of operative cost, clearly favoring the limited-incision technique.
Summary
The limited-incision carpal tunnel release provides an effective, reliable, and safe method
for decompression of the median nerve at the wrist. The technique minimizes risk of complica-
tion through the design of the instruments and the conceptual approach to the anatomy and
surgical exposure. This method combines the reduced postoperative pain and quicker recovery
of the ECTR technique with the safety and lower operative expense of the conventional open
technique.
Acknowledgments
We appreciate the assistance of Biomet, Inc. (Warsaw, IN) in permitting our use of photo-
graphs and drawings for this article.
References
[1] Chow JC. Endoscopic release of the carpal ligament for carpal tunnel syndrome: long-term results using the Chow
technique. Arthroscopy 1999;15:417–21.
[2] Lee WP, Plancher KD, Strickland JW. Carpal tunnel release with a small palmar incision. Hand Clin 1996;12:
271–84.
[3] Agee JM, McCarroll HR Jr, Tortosa RD, et al. Endoscopic release of the carpal tunnel: a randomized prospective
multicenter study. J Hand Surg 1992;17A:987–95.
[4] Brown RA, Gelberman RH, Seiler JG III, et al. Carpal tunnel release. A prospective, randomized assessment of
open and endoscopic methods. J Bone Joint Surg 1993;75A:1265–75.
[5] Palmer DH, Paulson JC, Lane-Larsen CL, Peulen VK, Olson JD. Endoscopic carpal tunnel release: a comparison of
two techniques with open release. Arthroscopy 1993;9:498–508.
[6] Trumble TE, Diao E, Abrams RA. Randomized prospective trial of endoscopic vs. open carpal tunnel release with
single portal technique [abstract 19]. Meeting Abstracts, Am Soc Surg Hand 55th Annual Meeting, Seattle, WA,
October 5–7, 2000.
[7] Boeckstyns ME, Sorensen AI. Does endoscopic carpal tunnel release have a higher rate of complications than open
carpal tunnel release? An analysis of published series. J Hand Surg 1999;24B:9–15.
[8] Chung KC, Walters MR, Greenfield ML, Chernew ME. Endoscopic versus open carpal tunnel release: a cost-
effectiveness analysis. Plast Reconstr Surg 1998;102:1089–99.
[9] Concannon MJ, Brownfield ML, Puckett CL. The incidence of recurrence after endoscopic carpal tunnel release.
Plast Reconstr Surg 2000;105:1662–5.
[10] Higgins JP, Graham TJ. Carpal tunnel release via limited palmar incision. Hand Clin 2002;105; in press.
[11] Vasen AP, Kuntz KM, Simmons BP, Katz JN. Open versus endoscopic carpal tunnel release: a decision analysis.
J Hand Surg 1999;24A:1109–17.
[12] Lee WP, Strickland JW. Safe carpal tunnel release via a limited palmar incision. Plast Reconstr Surg 1998;101:
418–24.
[13] Serra JM, Benito JR, Monner J. Carpal tunnel release with short incision. Plast Reconstr Surg 1997;99:129–35.
[14] Hallock GG, Lutz DA. Prospective comparison of minimal incision ‘‘open’’ and two-portal endoscopic carpal
tunnel release. Plast Reconstr Surg 1995;96:941–7.
[15] Shinya K, Lanzetta M, Conolly WB. Risk and complications in endoscopic carpal tunnel release. J Hand Surg
1995;20B:222–7.
Endoscopic carpal tunnel release: Chow technique

James C.Y. Chow, MD
Orthopaedic Center of Southern Illinois, 4121 Veterans Memorial Drive,
Mt. Vernon, IL 62864, USA1
Orthopaedic Research Foundation of Southern Illinois, 3001 Caroline, Mt. Vernon, IL 62864, USA
Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL 62702, USA
When the author began working on his technique in 1985, the author did not know that Dr.
Ichiro Okutsu of Japan, or Dr. John Agee in California, were working on similar goals at ap-
proximately the same time. Through trial and error of different approaches, the breakthrough of
the idea of the slotted cannula came sometime around late 1986. The procedure was completed
in May 1987, after 4 to 5 months of persistent practice on cadavers, before applying it to the first
patient in September 1987. Since that time there have been continued efforts made for the im-
provement of this procedure. During the 1988 Arthroscopy Association of North America’s
(AANA) annual spring meeting, Dr. George Schonholtz, President, presented a Presidential ad-
dress regarding the past, current, and future of arthroscopy. He presented a slide of Dr. Okutsu’s
that he had brought back from Japan showing the carpal ligament through a plastic tube.
The author believed that Dr. Schonholtz and the author were probably the only two people
present in that meeting who had ever seen the undersurface of the carpal ligament before.
The author also believes that this was the first presentation of an endoscopic view of the carpal
ligament undersurface at an official meeting. At that time, Dr. Schonholtz predicted that endo-
scopic release of the carpal ligament would be developed in the near future. The first two articles
regarding the endoscopic carpal tunnel release, written by Dr. Okutsu and the author, were pub-
lished in the March issue of Arthroscopy Journal in 1989 [1,2]. The first paper on endoscopic
carpal tunnel release, based on the author’s clinical results for the first 149 cases, was presented
at the 1990 AANA meeting in Orlando, Florida [3]. In the fall of that same year, at the 1990
American Society for Surgery of the Hand annual meeting in Toronto, Canada, Dr. John Agee
presented his paper on the clinical results of his multi-center study [4]. Therefore, three different
studies using three separate techniques of endoscopic carpal ligament release were started in dif-
ferent corners of the globe and aimed at the same idea of minimizing the incision for releasing
the carpal ligament for carpal tunnel syndrome by getting away from the traditional curved lon-
gitudinal incision in the palm region.
The three original techniques can be summarized as follows. The Chow procedure uses a slot-
ted cannula through dual portals, which allows the scope to be introduced at one end and the
instrumentation at the other end, allowing for release of the carpal ligament with direct visual-
ization [1,3,5,6]. In Japan, Dr. Okutsu used a clear plastic tube to introduce the scope so the
carpal ligament could be visualized. A hook knife was then brought alongside the plastic tube
to release the ligament [2]. Dr. John Agee used a transverse incision to introduce a specially
designed device. Under arthroscopic visualization he would pull a trigger, which elevated the
blade to cut the ligament [4,7].
E-mail address: ocsijc@charter.net (J.C.Y. Chow).

1
Address for correspondence.
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212 J.C.Y. Chow / Atlas Hand Clin 7 (2002) 211–222
The common denominator of these three procedures is that all utilize the current advance-
ment of arthroscopic technology, which brings visualization of the surgery to a television mon-
itor with the use of camera. Although the methods vary, the ideas are similar in that all attempt
to treat the carpal tunnel syndrome patient and preserve normal hand structures.
Since the first publications regarding the original endoscopic carpal ligament release tech-
niques there has been much interest among surgeons, with many variations developed. For exam-
ple, Dr. R. Lewicky modified the Chow technique by pulling a guide tube through the entry and
exit portals. The Linvatec technique pushes a probe knife proximally to distally in one step, the
Acufex technique of Terrence Orr, MD uses a hook knife to cut distally to proximally in one
motion, and Dr. Mirza described a uniportal technique of a palmar portal in the hand for in-
sertion of a device distally to proximally [8–11]. These are modifications to the original tech-
niques, not new ideas in themselves. Some modifications have resulted in limitations to the
flexibility or visualization of the original techniques; therefore, it is possible that these variations
might increase the risk to the patient.
Indications and contraindications
The author believes that every surgeon who treats carpal tunnel syndrome would agree that
not all patients require surgery. Patients’ symptoms become progressively severe with this dis-
ease; therefore, surgical decompression of the carpal canal is considered only after all non-
operative approaches have failed. Endoscopic release of the carpal ligament offers an alternative
to the surgical procedures for carpal tunnel syndrome; however, it does have its limitations as it
was designed to release the carpal ligament only. For example, it would not be the treatment of
choice if a neurolysis, tenosynovectomy, or decompression of the Guyon’s canal is also neces-
sary. If the surgeon suspects that there is a space-occupying lesion in the carpal canal or a severe
abnormality of muscle, tendon, or vessel in this area, a thorough exploration of this area
would be necessary [6,8,12–20]. Another contraindication would be if hyperextension of the fin-
gers and wrist were impossible or limited, due to either trauma or osteoarthritis, because the
patient must be able to hyperextend these joints to perform the Chow procedure safely. Other
absolute contraindications include localized soft-tissue infections, severe edema of the hand, or
tenuous vascular status of the upper extremities.
Setup and portals
Setup
A hand table is used. The surgeon and the assistant sit facing each other with two television
monitors so that both the surgeon and the assistant have a clear visualization of the procedure
(Fig. 1). Routinely, the tourniquet is applied to the patient’s arm but is not inflated.
Entry portal
Using the proximal pole of the pisiform as a landmark (depending upon the size of the hand)
a line is drawn 1.5 to 2 cm radially. A second line is drawn 0.5 cm proximal from the end of
this line. A third line is drawn 1 cm radially from the end of the second line to produce the
entry portal (Fig. 2).
Exit portal
An opening is made in the palmar surface (0.5 cm to 0.75 cm in length) on the bisect line of the
angle formed from the distal border of the fully abducted thumb and the third web space 1 cm
proximal to the junction of these lines (Fig. 3).
J.C.Y. Chow / Atlas Hand Clin 7 (2002) 211–222 213
Fig. 1. Setup requires two monitors so both the surgeon and assistant have clear visualization while sitting across from
each other.
Common mistakes and checkpoints
From the experience of teaching cadaver laboratory courses, it has been found that ulnar
placement of the entry portal is a common mistake made by beginners. Therefore, checkpoints
have been established to assist the surgeon who is interested in performing this procedure:
• Look at the entire width of the wrist to be sure that the entry portal is centrally located (Fig. 4)
• Ensure that the landmarks for the entry and exit portals are aligned along the long axis of
the forearm (Fig. 5)
Fig. 2. Using the proximal pole of the pisiform (pp) as a landmark, the entry portal is made by drawing a line 1.5–2 cm
radially (L1), then a second line 0.5 cm proximally from the end of the first line (L2). A third line is drawn 1 cm radially
from the end of the second line (L3) to indicate the entry portal.
Fig. 3. The exit portal is made in the palmar surface ( 0.5 cm in length) 1 cm proximal to the junction of the bisect
line of the angle formed from the distal border of the fully abducted thumb and the third web space.
• Surgeon should palpate the hook of Hamate, marking it on the hand, to be sure that both
the entry and exit portals are located radially to the hook of Hamate (Fig. 6)
• Palpate the ulnar artery to be sure that the pulsations are not just below the incision line
before marking the entry portal; obviously, if the tourniquet is used, this important guide-
line is lost (Fig. 7)
Attention should be paid throughout the entire procedure to ensure that the instruments intro-
duced into the wrist and hand follow the long axis of the forearm.
Fig. 4. Checkpoint #1. Look at the entire width of the wrist to be sure that the entry portal is centrally located.
Fig. 5. Checkpoint #2. Ensure that the landmarks for the entry and exit portals are aligned along the long axis of the
forearm.
Anesthesia
The local anesthesia given consists of 1% Xylocaine (Astra, Westboro, MA) without
epinephrine along with a general intravenous sedation of 1 to 2 mg of Versed (midazolam
hydrochloride; Roche, Knightly, NJ) when the patient first enters the operating room. Just
before the skin incision is made, 200 lg of Alfenta (alfentanil hydrochloride; Janssen Pharma-
ceutica, Inc, Piscataway, NJ) is given to the patient. If needed, an additional 100 lg of Alfenta
can be given.
Fig. 6. Checkpoint #3. Locate the hook of Hamate, marking it on the hand, to be sure that both the entry and exit
portals are located radially to the hook of Hamate.
Fig. 7. Checkpoint #4. Palpate the ulnar artery to be sure that the pulsations are not just below the incision line before
marking the entry portal.
Operative technique
The entry portal is made and blunt dissection is carried out to explore the fascia. A longitu-
dinal incision is made through the fascia. The proximal edge of the carpal ligament is carefully
identified. The distal edge of the entry portal incision is gently lifted with the small retractor,
which creates a vacuum, and a small space is seen between the carpal ligament and the ulnar
bursa. A curved dissector obturator-slotted cannula assembly, with the pointed side facing
the carpal ligament, is then used to enter this space and push the ulnar bursa free from the bot-
tom surface of the carpal ligament.
The underside of the carpal ligament forms a slight, gently curved shape that can be felt with
the curved dissector. When the dissector is maneuvered back and forth, a washboard or railroad
track effect is felt from the transverse fibers of the carpal ligament. Applying a lifting force with
the dissector tests the tightness of the carpal ligament and ensures proper placement beneath the
carpal ligament. Caution should be used to ensure that the dissector and the trocar follow
the long axis of the forearm. With the tip of the assembly touching the hook of Hamate, the
patient’s hand is lifted above the table while the wrist and fingers are hyperextended. The slotted
cannula assembly is gently advanced distally and pointed toward the exit portal until the tip can
be palpated at the palm region. A second small incision is made for the assembly to pass
through, and the hand is stabilized in the hand holder (Fig. 8). With the scope inserted at the
proximal opening of the tube, the entire length of the slotted cannula opening is examined to
be sure there is no other tissue caught between the slotted cannula and the carpal ligament
(Fig. 9). If the surgeon has any doubts, the tube should be removed and re-inserted.
Ligament cutting technique
With the scope still proximal in the tube and a probe inserted distally, the distal edge of
the carpal ligament is identified (Fig. 10). A sequence of cuts is then made to release the carpal
ligament beginning with the probe knife being introduced to cut distally to proximally, releasing
the distal edge of the carpal ligament (Fig. 11). The triangle knife is then inserted to cut through the
midsection of the carpal ligament (Fig. 12). The retrograde knife is positioned in this second cut
and drawn distally to join the first cut, completely releasing the distal half of the carpal ligament
(Fig. 13). The scope is removed from the proximal opening of the tube and inserted in the distal
opening, and the instrument is brought in proximally. The uncut proximal section of the
ligament is identified and the probe knife is used to release the proximal edge (Fig. 14). The
Fig. 8. Curved dissector obturator-slotted cannula assembly in place and hand being placed on the special hand holder.
retrograde knife is again inserted into the midsection and drawn proximally to complete the re-
lease of the carpal ligament (Fig. 15). If any additional cuts are needed, the surgeon may choose
the proper knife and proceed until satisfied. The trocar is then re-inserted and the slotted cannula
is removed from the hand.
There is rarely any bleeding, and only one suture is required at each portal. Active movement
is encouraged immediately after surgery, and the sutures are usually removed in 1 week. Direct
pressure to the palm area and heavy lifting should be avoided for 2 to 3 weeks or until the dis-
comfort disappears [1,3,7].
Discussion
At the time of this writing the author has performed over 2700 endoscopic carpal ligament
releases since 1987. Review of the clinical results of these 2700+ cases revealed no permanent
nerve or vessel damage, hematoma, or tendon laceration. There were two cases of transient
Fig. 9. The endoscope is placed in the proximal opening of the tube.

Fig. 10. The carpal ligament is identified by the transverse fibers.
ulnar nerve palsy (which recovered spontaneously) and one superficial infection, for a complica-
tion rate of 3/2700 (0.11%). There have been 12 cases that required open exploration and
neurolysis, for a failure rate of 12/2700 (0.44%), and 11 cases of recurrent carpal tunnel syn-
drome, for a recurrent rate of 11/2700 (0.41%). One case was converted to an open procedure
due a rare nerve variance (Fig. 16).
Based on 13+ years of experience using the Chow technique for endoscopic release of the
carpal ligament for carpal tunnel syndrome, the author believes that it is a safe and reliable
alternative for the treatment of carpal tunnel syndrome; however, it does have its limitations.
Surgeons who are interested in this technique should be aware of the steep learning curve
and the checkpoints that must be followed to avoid trouble. Any damage to any one of the im-
portant nerves and vessels surrounding this area could result in irreversible damage to the
patient; therefore, it is the author’s suggestion that the surgeon who is seriously interested in
Fig. 11. The first cut is made with the probe knife, cutting distally to proximally, to release the distal edge of the carpal
ligament.
Fig. 12. The second cut is made with the triangle knife, making a cut in the midsection of the carpal ligament.
the endoscopic release of the carpal ligament become familiar with the anatomy, including the
normal variances. The surgeon should also be familiar with the procedure itself, including using
the proper instrumentation and endoscope. Obviously, the surgeon must be experienced in using
a scope and have sharp motor skills.
Visualization is a critical portion of the procedure. If the surgeon’s view of the undersurface
of the carpal ligament is inadequate or is blocked by anatomical structures, this procedure
should never be carried out. As the author has indicated and strongly emphasized in the past,
a blind surgeon is never a good surgeon. If, for any reason, the surgeon is unable to perform the
endoscopic technique, the procedure should be abandoned without any feelings of guilt or
shame to their patient. The patient should have been informed of this possibility when the in-
formed consent was obtained prior to surgery.
Fig. 13. The third cut is made by placing the retrograde knife in the second cut and drawing it distally to join the first cut.
Fig. 14. The proximal section of the carpal ligament is identified and the proximal edge is released using the probe knife
to make the fourth cut.
Endoscopic techniques allow the surgeon to visualize the undersurface of the carpal ligament
before any cuts are made. For example, if there is an extremely ulnar transligamental motor
branch of the median nerve, the endoscopic technique allows visualization of this anatomical
variance before cutting (Fig. 16). The 5.5 mm slotted cannula is touching the hook of Hamate;
therefore, the center of the opened slot is 2.5 to 3 mm radial of the hook of Hamate. The author
has encountered an extremely ulnar transligamental motor branch of the median 12 times in the
past 13+ years, for an incident rate of 1:250 ( 0.4%).
According to the data gathered over the 13+ years, post-operative results for patients who
have an endoscopic carpal ligament release are better than those who have the standard open
procedure reported from literature. In fact, the data indicate that there is a significant decrease
Fig. 15. The final cut is made by reinserting the retrograde knife into the midsection and drawing it proximally to
complete the release of the carpal ligament.
Fig. 16. An endoscopic carpal tunnel release (ECTR) case was converted to an open procedure due to the presence of a
rare variance of the nerve.
in incidents of reflex sympathetic distrophy, bowstringing of the median nerve and flexor ten-
don, painful scars, pillar pain, and wrist stiffness compared to the standard open procedure.
The obvious advantages of endoscopic carpal tunnel release is decreased postoperative pain,
no loss of pinch and grip strength, and more rapid recovery time than can be achieved with
the conventional open procedure for the treatment of carpal tunnel syndrome.
References
[1] Chow JCY. Endoscopic release of the carpal ligament: a new technique for carpal tunnel syndrome. Arthroscopy
1989;5:19–24.
[2] Okutsu I, Nonomiya S, Takatori Y, Ugawa Y. Endoscopic management of carpal tunnel syndrome. Arthroscopy
1989;5:11–8.
[3] Chow JCY. Endoscopic carpal tunnel release—clinical results of 149 cases. Presented at the 9th Annual AANA
Meeting, Orlando, FL, April 26–29, 1990.
[4] Agee JM, Tortsua RD, Palmer CA, Berry C. Endoscopic release of the carpal tunnel: a prospective randomized
multicenter study. Presented at the 45th Annual Meeting of the American Society of the Hand, September 24–27,
1990, Toronto, Canada.
[5] Chow JCY. Endoscopic release of the carpal ligament: 22-month clinical results. Arthroscopy 1990;6:388–96.
[6] Chow JCY. The Chow technique of endoscopic release of the carpal ligament for carpal tunnel syndrome: four years
clinical results. Arthroscopy 1993;9:301–14.
[7] Agee JM, McCarroll Jr. HR, Tortosa RD, Berry DA, Szabo RM, Peimer CA. Endoscopic release of the carpal
tunnel: a randomized prospective multicenter study. J Hand Surg 1992;17A:987–95.
[8] Lewicky R. Endoscopic carpal tunnel release: the guide tube technique. Arthroscopy 1994;10:39–49.
[9] Menon J. Endoscopic carpal tunnel release: a preliminary report. Arthroscopy 1994;10:31–8.
[10] Mirza MA, King ET, Tanveer S. Palmar uniportal extrabursal endoscopic carpal tunnel release. Arthroscopy
1995;11:82–90.
[11] Orr T. Endoscopic carpal tunnel release. Presented at the 22nd Annual Meeting of the AASH, Washington, DC,
Sept. 17–19, 1992.
[12] Chow JCY, Malek M, Nagel D. Complications of endoscopic release of the carpal ligament using the Chow
technique. Presented at the 47th Annual Meeting of the AASH, Phoenix, AZ, Nov. 11–14, 1992.
[13] Gelberman RH, Pfeffer GB, Galbraith RT, Szabo RM, Rydevik B, Dimick M. Results of treatment of severe carpal
tunnel syndrome without internal neurolysis of the median nerve. J Bone Joint Surg 1987;69:896–903.
[14] Gelberman RJ, Hergenroeder PT, Hargens AR, Lundborg GN, Akeson WH. The carpal tunnel syndrome: a study
of carpal canal pressures. J Bone Joint Surg 1981;63:380–3.
[15] Kendall WW. Results of treatment of severe carpal tunnel syndrome without internal neurolysis of the median nerve
[letter]. J Bone Joint Surg 1988;70:151.
[16] Kerrigan JJ, Bertoni JM, Jaeger SH. Ganglion cysts and carpal tunnel syndrome. J Hand Surg 1988;13:763–5.
[17] Kremchek TE, Kremchek EJ. Carpal tunnel syndrome cause by flexor tendon sheath lipoma. Orthop Rev
1988;17:1083–5.
[18] Lowery WE, Follender AB. Interfascicular neurolysis in severe carpal tunnel syndrome: a prospective, randomized,
double-blind, controlled study. Clin Orthop 1988;227:251–4.
[19] Luallin SR, Toby EB. Incidental Guyon’s canal release during attempted endoscopic carpal tunnel release: an
anatomical study and report of two cases. Arthroscopy 1993;9:382–6.
[20] McGinty JB, Jackson R, et al. History of arthroscopy. In: McGinty JB, editor. Operative arthroscopy. New York:
Raven Press; 1991. p. 2–4.
Single distal portal endoscopic carpal tunnel release

Michael Sean Murphy, MD
Curtis National Hand Center, Union Memorial Hospital, Clinical Instructor, Orthopaedic Surgery,
Johns Hopkins University Medical School, Baltimore, MD 21218, USA
Carpal tunnel release is one of the most common surgical procedures currently performed.
Traditionally, skin incisions of different sizes and orientations have been utilized to achieve de-
compression. Because of dissatisfaction with postoperative scar sensitivity and protracted recov-
ery times, minimally invasive surgical procedures have been advocated. This has lead to
endoscopic release of the carpal tunnel utilizing varied surgical approaches. The focus of this
article will be endoscopic decompression by a single distal portal.
Surgical technique
The surgical procedure can be performed under a local with sedation, Bier block, or general
anesthesia. Tourniquets may be placed on the proximal forearm or wrist, because instrumenta-
tion is from a distal to proximal orientation. In the lightly sedated patient, this distal tourniquet
is often better tolerated than more proximal placement.
The surgical incision is located by triangulating between the axis of the ring digit and the first
web space (Fig. 1). A minimal volume of local anesthetic is instilled. Use of a large volume can
obscure the view obtained and make the dissection more difficult. A transverse incision is cre-
ated, exploiting available skin creases when available. The palmar fascia is identified and released.
This exposes the superficial arterial arch and the common digital nerve to the fourth web space
(Fig. 2). Use of loupe magnification can be very helpful at this stage. The procedure can be per-
formed with currently available endoscopic equipment. More recently, endoscopic instruments
specifically designed for the distal portal technique have become available.
Once the neurovascular structures have been identified, a synovial elevator is passed, con-
firming the location of the hook of hamate (Fig. 3). This allows for the atraumatic release of
adherent synovium. Next, the canal is dilated (Fig. 4). This is followed by passage of the endo-
scope from distal to proximal (Fig. 5A, B). Release is begun proximally at the anterior forearm
fascia. Bimanual palpation can facilitate this more proximal release. Care must be taken not to
injure the overlying skin of the distal forearm and distal wrist crease. The level of the distal wrist
crease is often made endoscopically, by the visualization of hyothenar fat (Fig. 6). Next, the
transverse flexor retinaculum is visualized (Fig. 7). Controlled division is performed (Fig. 8).
Exposure of the palmar brevis muscle can serve as a useful indicator that the undersurface of
the flexor retinaculum has been released (Fig. 9).
Bleeding is controlled, and the skin incision closed. A bulky compressive dressing is applied,
and digital mobilization encouraged.
E-mail address: mmurphy@chesapeakehand.com (M.S. Murphy).
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224 M.S. Murphy / Atlas Hand Clin 7 (2002) 223–228
Fig. 1. The location of the distal endoscopic incision is determined by triangulating between the axis of the ring finger
and the first web space.
Fig. 2. (A, B) The superficial arterial arch and the common digital nerve to the fourth web space are identified and protected.
M.S. Murphy / Atlas Hand Clin 7 (2002) 223–228 225
Fig. 3. (A, B) Passage of the synovial elevator releases adherent synovium within the carpal canal. It also provides the
operator with a three-dimensional sense of the hook of Hamate location.
Discussion
Endoscopic carpal tunnel release has been reported to carry a greater risk of injury to neuro-
vascular structures. Complete or partial laceration of the median nerve, ulnar nerve, and their
common digital branches has been reported. In addition, transection of the superficial arterial
arch, common digital artery, and flexor tendons are additional potential complications. Finally,
incomplete release of the transverse carpal ligament (TCL), especially at its distal portion, may
occur when decompression is approached endoscopically. This latter complication is primarily
the result of the inability of the operator to distinguish the distal edge of the transverse carpal
ligament from the palmar fascia.
Single portal distal release can frequently minimize many of these potential complications.
The surgical exposure is created in the palm, allowing for identification of the superficial arch,
common digital nerve to the fourth web space, and the distal edge of the TCL. The neurovas-
cular structures are well controlled, and can easily be protected. Because the distal extent of the
TCL is well defined, the potential for incomplete distal release is minimized.
Single portal distal endoscopic release has the disadvantage of creating an incision on
the working surface of the palm, which may become sensitive. It is less familiar to surgeons
currently, but it has the potential to diminish some of the potential complications of currently
more widely accepted techniques.
Fig. 4. (A, B) Mechanical dilation of the carpal canal facilitates the passage of the endoscope.
Fig. 5. (A, B) Passage of the endoscope from proximal to distal.

M.S. Murphy / Atlas Hand Clin 7 (2002) 223–228 227
Fig. 5 (continued )
Fig. 6. Proximal extent of the TCL, which is often

marked by hypothenar fat (A). Fig. 7. Tranverse carpal ligament.
Fig. 9. Endoscopic visualization of the transected

Palmar Brevis muscle is a good indicator of successful
Fig. 8. Division of the TCL. TCL division.
Suggested reading
Adams BD. Endoscopic carpal tunnel release. J Am Acad Orthop Surg 1994;2:179–84.
Agee JM, Peimer CA, Pyrek JD, Walsh WE. Endoscopic carpal tunnel release: a prospective study of complications and
surgical experience. J Hand Surg [Am] 1995;20:165–71.
Boeckstyns ME, Sorensen AI. Does endoscopic carpal tunnel release have a higher rate of complications than open
carpal tunnel release? An analysis of published series. J Hand Surg [Br] 1999;24:9–15.
Chow JC. Ulnar nerve transection as a complication of two-portal endoscopic carpal tunnel release. J Hand Surg [Am]
1994;19(3):522.
Cobb TK, Cooney WP, An KN. Clinical location of hook of hamate: a technical note for endoscopic carpal tunnel
release. J Hand Surg 1994;19:516–18.
Concannon MJ, Brownfield ML, Puckett CL. The incidence of recurrence after endoscopic carpal tunnel release. Plast
Reconstr Surg 2000;105:1662–5.
Dheansa BS, Belcher HJ. Median nerve contusion during endoscopic carpal tunnel release. J Hand Surg [Br]
1998;23:110–1.
Ecker HAJ. Persistent or recurrent carpal tunnel surgery following prior endoscopic carpal tunnel release. J Hand Surg
[Am] 1999;24:647–8.
Einhorn N, Leddy JP. Pitfalls of endoscopic carpal tunnel release. Orthop Clin N Am 1996;27:373–80.
Forman DL, Watson HK, Caulfield KA, Shenko J, Caputo AE, Ashmead D. Persistent or recurrent carpal tunnel
syndrome following prior endoscopic carpal tunnel release. J Hand Surg [Am] 1998;23:1010–4.
Kasdan ML. Complications of endoscopic and open carpal tunnel release. J Hand Surg [Am] 2000;25(1):185.
Lee WP, Strickland JW. Safe carpal tunnel release via a limited palmar incision. Plast Reconstr Surg 1998;101:
418–24.
Palmer AK. Complications of endoscopic and open carpal tunnel release. J Hand Surg [Am] 2000;25(1):185.
Ruch DS, Poehling GG. Endoscopic carpal tunnel release. The Agee technique. Hand Clin 1996;12:299–303.
Stark RH. Ulnar nerve transection as a complication of two-portal endoscopic carpal tunnel release. J Hand Surg [Am]
1994;19:522–3.
Steinberg DR, Szabo RM. Anatomy of the median nerve at the wrist. Open carpal tunnel release—classic. Hand Clin
1996;12:259–69.
Single-portal endoscopic carpal tunnel release

Scott H. Kozin, MD*
Temple University, 3550 North Broad Street, Philadelphia, PA 19140, USA
Shriners Hospitals for Children, 3551 North Broad Street, Philadelphia, PA 19140, USA1
‘‘A good hand surgeon should slip into the hand and out again without the hand ever knowing he
was there.’’ Sterling Bunnell
Carpal tunnel syndrome is the most common entrapment neuropathy of the upper extremity.
Carpal tunnel release is the standard treatment for persistent median nerve compression at the
wrist [1–4]. Division of the transverse carpal ligament (TCL) reduces carpal tunnel pressure,
increases canal volume, and relieves median nerve compression [5,6]. Internal neurolysis, exter-
nal neurolysis, and epineurotomy do not provide any additional benefit. These findings have
lead to the development of less invasive procedures to incise the TCL in an attempt to improve
the outcome after carpal tunnel release [7–9]. The rationale for these limited incision techniques
is based upon diminished scar formation, less post-operative pain, and sparing of the normal
anatomy [10–12]. The palmar fascia, subcutaneous tissue, cutaneous nerves, and palmar skin are
minimally affected using these techniques. A single proximal portal endoscopic carpal tunnel
release involves division of the TCL without a palmar incision [7]. This paper describes the tech-
nique of single-portal endoscopic carpal tunnel release using the Agee Carpal Tunnel Release
System (3M Health Care, St. Paul, MN).
Relevant anatomy
The carpal tunnel forms the primary flexor compartment along the palmar aspect of the
wrist. The carpal bones form the walls of the carpal tunnel and the overlying TCL constitutes
the roof [13]. The TCL attaches to the scaphoid tubercle and trapezial ridge on the radial side
and the hook of the hamate and pisiform on the ulnar side. The TCL varies in length from 26 to
34 mm [14]. The TCL also forms the floor of Guyon’s canal, which contains the ulnar artery and
nerve. Nine tendons and the median nerve are within the carpal tunnel. The flexor digitorum
superficialis tendons lie just ulnar to the nerve, the long and ring superficialis tendons more pal-
mar than the index and small. Beneath the flexor digitorum superficialis is the flexor digitorum
profundus tendons, which are arranged in a single plane. The flexor pollicis longus runs deep to
the median nerve along the radial border of the carpal tunnel.
The palmar cutaneous branch arises from the median nerve 5 cm proximal to the wrist
joint and supplies sensibility to the thenar eminence. A recurrent motor branch originates from
the central or radial portion of the median nerve during its passage through the carpal tunnel. The
recurrent branch usually passes distal to the TCL and innervates the thenar muscles [15]. The
median nerve terminates into multiple sensory branches, which supply sensibility to the thumb,
index, long, and ring (radial side) fingers. Approximately 80% of individuals will have a commu-
nicating branch between the third and fourth common digital nerves. This branch crosses the
superficial palmar arch and usually conveys sensory fibers from the superficial ulnar nerve to
the radial digital nerve of the ring finger [13,16]. This ulnar to median nerve connection can
be injured by inadvertent incision of structures extremely distal to the TCL.
* E-mail address: skozin@shrinenet.org (S.H. Kozin).

1
Address for correspondence.
PII: S 1 0 8 2 - 3 1 3 1 ( 0 2 ) 0 0 0 0 6 - 7
230 S.H. Kozin / Atlas Hand Clin 7 (2002) 229–241
Anomalous branching of the median nerve is at jeopardy during both open and endoscopic
carpal tunnel release [17]. The authors dissected 101 fresh-frozen cadavers to spatially define the
origin of the median nerve and define its course with respect the distal edge of the TCL [15]. The
orientation was extremely consistent, with 100 (99%) recurrent branches originated either from
the central portion or just radial to it. One recurrent nerve originated directly radial from the
median nerve. There were no ulnar origins identified, and there have only been isolated reports
of ulnar origin [18–20]. The recurrent branch was extraligamentous in 94 cadavers (93%),
although 75 (74%) did course through a separate tunnel with fascia either completely or partially
surrounding the nerve (Fig. 1). Only 7 specimens (7%) had a transligamentous recurrent branch
(Fig. 2). Four cadavers (4%) had more than one recurrent branch, and 18 had a common trunk
for origin of the recurrent branch, sensory branches to the thumb, and proper sensory nerve to
the radial side of the index (Fig. 3).
A line drawn across the palm parallel to the fully abducted thumb (ie, Kaplan’s cardinal line)
approximates the location of the superficial palmar arch [13]. The arch is located just past the
distal edge of the TCL. The deep palmar arch is located 1 cm proximal to the superficial palmar
arch and is beneath the flexor tendons. Although considerable variability exists, the superficial
palmar arch typically provides palmar blood vessels to the index (ulnar side), long, ring, and
small fingers while the deep palmar arch supplies blood vessels to the thumb and index digit
(radial side).
The anatomic relationships of an endoscopic carpal tunnel device to surrounding structures
have been studied in detail [21]. The median nerve resides just radial to an endoscopic device
inserted in line with the ring digit axis (Fig. 4). The distance from the center of the device to the
median nerve in the carpal tunnel averaged 3.3 mm in the ring digit axis. A device placed in the
long-ring interspace axis resided only 2.5 mm from the center of housing to the median nerve.
The average distance from the distal edge of the TCL to the superficial palmar arch was 4.8 mm
in the ring finger axis and 5.5 mm in the long-ring interspace axis. Rotation of the device toward
the median nerve placed the nerve between the device and TCL. The flexor tendons were con-
sistently found dorsal or ulnar to the device. A separate adherent fascial layer was often found
palmar to the TCL that is derived from the thenar and hypothenar muscle fascia. The proximal
extent of the fat pad was usually proximal to the distal edge of the TCL, averaging 2.8 mm in the
ring digit axis and 0.8 mm in the long-ring interspace axis. The distal edge of the TCL was more
clearly defined along the ring finger axis than the long-ring interspace. These results emphasize
the necessity of placing the endoscopic device in the ring finger axis and not the long-ring inter-
space axis.
The thenar muscles are the opponens pollicis, flexor pollicis brevis, abductor pollicis, and the
recurrent branch of the median nerve innervates all. The flexor pollicis brevis muscle receives
Fig. 1. Extraligamentous recurrent branch that entered a separate tunnel with fascia completely surrounding the nerve.
S.H. Kozin / Atlas Hand Clin 7 (2002) 229–241 231
Fig. 2. Transligamentous recurrent branch that perforated the TCL.
dual innervation from both the recurrent branch (superficial head) and the deep motor branch
of the ulnar nerve (deep head).
Diagnosis
Diagnosis of carpal tunnel syndrome is made by history and physical examination and vali-
dated by electrodiagnostic studies. Typical carpal tunnel syndrome symptoms include numb-
ness, tingling, weakness, and pain at night or with activity. Physical examination reveals a
positive Tinel’s sign, positive Phalen’s sign, and a positive carpal tunnel compression test. Elec-
trodiagnostic studies are used as an adjunctive evaluation in equivocal cases or to verify the
extent of compression.
Indications for endoscopic carpal tunnel release
Carpal tunnel release is indicated for patients that have failed conservative measures (splint-
ing, injection, and activity modification), continual numbness, and weakness of the thenar
Fig. 3. Common trunk origin for the recurrent branch, sensory branches to the thumb, and proper sensory nerve to the
radial side of the index.
Fig. 4. Cross-sectional diagram of carpal tunnel showing position of Agee endoscope in relation to surrounding
structures. (From Rotman MB, Manske PR. Anatomic relationships of an endoscopic carpal tunnel device to sur-
rounding structures. J Hand Surg 1993;18A:442–50.)
muscles, which is indicative of denervation. Endoscopic carpal tunnel release is contraindicated

in patients with distorted anatomy (eg, severe deformity after distal radius fracture), inflamma-
tory arthritis, or previous carpal tunnel release.
The choice of carpal tunnel release technique depends not only upon the patient, but also the
surgeon, who must have an understanding of relevant anatomy, familiarity with endoscopic
techniques, and previous experience. Endoscopic carpal tunnel release is not a technique for the
‘‘occasional’’ carpal tunnel surgeon that does not routinely perform this type of procedure.
Surgical technique
Preoperative discussion
A thorough discussion of the various techniques to release the carpal tunnel is mandatory.
The advantages and disadvantages of open versus endoscopic carpal tunnel release must be dis-
cussed. The standard complications of any surgical procedure, including bleeding and infection,
are mentioned as possible sequelae. The author explains that nerve and artery injuries have been
reported after both open and endoscopic carpal tunnel releases [17,22]. The authors also discuss
that anomalous anatomy predisposes an individual to inadvertent injury to the neurovascular
structures and this finding is impossible to determine prior to surgery. The authors do indicate
that endoscopic release has a higher incidence of nerve injury and an unobstructed view of the
TCL is a prerequisite to perform this technique. Failure to completely visualize the ligament
requires conversion to an open procedure and this problem occurs in 1% to 5% of patients.
Therefore, the surgical consent reads ‘‘endoscopic, possible open carpal tunnel release.’’
Anesthesia
The type of anesthesia varies with the surgeon, anesthesiologist, and familiarity with endo-
scopic carpal tunnel release. The patient should be comfortable and must lie still during the pro-
cedure. The initial insertion of the device can cause discomfort from distention within the carpal
tunnel. Therefore, the surgeon must communicate with the anesthesiologist to prevent inadver-
tent movement of the extremity. The amount of sedation is routinely increased just prior to
insertion of the device within the canal.
The author prefers to use local infiltration anesthesia at the distal wrist crease and intra-
venous sedation with a short-acting agent (eg, mivacurium chloride). The distal wrist crease is
infiltrated with local anesthesia before or after prepping and draping (Fig. 5). The carpal tunnel
is not injected as fluid within the tunnel can obscure visualization.
Patient positioning
The patient is placed on the operating room table in the supine position. A pneumatic tour-
niquet is applied to the proximal arm. The endoscopic device and video equipment are checked
prior to initiation of the procedure. The disposable blade is inserted onto the device and tightly
secured. The placement of the video screen should be across from the surgeon to prevent head
turning to view the screen. This maneuver tends to rotate the device away from the intended
position within the carpal tunnel. In general, the device should be utilized in the dominant hand
of the surgeon, unless he or she is ambidextrous. For a right-handed individual, the video should
be positioned above the arm during a right endoscopic carpal tunnel release and the surgeon
seated in the axilla. In contrast, the video is placed below the arm during a left endoscopic carpal
tunnel release and the surgeon seated above the arm. These preliminary steps will considerably
enhance the success of the surgery.
Fogging of the endoscopic can occur during insertion of a cold device into a warm extremity.
This problem is alleviated by either having the device warmed with saline prior to the procedure
or by placing an anti-fog substance on the endoscope.
Operative procedure
The distal wrist crease is infiltrated with local anesthesia and the extremity is prepped and
draped. The surface anatomy is carefully marked on the skin because these landmarks will guide
placement of the endoscopic device (Fig. 6). The pisiform, hamate, Kaplan’s cardinal line, ring
digit axis, and wrist crease are delineated. There may be multiple wrist creases; the surgeon
should select a crease that is just proximal to the palm. Selection of a wrist crease too distal will
allow the palmar fat to fall into the incision. The safe zone for endoscopic carpal tunnel release
resides in line with the ring digit axis and proximal to Kaplan’s cardinal line.
The limb is exsanguinated and a pneumatic tourniquet inflated at the proximal arm level. A
1- to 1.5-cm transverse wrist incision is made along the wrist crease and ulnar to the palmaris
longus (Fig. 7). Meticulous hemostasis is obtained with a bipolar elctrocautery. Spreading dis-
section is performed and the antebrachial fascia is identified, which is just deep to the palmaris
longus tendon. A rectangular flap of antebrachial fascia is raised leaving its distal attachment
(Fig. 8). The flap is made as wide a possible and must be raised carefully to prevent injury to
the underlying median nerve. A double-prong skin hook is placed into the flap and the assistant
Fig. 5. The distal wrist crease is infiltrated with local anesthesia while avoiding injection within the carpal tunnel.
Fig. 6. Surface anatomy marked on the skin including the pisiform, hamate, Kaplan’s cardinal line, ring finger axis, and
wrist crease.
Fig. 7. Diagram of wrist incision beginning ulnar to the palmaris longus and extending 1–1.5 cm in length.
Fig. 8. Rectangular flap of antebrachial fascia elevated from underlying median nerve to reveal the leading edge of the
carpal tunnel.
lifts the fascia upward to reveal the leading edge of the carpal tunnel and its contents. The assis-
tant continues to hold this flap upward until the carpal tunnel has been released.
At this point, the surgeon must position his other hand about the patient’s hand and the tech-
nique becomes bimanual. The hand not holding the device is used to adjust the wrist position
and provide proprioception during release of the TCL. This hand cups the ulnar border of the
patient’s hand and the thumb is placed just proximal to Kaplan’s cardinal line and in line with
the ring digit axis (Fig. 9). This palpation of the safe zone facilitates single-portal endoscopic
carpal tunnel. The wrist is usually positioned in slight extension (20° to 30°) during single-portal
endoscopic carpal tunnel release. Similar to the assistant holding up the antebrachial fascial, this
hand is not removed until the procedure has been completed.
All instruments pass in line with the ring digit axis to ensure safety. The orientation of inser-
tion is 30° from palmar to dorsal. The synovial reflector is the first instrument placed with the
carpal tunnel and the ulnar border palpated by feeling the hook of the hamate. Once the instru-
ment passes through the canal the reflector can be palpated with the surgeon’s contralateral
thumb over the safe zone (Fig. 10). The synovial reflector is used to clear the separate adherent
fascial layer palmar to the TCL (ie, ulnar bursae) and to push the fat pad in a distal direction to
enhance visualization of the distal TCL. Multiple passes in a back-and-forth motion are neces-
sary to scrape the adherent fascia layer. Eventually the transverse fibers of the TCL can be
appreciated via palpation with the reflector. Failure to adequately remove this fascial layer will
obscure endoscopic visualization of the TCL.
The hooks of the hamate dilators are subsequently inserted in line with the ring digit axis
(Fig. 11). The placement of these instruments serves to dilate the carpal tunnel and allows prac-
tice regarding the orientation of insertion. Recently, an additional device has been manufac-
tured that replicates the dimensions of the Agee endoscope and this instrument is also inserted.
The Agee endoscope is then passed into the canal without holding the trigger (Fig. 12). This
method prevents unintentional elevation of the blade during insertion. The endoscope is held
snugly against the undersurface of the TCL and slowly advanced toward the distal portion of
the TCL and safe zone. In small hands or ‘‘tight’’ carpal tunnels, insertion can be facilitated
Fig. 9. The surgeon’s hand cups the ulnar border of the patient’s hand and the thumb is placed over the safe zone. This
hand is used to adjust the wrist position and provide proprioception during release of the TCL.
Fig. 10. The synovial reflector is passed into the carpal tunnel in line with the ring digit axis. The reflector can be
palpated with the surgeon’s contralateral thumb over the safe zone.
by slight flexion of the wrist to increase the opening for device placement. After the device is
placed within the carpal tunnel, the wrist is gradually extended.
During insertion, the undersurface of the TCL is viewed by way of the endoscope from prox-
imal to distal. The transverse fibers should be clearly pictured on the screen without overlying
tissue interposition (Fig. 13). Persistent tissue that overlies the TCL requires removal of the
device and repeated insertion of the synovial reflector. The field should also be clear of all
objects that may be neurovascular structures. The device should not be rotated toward the
median nerve for identification purposes. This tactic often captures the epineurium, which tends
to entrap the nerve between the TCL and endoscope.
Fig. 11. Hooks of the hamate dilators are inserted along the ring digit axis to dilate the carpal tunnel and confirm
alignment.
Fig. 12. Insertion of Agee endoscope without holding the trigger and in line with the ring digit axis. The surgeon’s
contralateral hand controls wrist position and provides proprioception.
The initial part of the carpal tunnel release concentrates on the distal half of the ligament.
Incision of the proximal half should be delayed until the distal half has been incised. Proximal
division allows palmar fat to fall into the field, which obscures identification of the distal TCL
fibers. The distal aspect, or nose of the endoscope, is used to push any remaining fat pad in a
distal direction. The distal edge of the TCL is visualized and the safe zone ballotted with the
surgeon’s holding hand. The TCL will not move during this maneuver while the area directly
distal to the ligament will move up and down. Once the distal edge of the ligament is identified,
the blade assembly is fully engaged by depressing the trigger. The distal half of the ligament is
incised by gradual withdrawal of the endoscope and direct observation on the video screen
(Fig. 14). The blade is disengaged and the endoscope passed in a distal direction to assess the
extent of release, including the status of the most distal fibers and the depth of division
(Fig. 15). Inadequate division requires repeat blade passage under direct visualization until com-
plete release is confirmed. The proximal half of the TCL is considerable easier to release and
follows a similar sequence. The divided TCL separates into two leaflets that should disconnect
after complete release. The leaflets often spread considerably apart, such that rotation of the
endoscope is necessary to view each leaflet. During this rotation, the location of the median
nerve can be appreciated by its proximity to the radial leaflet (Fig. 16).
After verification of complete TCL division, the antebrachial fascia is split in the midline for
1 inch (Fig. 17). This prevents a leading edge of fascia from irritating the decompressed
Fig. 13. Clear endoscopic visualization of the transverse fibers of the TCL.
Fig. 14. Division of the distal edge of the TCL as a result of blade elevation and gradual withdrawal of the Agee
endoscopic device.
Fig. 15. Division of the distal half of the TCL as viewed from the endoscope.
median nerve. The wound is closed with a subcutaneous absorbable suture, a bulky soft dressing
and an ace bandage with the wrist positioned in slight extension. The patient is instructed to
move the fingers and use the hand for activities of daily living. The patient is evaluated 7 to
10 days after surgery and the dressings removed. Formal therapy is usually not necessary after
endoscopic carpal tunnel release.
Fig. 16. Rotation of the endoscope to confirm complete TCL division reveals separation of the radial leaflet and
adjacent median nerve.
Fig. 17. Midline division of the antebrachial fascia to eliminate any leading edge of fascia that may irritate the
decompressed median nerve.
Results
There is no difference in the resolution of parasthesias or nocturnal pain between open and
endoscopic carpal tunnel release techniques [23]. In fact, there is no difference in the long-term
results between the techniques. The benefits of endoscopic carpal tunnel release are in the short-
term [7–9,23]. The improved short-term outcome noted with endoscopic carpal tunnel release is
mutlifactorial. Preservation of the fascia superficial to the TCL, which serves as attachment sites
for the thenar and hypothenar muscles, leads to a quicker return of pinch strength. Maintenance
of a portion of the fibro-osseous pulley system for the flexor tendons contributes to a faster
return of grip strength. The minimal postoperative pain after endoscopic carpal tunnel release
fosters earlier use of the hand and rapid restoration of strength. The single-portal method also
has less palmar pain than the two-portal technique [23]. The smaller incision that avoids the
palm encourages re-establishment of wrist motion significantly faster than open surgery.
Return to work is earlier after endoscopic carpal tunnel release than open methods [7,23].
This beneficial return is evident in workers’ compensation and non-workers’ compensation,
although patients not involved in workers’ compensation return quicker [23]. Return to work
data must be interpreted carefully as additional factors, such as patient motivation and second-
ary gain, play important roles.
Complications
Incomplete release
Incomplete release of the TCL can lead to persistent symptoms of carpal tunnel syndrome.
This complication can occur following open and endoscopic carpal tunnel release [17,21]. The
distal edge of the TCL usually extends into the fat pad, which must cleared during endoscopic
carpal tunnel release for complete division of the ligament. The distal edge of the TCL must be
identified and the separation of the leaflets verified to avoid leaving the distal TCL fibers intact.
Because proximal division often permits fat to fall into the carpal tunnel and obscure visualiza-
tion, initial release of the distal half of the TCL will ensure complete division of the most distal
fibers.
Nerve injury
Median nerve injury has been reported following endoscopic carpal tunnel to either the main
trunk or its common digital branches [7,22]. The exact cause leading to these injuries is often
unclear. Placement of the device along the incorrect axis or rotation of the blade toward the
median nerve places the nerve in jeopardy [21]. Endoscopic carpal tunnel release has a narrow
tolerance for error within the carpal tunnel. Meticulous attention to detail from beginning to
end will limit the possibility of inadvertent nerve injury. This process begins with careful mark-
ing of the surface anatomy and progresses through each surgical step. Clear visualization of the
TCL fibers is mandatory and requires reflecting the fascia from the undersurface of the TCL.
During insertion of the device, the endoscopic device must be held snugly against the undersur-
face of the TCL. Inadequate visualization of the TCL and its borders requires conversion to an
open procedure. The surgeon and patient may be initially disappointed, but this disenchantment
far outweighs accidental nerve laceration.
Arterial injury
The superficial palmar arch is located 5 mm from the distal edge of the TCL in the ring digit
axis [21]. Careful endoscopic release will avoid iatrogenic injury to the arch. Visualization of the
arch is not routinely performed. If there is any question as to its location, a second incision can
be made in the palm, similar to a two-portal endoscopic technique.
Weakness
The TCL functions as a fibro-osseous pulley system that regulates the moment arm of the
flexor tendons. Cadaver studies have demonstrated an increase in the flexor moment at the
wrist after carpal tunnel release [24–26]. A significant increase in required tendon excursion was
noted after single portal (28%), dual portal (30%), and open carpal tunnel release (43%). The
increase in excursion was present only in the flexion arc of wrist motion, however.
The authors studied the effect of TCL division on reactive grip strength changes in 41 hands
that underwent isolated release of the TCL under local anesthesia with sedation [27]. Digit spe-
cific and total grip strength was measured using a computerized dynamometer (NK Biotechnical
Corporation, Minneapolis, MN). Data acquisition was performed pre-operatively, immediately
after TCL incision, and at 1-, 3-, and 5-week intervals. There was no significant difference
between total grip strength recorded pre-operatively and immediately after TCL division. Sig-
nificant weakness was evident 1 week following surgery in the self-selected wrist position, how-
ever. This post-operative weakness gradually returned to the pre-operative level over the ensuing
3 to 5 weeks, which parallels previous studies of grip strength return after endoscopic carpal tun-
nel release [7,28]. These results indicate that the grip deficit after carpal tunnel release requires
further investigation into factors other than TCL division such as post-operative pain, bleeding,
swelling, secondary flexor tenosynovitis, or as a response to healing.
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Presented at the American Association for Hand Surgery, 28th Annual Meeting, Scottsdale, Arizona, January 1998.
[28] Erdmann MWH. Endoscopic carpal tunnel decompression. J Hand Surg 1994;19B:5–13.
The benefit of transverse carpal ligament

reconstruction following open carpal tunnel release
David T. Netscher, MDa,b,*, Paula Lee Valkov, MSc
a
Division of Plastic Surgery, Baylor College of Medicine, 6560 Fannin Street, Houston, TX 77030, USA
b
Surgical Service, Department of Veterans Affairs Medical Center,
2002 Bellaire Boulevard, Houston, TX 77030, USA
c
Baylor College of Medicine, 6560 Fannin Street, Houston, TX 77030, USA
Symptoms of pain and weakness after carpal tunnel release (CTR) remain problematic. In
one study 35% of patients demonstrated 20% less than preoperative grip strength at three
months after open CTR [1]. Worker’s compensation patients in particular have been noted to
have increased duration of pain and post-operative weakness after CTR [2].
A few studies have evaluated the potential benefit of transverse carpal ligament (TCL) recon-
struction after open CTR [3–6]. Magnetic resonance imaging (MRI) studies have demonstrated
an increased volume of the carpal canal and volar migration of the median nerve and flexor ten-
dons after CTR [7–9], suggesting an element of bowstringing. The TCL is thought to play a role
in the digital flexor pulley system [10–13]. The authors speculate that the reported loss in grip
strength following open CTR may be related to the bowstringing effect on the flexor tendons
and hence loss of available tendon excursion for gripping activities [14]. Other investigators have
also reasoned that ligament reconstruction provides protection to the median nerve and helps
preserve innate nerve gliding [5,15].
Methods of TCL reconstruction
Different types of carpal ligament repair have made use of reconstruction from either the
TCL itself or a combination of the TCL and the palmar aponeurosis. The normal anatomy
of the TCL and palmar aponeurosis is shown in Fig. 1. One described method of TLC recon-
struction involves a step-cut zigzag division of the TCL [3]. The apices of the ligament flaps
on each side are then sutured to each other (Fig. 2) allowing the TCL to heal in a widened
position. The investigators who reported this method of reconstruction found that 97% of
operated patients returned to work within 2 months with no recurrence of nerve compression
symptoms [3].
Another described method of TCL reconstruction involves a staggered longitudinal division
of the palmar aponeurosis and the TCL (Figs. 3, 4) [7,13,14]. In this way there is a broad ulnar
based flap of the aponeurosis and a wide radial based flap of the TCL. Suturing the ulnar cut edge
of the aponeurosis to the radial cut edge of the TCL effectively widens the span of the recon-
structed TCL. This repair is performed with 5–0 absorbable interrupted sutures such as Vicryl
(Braided Polyglactin, Ethicon Inc.).
Our preferred technique of TCL reconstruction with open CTR is simple to perform [7,13,14]
and is done by creating a transposition flap of TCL (Figs. 5, 6). The TCL is divided longitudi-
nally toward its ulnar aspect. This leaves the radial cut edge relatively long. Taking care to iden-
tify and avoid the radial recurrent motor branch of the median nerve, a proximally based
rectangular flap is designed on the radial side flap of the TCL. This is cut long enough so that
E-mail address: netscher@bcm.tmc.edu (D.T. Netscher).
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244 D.T. Netscher, P.L. Valkov / Atlas Hand Clin 7 (2002) 243–249
Fig. 1. Normal anatomy of the hand before reconstruction of the transverse carpal ligament (TCL). (A) Palmar view.
(B) Cross-sectional view with radial side to the right of the diagram.
Fig. 2. Diagrammatic representation of the step-cut zigzag flap of the transverse carpal ligament (TCL). (A) Step cut
zigzag division of the TCL. (B) The apices of the zigzag flaps (flap A and flap B) are sutured together allowing the
ligament to be repaired in a widened position. (Apices of flaps are marked by asterisks).
D.T. Netscher, P.L. Valkov / Atlas Hand Clin 7 (2002) 243–249 245
Fig. 4. Clinical case demonstrating the diagrammatic representation in Fig. 3. (A) Ulnar based flap of palmar aponeurosis
is marked. (B) Aponeurosis flap has been raised and the radial based long TCL flap is marked. (C) Both the aponeurosis
and the TCL flaps have been divided. (D) Repair of the two flaps (the edge of the aponeurosis to the opposite edge of the
TCL) easily allows passage of a surgical instrument showing that there is no compression on the carpal tunnel. (E)
Diagrammatic representation of (A) showing the preparation and marking of the ulnar based flap of the palmar
aponeurosis.
b
Fig. 3. Diagrammatic representation of the transverse carpal ligament (TCL) reconstruction using the radial cut edge of
the palmar aponeurosis to the ulnar cut edge of the TCL (each of these are kept ‘‘long’’ cutting the aponeurosis over to
the radial side and the TCL close to its ulnar attachment to the hook of the hamate). Suturing the two limbs to each
other effectively lengthens the span of the TCL as both the TCL and the palmar aponeurosis are cut longitudinally in a
stepwise fashion. (A) Palmar view. (B) Cross-sectional view with radial side to the right of the diagram.
Fig. 5. Diagrammatic representation of our favored technique of transverse carpal ligament (TCL) reconstruction with
open carpal tunnel release (CTR). (A) Complete division of the TCL longitudinally along the ulnar aspect and partial
division of the TCL along the radial aspect. (B) Suturing the distal radial tip (*) of the transposition flap to the ulnar
edge of the TCL in the vicinity of the hook of the Hamate. The release down the radial side must allow sufficient mobility
of the transposition flap to enable tension free suturing with sufficient laxity of the flap to allow enough free space to pass
a hemostat.
Fig. 7. Flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendon excursions required to
achieve fingertip-to-palm contact are represented for each wrist position and each surgical procedure (before open CTR,
following open CTR, aponeurotic TCL reconstruction, transposition flap TCL reconstruction). Note a greater excursion
is required for the open release and no ligament repair and also for the aponeurotic repair compared to the transposition
flap ligament repair. #P < 0.05 for flap repair versus no repair; *P < 0.05 for aponeurotic repair versus no repair.
it easily transposes across the carpal canal and the flap tip is stitched with 4–0 figure of eight
non-absorbable suture material to the ulnar edge of the TCL in the vicinity of hook of the
Hamate. Following the reconstruction, a hemostat easily passes under this loose reconstruction,
thus avoiding recurrence of median nerve compression symptoms.
b
Fig. 6. Clinical case demonstrating the diagrammatic representation in Fig. 5. The transposition flap is simple to
perform with open carpal tunnel release (CTR). The TCL is divided longitudinally toward its ulnar aspect. (A) This
leaves the radial cut edge relatively long, taking care to identify and avoid the radial recurrent motor branch of the
median nerve. (B) A proximally based rectangular flap is designed on the radial side flap of the TCL. (C) This is cut long
enough so that it easily transposes across the carpal canal and the flap tip is stitched with 4:0 figure of eight non-
absorbable suture material to the ulnar edge of the TCL in the vicinity of the hook of the Hamate. (D) Following the
reconstruction, a hemostat easily passes under this loose reconstruction, thus avoiding recurrence of median nerve
compression symptoms.
Rationale and indications for transposition flap TCL reconstruction
The authors have performed a study in which it was found that division of the TCL required
greater tendon excursion to achieve fingertip–palm contact in a cadaver model [13]. The two
types of TCL repair described in Fig. 3 and Fig. 5 were performed. The repair using the palmar
aponeurosis had minimal effect on the needed flexor tendon excursion to produce fingertip–palm
contact. When a transposition flap repair made from the radial cut edge of the TCL was
performed, however, a significant reduction in tendon excursion was required to achieve
fingertip–palm contact (P < 0.05) (Fig. 7), approximating the values for an intact TCL. The
authors found an adverse effect on flexor tendon excursion when the TCL was left unrepaired,
as has been found by others as well.
The authors have found that with this transposition flap repair, both grip and pinch strength
improved significantly faster than in patients with an unrepaired TCL [7,14]. Thus it does seem
that the pulley effect of the transverse carpal ligament on bowstringing and impaired linear ten-
don excursion translates into clinically reduced pinch and grip strength. The division of the dig-
ital and palmar aponeurosis pulleys appears to have a similar effect on tendon excursion, as does
division of the TCL [10,16–18].
The authors’ clinical and anatomic studies, as well as review of the available published liter-
ature, support the reconstruction of the transverse carpal ligament after open carpal tunnel
release. One might argue that the transposition flap technique places undue compression on the
contents of the carpal tunnel. However, using the technique of ligament transposition repair in
well over 200 consecutive cases, and always ensuring that there is a clear ‘‘free space’’ that read-
ily admits the passage of a hemostat beneath the repaired ligament, no patients have reported
recurrent symptoms of carpal tunnel compression. In the long term there may not possibly
be any difference if one were to reconstruct the ligament or not following open CTR and it is
difficult to extrapolate the findings from cadaver studies to clinical impressions that involve
wound healing. The authors definitely recommend TCL reconstruction when performing open
CTR in the following situations, however:
1. Worker’s compensation patients
2. Rheumatoid patients because of their pre-existing potential for volar subluxation of musculo-
skeletal structures at both the wrist and MPJ levels
3. Whenever the carpal tunnel needs to be open to perform flexor tendon repair—the authors
always try to avoid dividing the TCL completely under these circumstances [19]; however, if
complete division of the TCL is required for exposure of the injury, then ligament repair
should be done
4. Patients who have physically demanding occupations, especially those who might require
strong gripping with a flexed wrist, such as furniture movers
5. Whenever other pulley systems are to be sacrificed so that the additive effect may potentially
result in tendon bowstringing and ineffective gripping—such as a combination of CTR and
Dupuytren’s contracture release (removing the palmar transverse fiber aponeurosis pulley
structure [18]), or a combination of CTR and trigger finger release (which also divides
the A-1 pulley [16–17]); the authors have at least one patient in the latter group who was
unable to achieve fingertip–palm contact following open CTR without ligament reconstruc-
tion, which was a significant functional problem for that person
6. Patients undergoing release of TCL for recurrent carpal tunnel symptoms
References
[1] Young VL, Logan SE, Fernanco B, Grasse P, Seaton M, Young AE. Grip strength before and after carpal tunnel
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[2] Luis DS, Calkins ER, Harris PG. Carpal tunnel syndrome in the work place. Hand Clin 1996;12:305–8.
[3] Jakab E, Janos DE, Cook FW. Transverse carpal reconstruction in surgery for carpal tunnel syndrome: a new
technique. J Hand Surg 1991;16A:202–6.
[4] Schlenker JD, Koulis CP, Kho LK. Synovialectomy and reconstruction of the retinaculum flexorum in median
nerve decompression: technique and early results. Handchir Mikrochir Plast Chir 1993;25:66–71.
[5] Furrer M, Bischof TP, Hodler J, Meyer BE. Is the ‘‘classical’’ release of the flexor retinaculum and carpal tunnel
syndrome obsolete? Schweiz Med Wochenschr 1994;124:940–4.
[6] Rosen HR, Ammer K, Rathkolv O, Fux B, Eckstein G, Matzinger H. Is mere surgical division of the transverse
carpal ligament in treatment of carpal tunnel syndrome adequate? Chirurg 1990;61:150–2.
[7] Netscher DT, Mosharrafa A, Lee M, Polsen C, Choi H, Steadman AK, et al. Transverse carpal ligament: its effect
on flexor tendon excursion, morphologic changes of the carpal canal and on pinch and grip strength after open
carpal tunnel release. Plast Reconstr Surg 1997;100:636–42.
[8] Richman JA, Gelberman RH, Rydevik VL, Hajek PC, Braun RM, Gylys-Morin VM, et al. Carpal tunnel
syndrome. Morphologic changes after release of the transverse carpal ligament. J Hand Surg 1989;14A:852–7.
[9] Ablove RH, Peimer CA, Dao E, Oliverio R, Kuhn P. Morphologic changes following endoscopic and two-portal
subcutaneous carpal tunnel release. J Hand Surg 1994;19A:821–6.
[10] Idler RS. Anatomy of and biomechanics of the digital flexor tendons. Hand Clin 1985;1:3–11.
[11] Kline SC, Moore JR. The transverse carpal ligament: an important component of the digital flexor pulley system.
J Bone Joint Surg 1992;74A:1478–85.
[12] Simmons VP, DeLaCaffiniere JY. Physiology and flexion of the fingers. In: Tubiana R, editor. The hand.
Philadelphia: W.B. Saunders; 1981. p. 377–88.
[13] Netscher DT, Lee M, Thornby J, Polsen C. The effect of division of the transverse carpal ligament on flexor tendon
excursion. J Hand Surg 1997;22A:1016–24.
[14] Netscher DT, Steadman AK, Thornby J, Cohen V. Temporal changes in grip and pinch strength after open carpal
tunnel release and the effect of ligament reconstruction. J Hand Surg 1998;23A:48–54.
[15] Hunter JM. Reconstruction of the transverse carpal ligament to restore median nerve gliding: the rationale of a new
technique for revision of recurrent median nerve neuropathy. Hand Clin 1996;12:365–78.
[16] Doyle JR, Blythe W. The finger flexor tendon sheath and pulleys: anatomy and reconstruction. In: AAOS
symposium: tendon surgery in the hand. St. Louis: C.V. Mosby; 1975. p. 81–7.
[17] Doyle JR. Anatomy of the finger flexor tendon sheath and pulley system. J Hand Surg 1988;13A:473–84.
[18] Manske PR, Lesker PA. Palmar aponeurosis pulley. J Hand Surg 1983;8:259–63.
[19] Kleinert HE, Stillwell JH, Netscher DT. Complications of tendon surgery in the hand. In: Sandzen SC, editor.
Current management of complications in orthopedics: the hand and wrist. Baltimore/London: Williams & Wilkins;
1985. p. 206–27.
Carpal tunnel syndrome in rheumatoid

or inflammatory arthritic patients
Andrew L. Terrono, MD
Tuft’s University, Department of Orthopaedics, New England Baptist Hospital,
New England Baptist Bone & Joint Institute,
125 Parker Hill Avenue, Boston, MA 02120, USA
Carpal tunnel syndrome (CTS) is the most common compression neuropathy seen in patients
with rheumatoid arthritis (RA), being seen in 23%. It might be the initial manifestation of the
disease. Patients might present with the usual complaints seen in idiopathic CTS. These include
symptoms of numbness and or paresthesias in the median nerve distribution (thumb, index,
middle and radial half of the ring finger) that are more prominent at night. Additional symp-
toms of pain, weakness, or loss of dexterity can also be seen. As with idiopathic carpal tunnel
syndrome, a high percentage can be present bilaterally.
CTS in patients with inflammatory arthritis might not be obvious. In patients with inflamma-
tory arthritis pain, weakness, loss of dexterity, and altered sensibility are common complaints.
Patients become accustomed to having compromised function and often do not complain of
CTS. Every patient with inflammatory arthritis should be evaluated for CTS.
Flexor tenosynovitis is the common denominator for patients with CTS and inflammatory
arthritis. Flexor tenosynovitis at the wrist might initially cause only symptoms of median nerve
compression. As the proliferation continues, however, flexor tendon function becomes affected.
There is early minimal loss of active digital flexion, but passive flexion is preserved. As the dis-
ease progresses, however, severe limitation of digital flexion and thenar atrophy might be seen.
In addition to wrist flexor tenosynovitis, the tenosynovium might extend into the palm and dig-
its; one should evaluate these areas.
Another complication of wrist flexor tenosynovitis is tendon rupture. Although not common,
tenosynovium can infiltrate into the flexor tendons, resulting in their rupture. When a tendon
rupture is diagnosed, one must differentiate whether the rupture occurred at the wrist, palm,
or digital level. Tendon rupture can also occur on a bone spur. Most commonly this is on
the volar aspect of the scaphoid (Mannerfelt lesion) affecting the flexor pollicis longus (FPL,
Fig. 1), although any combination of tendons can be affected and spurs can occur in other
locations.
CTS can be seen associated with severe wrist destruction and volar subluxation; concomitant
wrist arthrodesis might also have to be performed. CTS has also been seen after wrist arthro-
desis in patients with RA. This is more commonly seen if severe volar subluxation of the carpus
has been corrected. The volar surface of the radius might project into the carpal tunnel. This
should be treated with decompression of the median nerve with resection of any bone promi-
nence from the volar aspect of the distal radius.
The author does not have any relationship with a commercial company that has a direct financial interest in the
subject matter or materials discussed in this article or with a company making a competing product.
PII: S 1 0 8 2 - 3 1 3 1 ( 0 1 ) 0 0 0 0 3 - 6
252 A.L. Terrono / Atlas Hand Clin 7 (2002) 251–258
Fig. 1. Radiograph of a bone spur on the scaphoid (arrow).
Anatomy
The carpal tunnel is bounded dorsally and laterally by carpal bones and on the volar surface
by the thick transverse carpal ligament. Through this space nine flexor tendons and the median
nerve pass. Any tenosynovial proliferation or wrist joint abnormality can lead to CTS.
The inflammatory process affects the synovium-lined sheaths that surround each of the ten-
dons. This often occurs prior to joint disease. Tenosynovium can vary in consistency from thin
with much fluid (early) to thick with little fluid (later). Small, fibrinoid ‘‘rice bodies’’ might fill
the tendon sheaths (Fig. 2). Rheumatoid nodules might be found within the tendon substance.
Evaluation
The patient is asked to express all of their problems including pain and functional deficits.
They are asked specifically what they can’t do and what they would like to do. Physical exami-
nation of the entire upper extremity is performed. Active and passive range of motion of the
digits, wrist, forearm, elbow, and shoulder are recorded (Fig. 3). Joint stiffness can occur limit-
ing passive motion, which makes the diagnosis of flexor tenosynovitis more difficult because one
cannot differentiate between lack of finger motion due to joint stiffness or due to restricted ex-
cursion of the flexor tendons. Areas of tenosynovitis, synovitis, tenderness, and instability are
Fig. 2. Rice bodies (arrow) seen at the time of tenosynovectomy.

A.L. Terrono / Atlas Hand Clin 7 (2002) 251–258 253
Fig. 3. Finger motion in a patient with significant flexor tenosynovitis. (A) Limited active motion. (B) Full passive
motion.
sought. Tenosynovitis causes swelling that is difficult to see in the carpal tunnel (Fig. 4). Signs
and symptoms of CTS are sought. Provocative testing including Tinel’s and Phalen’s nerve com-
pression tests are performed. Thenar motor strength and sensibility are assessed. Assessment of
sensibility is performed with light touch, two-point discrimination or Semmes-Weinstein mono-
filaments as needed. The function of each tendon is evaluated. In patients with inflammatory
arthritis joints are often affected and do not have full motion; this makes the assessment of ten-
don rupture difficult (Fig. 5). The tenodesis effect should be evaluated in each patient with loss
of active motion. This can be difficult, however, because wrist motion might be limited.
Neutral posterior-anterior (PA), lateral, and oblique radiographs including the wrist and
hand to evaluate the radiocarpal joint for subluxation or spurs are obtained.
While the decision to operate is a matter of clinical judgment, electrophysiological studies
(EPS; eg, NCV/EMG) can be helpful but do not always need to be performed. They are per-
formed when the clinical diagnosis is uncertain. EPS will confirm the diagnosis and can rule
out co-existing conditions such as polyneuropathy or proximal compression such as cervical
radiculopathy or proximal median neuropathy. Diagnosis can be confusing if there are tendon
Fig. 4. Flexor tenosynovitis can be best seen (arrow) from the side just proximal to the carpal tunnel.
Fig. 5. A patient with limited motion of all fingers but obvious altered posture of the index finger indicating a flexor
tendon rupture.
ruptures such as the flexor pollicis longus (FPL) and median nerve sensory changes because this
will simulate proximal median nerve compression.
Differential diagnosis
The differential diagnosis of sensory loss in the median nerve distribution includes CTS, prox-
imal median nerve compression, cervical radiculopathy, or a polyneuropathy. Rarely, a severe
mononeuropathy multiplex can be seen.
Proximal median nerve entrapment usually does not have nocturnal symptoms. It has altered
sensibility in the palm and involvement of proximal muscles (FPL, flexor digitorum profundus
[FDP]), which is not seen in CTS. Radiculopathy at the C6 level is characterized primarily by
denervation of muscles in the C6 myotome with normal nerve conduction studies. A C6 radicul-
opathy and CTS can occur together; this has been called the double crush syndrome and might
be a reason that a patient with definite CTS does not improve following carpal tunnel surgery.
Polyneuropathy is common in patients with inflammatory arthritis and can coexist. Polyneuro-
pathy is not a contraindication to surgery if the diagnosis of CTS is clear. EPS will be helpful in
these cases.
Thenar atrophy is common in RA. It can be associated with cervical spine disease, median
nerve compression, and disuse atrophy from pain and joint involvement. If there is significant
thenar atrophy without significant symptoms or signs of CTS, EPS will help determine the
diagnosis.
Loss of active motion can also be secondary to flexor teno synovitis (FTS) at the wrist or
distally in the palm or finger or tendon rupture. Each tendon must be evaluated and treated.
Non-operative treatment
Medical management including rest, splinting, and local injection of a steroid might result in
remission. If there is no improvement after 4 to 6 months of appropriate medical management,
symptoms are constant, or there is thenar atrophy attributable to CTS, surgery is indicated.
Loss of active motion and tendon rupture are also indications for surgery.
Operative treatment
Operative treatment in patients with inflammatory arthritis falls into two categories. This in-
cludes patients with little FTS (similar to idiopathic CTS) and patients with significant FTS. The
author will discuss the treatment for patients with significant FTS.
The patient is placed in the supine position and a hand table is used for support of the arm.
The procedure is usually performed while the patient is under regional or general anesthesia
with tourniquet control. The extent of the disease usually—but not always—precludes the use of
local anesthesia. Loupe magnification is recommended to avoid soft tissue injury. Preoperative
Fig. 6. Typical incision drawn out for flexor tenosynovectomy in a patient with rheumatoid arthritis.
intravenous antibiotics are routinely administered before the tourniquet is inflated. The extrem-
ity is prepared and draped to the mid-humeral level.
A standard carpal tunnel incision just radial to the hook of Hamate parallel to the interemi-
nence crease is extended proximal to the wrist crease between the palmaris longus and the flexor
carpi ulnaris tendons for 4 to 5 cm in a zigzag manner (Fig. 6). This incision allows complete
exposure of the flexor tendons proximal to the carpal tunnel and the contents of the carpal tun-
nel to the superficial palmar arch. This incision also avoids injury to the palmar cutaneous
branch of the median nerve. After the skin is incised the palmar fascia is split longitudinally.
The antebrachial fascia and the transverse ligament are then incised longitudinally. Careful me-
dian nerve decompression is performed (Fig. 7). Tenosynovectomy is performed for the flexor
pollicis longus and each flexor digitorum sublimis and the flexor digitorum profundus usually
as a group (Fig. 8). A Penrose drain is used to retract the superficial flexors and expose the deep
flexors. The fingers should be flexed and extended during the tenosynovectomy to facilitate de-
livery of the tendons into the wound. If the tendons are frayed they are repaired. Occasionally,
unsuspected ruptures of the deep flexor tendons might be discovered at this time (Fig. 9). It is
Fig. 7. The median nerve is carefully exposed (closed arrow) and bulging tenosynovium is seen (open arrow).
Fig. 8. Tenosynovectomy is performed (arrow) and tendons are retracted in a Penrose drain.
therefore critical that the function of the flexor tendons is known prior to surgery. If there are
multiple flexor digitorum profundus tendon ruptures but the tendons are functioning well by
pulling through scar tissue, complete removal of all diseased tissue is not performed. Traction
is applied to each flexor tendon to check finger motion. Smooth motion of the fingers and thumb
should be present. If smooth motion of the tendons is not present, the involved tendon must be
explored as far distally as necessary to remove the nodules and tenosynovitis. Any nodule
present is removed and the defect in the tendon is repaired with interrupted fine sutures.
Fig. 9. Multiple ruptures of the flexor digitorum profundus (arrow) are found unexpectedly in a patient with good flexor
function.
Fig. 10. Scaphoid spur (closed arrow) is seen with a flexor pollicis longus rupture (*) in the patient in Fig. 9 with multiple
flexor digitorum profundus ruptures (open arrow).
After tenosynovectomy is performed the floor of the carpal canal is inspected and palpated.
Spurs must be removed and the adjacent joint must be debrided of synovitis (Fig. 10). Rotation
of a capsular flap allows the exposed bone to be covered and creates a smooth bed for tendon
gliding. Any tendon ruptures are treated (Fig. 11).
In addition to tenosynovitis, CTS can be associated with both wrist joint subluxation and lat-
eral or fixed flexion contractures. Correction of the deformity might be necessary at the time of
carpal tunnel release.
All wounds are closed with interrupted 5-0 nylon sutures. Soft tissues might be infiltrated
with long-acting local anesthesia for post-operative pain control. A drain is often used and re-
moved the following day when the dressing is changed. A bulky compression dressing is applied
with a volar plaster splint, leaving the digits free.
Fig. 11. A patient with attrition tendon ruptures (arrows) that will be treated with an intercalated graft.
Post-operative care
Immediately after wrist flexor tenosynovectomy, patients are instructed in active, assisted
range-of-motion of the digits following surgery. This will limit the amount of adhesions that de-
velop among the flexor tendons. The sutures are removed at 10 to 14 days. The volar splint is
discontinued at 3 weeks. Most patients can perform therapy on their own. Individual joint mo-
tion using blocking exercises is prescribed. Supervised hand therapy might be needed if range of
motion remains poor. Intermittent extension splinting of the proximal interphalangial (PIP)
joint might be needed if there is a developing flexion contracture.
Summary
CTS is common in patients with inflammatory arthritis. Patients might not have the usual
symptoms, so each patient should be evaluated for CTS. Flexor tenosynovectomy is often
needed. Each tendon’s function must be evaluated, and active and passive motion should be
equal at the end of the procedure. The floor of the carpal tunnel should have all spurs removed.
Tendon ruptures are evaluated and treated. If the FDP tendons have multiple ruptures but have
good function, they are left alone.
Suggested readings
Ertel AN, Millender LH, Nalebuff EA, et al. Flexor tendon ruptures in patients with rheumatoid arthritis. J Hand Surg
1988;13A:860–6.
Feldon P, Terrono AL, Nalebuff EA, et al. Rheumatoid arthritis and other connective tissue diseases. In: Green DP,
Hotchkiss RN, Pedersen WC, editors. Green’s operative hand surgery, 4th edition. Churchill Livingstone; 1999.
p. 1651–739.
Ferlic DC. Rheumatoid flexor tenosynovectomy. Hand Clin 1996;12:561–72.
Millender LH, Nalebuff EA. Preventive surgery-tenosynovectomy and synovectomy. Orthop Clin N Am 1975;6:765–92.
Millender LH, Terrono AL, O’Malley MJ. Neurological involvement of the extremities with rheumatoid arthritis. In:
Omer GE, Spinner M, Van Beek AL, editors. Management of peripheral nerve problems. 2nd edition. Philadelphia:
W.B. Saunders; 1998. p. 587–96.
Nalebuff EA, Potter TA. Rheumatoid involvement of tendon and tendon sheaths in the hand. Clin Orthop 1968;59:
147–59.
Terrono AL. Carpal tunnel syndrome. In: Dawson DM, Hallet M, Wilbourn AJ, Campbell WW, Terrono AL, Trepman
E, editors. Entrapment neuropathies. 3rd edition. Philadelphia: Lippincott-Raven; 1999. p. 95–122.
Median nerve injuries associated with distal radius

fractures: current concepts in management
Keith B. Raskin, MD*, Jeffrey Klugman, MD, Michael E. Rettig, MD
Department of Orthopaedic Surgery, New York University Medical Center, Hospital for Joint Diseases,
317 East 34th Street, Third Floor, New York, NY 10016, USA
Median neuropathy following fracture of the distal radius was traditionally considered to be a
rare condition. Distal radius fractures can be divided into the low velocity Colles’ type of extra-
articular fracture common in the elderly patient, and the high velocity unstable intra-articular
fracture seen with escalating frequency in the younger athletic patient. Throughout the years
there has been an increase in the recognition of associated soft tissue damage to surrounding inter-
carpal ligaments, tendons, and median nerve as our understanding of these complex injuries
expands. There should no longer exist the belief that all median nerve symptoms associated with
distal radius fractures will completely resolve with time. Instead, it is now more important than
ever that timely assessment and treatment be rendered to those patients in whom long-term com-
plications from carpal tunnel syndrome would result in significant functional limitations (Fig. 1).
In 1933, Abbott and Saunders [1] originally classified median nerve injuries associated with
fractures of the distal radius. For the most part, this classification has maintained its significance
throughout the years. The injuries are divided into primary, secondary, late (or delayed), and
iatrogenic. The primary injuries are immediate apparent, while secondary are recognized during
the time of loss of reduction or early malunion. The late presentation occurs several months or
years after the fracture. Iatrogenic conditions are often related to the posture of the wrist
required for reduction and the cast application.
In 1981, Bauman et al [2] employed a wick catheter to distinguish a difference between acute
carpal tunnel syndrome and median nerve contusion. These landmark studies have established
the groundwork for present-day assessment and treatment of median neuropathy associated
with fractures of the distal radius.
Primary injuries
There has been an increased incidence in distal radius fractures in the younger population
secondary to a more forceful mechanism injury, as seen with in line skating, snowboarding,
mountain biking, and a growing popularity of competitive sports (Fig. 2A–C). It is important
to differentiate the high velocity unstable intra-articular displaced fracture of the distal radius
in the young patient from the low velocity extra-articular fracture commonly incurred in a
senior populace (Fig. 2). Both groups of patients can present with median nerve symptoms, yet
the different etiologies require varied management accordingly.
Median nerve contusion
Despite the proximity of the median nerve to the distal radius, direct impalement or nerve
transection is exceedingly rare [3–7]. In high-velocity injuries median nerve contusion due to
E-mail address: DRRASKIN@aol.com (K.B. Raskin).
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Fig. 1. Lateral radiograph of unstable distal radius fracture with dorsal angulation and volar fragment prominence
leading to median nerve symptoms.
hematoma formation, soft tissue edema, and fracture displacement is being recognized with an
increase in frequency (Fig. 3A–C). This is often associated with a severely displaced dorsal or
volar angulated fracture of the distal radius. A prolonged duration of time in a malaligned
position can lead to further detrimental effects. The mainstay of treatment for distal radius
fractures with severe angulation and associated median neuropathy is directed towards initial
gross realignment of the fracture, even in those unstable injuries that may ultimately require
further skeletal stabilization (Fig. 4).
Rarely, fracture fragmentation with significant volar displacement can either impale the
median nerve prior to entering the carpal canal, or more commonly result in further hemorrhage
as a result of disruption of the pronator quadratus muscle (Fig. 5A–F) [6,8]. Oftentimes, this
fracture configuration is not amenable to attempts of closed reduction and instead necessitates
open reduction at the time of definitive fracture stabilization. Median nerve decompression and
external neurolysis is an essential component of this surgical intervention. An extended carpal
tunnel incision allows for complete nerve release while facilitating an optimal approach to the
distal radius fracture site.
Acute carpal tunnel syndrome
In contrast to median nerve contusion, acute carpal tunnel syndrome represents the equiva-
lent of a localized compartment syndrome. The patient can present initially with normal sensa-
tion and over a short period of time develops progressive pain and sensory loss [1,3,9]. The digits
may be postured in hyperextension of the metacarpophalangeal joints and flexion of the prox-
imal interphalangeal joints if a related elevated compartment pressure within the intrinsic com-
partments of the hand is present (Fig. 6A–H). Elevated compartment pressures within the carpal
canal have been previously described in association with distal radius fractures and early surgi-
cal intervention recommended [9–13].
Secondary injuries
Carpal tunnel syndrome
Similar clinical findings of progressive carpal tunnel syndrome may occur during the subacute
period of treating and healing of distal radius fractures [3,14,15]. The structural constraints of
K.B. Raskin et al / Atlas Hand Clin 7 (2002) 259–272 261
Fig. 2. (A) Clinical presentation of a severely displaced distal radius fracture secondary to a high velocity injury in a
young adult. (B) Preoperative lateral radiograph confirming the degree of dorsal fracture displacement. (C) Post-
operative radiograph revealing restored alignment of the fracture after external fixation. The associated median nerve
symptoms resolved after fracture reduction.
Fig. 3. (A, B) Typical initial presentation of a significantly displaced distal radius fracture with associated soft tissue injury
and median nerve dysfunction. (C) Lateral radiograph demonstrating an unstable, angulated fracture of the distal radius.
Fig. 4. Lateral radiograph after reduction for comminuted distal radius fracture with improvement in median nerve symp-
toms. Volar splint immobilization and limb elevation are recommended prior to surgical intervention for skeletal fixation.
the carpal tunnel are often further compromised due to the adjacent skeletal malalignment,
progressive hematoma formation, or edematous changes (Fig. 7A–C). Once median nerve com-
pression has been clinically identified, the subsequent management consists of cast removal,
improved fracture reduction, and possible skeletal fixation with either percutaneous Kirschner
wire stabilization and external fixation, or a combination of both. If median nerve symptoms
persist, decompression should be performed at the time of skeletal fixation or in early follow-up.
Late or delayed injuries
Tardy carpal tunnel syndrome
Several months or years after a fracture of the distal radius that has healed with a degree
of either dorsal or volar malalignment, median nerve function can be diminished resulting in
late carpal tunnel syndrome (Fig. 8A–D) [1,16]. Oftentimes, these patients have demonstrated
increasing symptoms of dysesthesias and associated weakness. Preoperative electrodiagnostic
studies commonly confirm the diagnosis of carpal tunnel syndrome [17]. Simultaneous decom-
pression of the median nerve at the time of corrective osteotomy is recommended (Fig. 9A, B).
Iatrogenic-related injuries
Fracture manipulation
Soft tissue trauma related to a displaced distal radius fracture is often a significant compo-
nent of this injury. Although most patients may not present with immediate median nerve symp-
toms, after a direct reduction and cast immobilization the patient may experience nerve
symptoms, which can be mistaken for prolonged anesthetic response to the hematoma block.
It is preferable to employ an indirect reduction technique with finger trap apparatus and a coun-
terweight at a 90° flexed elbow. A hematoma block with 2% plain Xylocaine and intravenous
sedation as needed allows for a more gentler indirect reduction technique, thereby avoiding fur-
ther nerve contusion or entrapment of the nerve within the fracture site.
Cast immobilization
Most treating physicians are aware of the potential complications of a poorly posi-
tioned wrist and improper application of initial splint or cast immobilization [1,7,8,11]. The
Fig. 5. (A, B) Radiographic views of a unstable complex wrist injury sustained during a high velocity injury resulting in a
distal radius fracture along with median nerve impalement. (C,D,E) Intra-operative findings of direct median nerve and
palmar cutaneous branch injury secondary to fracture displacement. (F) Long-term follow-up radiograph with complete
union in restored position.
Cotton-Loder position of hyperflexion and excessive ulnar deviation is one of the leading causes
for median neuropathies in distal radius fractures managed by cast immobilization. Further
compromise can be seen in a poorly padded cast or one that extends beyond the distal palmar
crease and prohibits early digit active motion (Fig. 10A, B). The probability of decreasing the
related soft tissue swelling is greatly diminished if active finger range of motion is impaired.
Immediate circumferential cast immobilization should be avoided in the majority of patients
with distal radius fractures due to the potential complication related to constriction of the skin,
soft tissue, and median nerve. A thoroughly bivalved cast or sugar tong splint will provide equiv-
alent fracture stabilization within diminished likelihood of soft tissue compromise.
Fig. 6. (A, B) Radiographs of a intricate wrist injury comprised of a concomitant scaphoid and distal radius fracture
along with intrinsic compartment syndrome and median nerve impalement. (C,D) Preoperative assessment of soft tissue
component of injury with well placed incisions for intrinsic compartment decompression and median nerve release along
with internal fracture fixation. (E,F,G) Intraoperative findings of median nerve direct injury, with displaced volar
fracture fragments, followed by reduction and plate fixation. (H) Long-term follow-up radiograph confirming successful
union with restored carpal and radius alignment.
Fig. 7. (A) Lateral radiograph of a dorsally displaced distal radius fracture with considerable displacement and
associated neuropathy of the median nerve. (B) Closed reduction with slight improvement in nerve complaints and
incomplete fracture realignment. (C) Post-operative restoration of skeletal alignment after external fixation.
Fig. 8. (A) Preoperative radiograph of a dorsal malunion of the distal radius with persistent median neuropathy. (B) Post
reduction restored alignment of the fracture with internal fixation. Carpal tunnel decompression was performed at the time
of osteotomy. (C) Preoperative radiograph of a volar distal radius malunion with associated median nerve symptoms.
(D) Post reduction radiograph of long-term results after nerve decompression, bone grafting, and plate fixation.
Fig. 9. (A) Unstable distal radius nonunion with dorsal collapse after previous volar buttress plating. The patient
demonstrated a recurrent carpal tunnel syndrome. (B) Postoperative radiograph after median nerve decompression,
neurolysis, removal of hardware and internal fixation.
Special considerations
Pre-existing median neuropathy
There are several specific factors to consider when managing a senior patient with a distal
radius facture who has a concomitant carpal tunnel syndrome. The most common concern is
a pre-existing median neuropathy in which the patient is either aware of prior to the fracture,
or one that may have had some clinical resolution over the years. A medical history of long-
standing diabetes or thyroid disease may also confuse the presentation of a median nerve con-
tusion. A thorough history and physical examination is essential in determining the nature of a
previous existing condition and identifying associated thenar atrophy. Oftentimes, closed reduc-
tion with restored skeletal alignment will significantly relieve the acute symptoms in the elderly
patients and restore them to their previous state of nerve function.
Fig. 10. (A, B) Poorly applied cast for an unstable distal radius fracture with a high potential to result in soft tissue
compromise, median nerve damage, stiff digits, and possible compartment syndrome.
Pediatric epiphyseal fracture dislocations
Severely displaced epiphyseal fractures in young children and adolescents can be associated
with significant soft tissue injury (Fig. 11A, B). Median nerve damage is uncommon in the
younger population, and transient symptoms are often due to the degree of initial displacement.
Median nerve symptoms will resolve in the pediatric patient with great consistency after fracture
reduction. As in adults, it is equally important in children to avoid forceful manipulation or
tight casts in a hyperflexed posture. In the rare occurrence that the fracture displacement and
inherent instability would require extreme wrist flexion then percutaneous smooth wire fixation
in conjunction with splint immobilization should be considered and may optimize fracture sta-
bilization while avoiding further median nerve compromise.
Direct median nerve impalement in pediatric patients is extremely uncommon. If left un-
treated, permanent residual nerve dysfunction can occur. Early detection through physical
examination and radiographic assessment is essential in promoting prompt surgical decom-
pression and fracture fixation (Fig. 12A–G).
Personal experience
There is a great potential for most median nerve symptoms associated with fractures of the
distal radius to resolve with non-operative management. Care for the median nerve must begin
at the initial time of fracture management. A thorough history and initial physical examination
is essential. The closed reduction technique must be inclusive of a well-positioned patient and
upper extremity along with longitudinal traction prior to manipulation and the fracture site.
A well-padded bivalve cast can then be applied while avoiding the extremes of flexion and ulnar
deviation. The patient is instructed to begin immediate active digit range of motion with the arm
elevated in the proper position.
In the majority of patients the initial carpal tunnel symptoms will gradually diminish and
soon resolve after appropriate reduction and immobilization. Close follow-up during the first
several days after fracture reduction is suggested for those patients with associated carpal tunnel
syndrome.
If during the time between emergency care and follow-up, the fracture demonstrates signifi-
cant instability and displacement, skeletal fixation should be considered. Typically, if minimal
residual median nerve symptoms are present at the time of surgery, which have decreased in in-
tensity after initial reduction, there will be a continued resolution in most cases following accu-
rate skeletal reduction and rigid fixation. If there is persistence or progression of median nerve
symptoms, however, carpal tunnel decompression should be performed at the time of definitive
surgical fracture management. Patients with a history of long-standing carpal tunnel syndrome
should also undergo median nerve decompression at the time of fracture fixation.
In those rare cases in which acute symptoms are rapidly progressive in nature despite the pre-
viously mentioned initial measures of fracture reduction, emergent decompression within the
Fig. 11. (A) Salter Harris Type II displaced fracture of the distal radius in a child associated with median nerve
hypoesthesias. (B) Post reduction lateral radiograph in a bivalved cast with restored position at the fracture site. The
median symptoms resolved after reduction.
Fig. 12. (A, B) PA and lateral radiographs of a severely unstable epiphyseal fracture of the distal radius with associated
clinical signs of direct median nerve injury. (C) Clinical presentation of distal forearm, with volar hematoma. (D)
Incision site. (E) Initial dissection revealing hemorrhagic changes within the median nerve. (F) Decompression and
neurolysis completed. (G) Direct nerve impalement from the displaced fracture fragment penetrating through the
pronator quadratus muscle.
first 24 to 48 hours along with fracture stabilization is recommended. In the authors’ experience
these patients often have experienced an extremely high velocity injury with considerable initial
fracture displacement, hematoma formation, and soft tissue edema. Based upon the history,
physical findings, and fracture configuration a high index of suspicion should be maintained
in those cases where severe displacement occurred or direct facture impalement may be present.
The authors’ preferred surgical technique for median nerve decompression in association
with distal radius fractures is inclusive of an extended carpal tunnel incision, which spans the
proximal palmar region of the hand across the volar wrist crease in a curvilinear fashion to
the distal forearm avoiding the palmar cutaneous branch of the median nerve. The antebrachial
and palmar fascia are incised followed by identification of the median nerve proximal to the
transverse carpal ligament. Under direct visualization the ulnar border of the transverse carpal
ligament is then divided and reflected. The hematoma is evacuated, and an external neurolysis
performed. The palmar cutaneous branch should be routinely identified and protected prior to
deeper dissection for fracture fixation (Fig. 13A–D).
Most patients with distal radius dosal or volar malunions that have associated median nerve
dysfunction should undergo carpal tunnel decompression at the time of corrected osteotomy
because of the chronicity of the condition and poor potential for recovery with observation
alone (Fig. 14A, B).
Summary
The growing understanding of the pathoanatomy of distal radius fractures is inclusive of

associated soft tissue injuries. Foremost amongst these potential sites of related trauma is the
median nerve due to its proximity to the distal radius, its confinements within the boundaries
of the carpal tunnel, and its sensitivity to deformity and compression. Comprehensive treatment
for median nerve entrapment is comprised of accurate fracture reduction, soft tissue consider-
ations during manipulation and immobilization, careful patient follow-up, and surgical decom-
pression when indicated.
Fig. 13. (A) Skin incision for median nerve decompression in cases associated with distal radius fractures. (B) Palmar
and antebrachial fascia are released to the level of the distal forearm. (C) Transverse carpal ligament is released along the
ulnar border under direct visualization. (D) Hematoma evacuation and external neurolysis of the median nerve.
Fig. 13 (continued )
Fig. 14. (A, B) Pre- and post-operative lateral radiographs of a dorsally displaced distal radius malunion with associated
carpal tunnel syndrome.
References
[1] Abbott LC, Saunders JB. Injuries of the median nerve infractures of the lower end of the radius. Surg Gynec and
Obstet 1933;57:507–16.
[2] Bauman TD, Gelberman RH, Mubarak SJ, Garfin SR. The acute carpal tunnel syndrome. Clin Orthop 1981;
156:151–6.
[3] Kozin SH, Wood MB. Early soft-tissue complications after fractures of the distal part of the radius. J Bone Joint
Surg 1993;75A:144–53.
[4] Mack GR, McPherson SA, Lutz RB. Acute median neuropathy after wrist trauma. Clin Orthop 1994;300:141–46.
[5] McCarroll HR. Nerve injuries associated with wrist trauma. Orthop Clin N Am 1984;15:279–87.
[6] Paley D, McMurtry RY. Median nerve compression by volarly displaced fragments of the distal radius. Clin Orthop
1987;215:139–47.
[7] Stewart HD, Innes AR, Burke FD. The hand complications of Colle’s fractures. J Hand Surg 1985;10B:103–6.
[8] Cooney WP, Dobyns JH, Linscheid RL. Complications of Colles’ fractures. J Bone Joint Surg 1980;62A:613–19.
[9] Ford DJ. Acute carpal tunnel syndrome complications of delayed decompression. J Bone Joint Surg 1986;68B:
758–9.
[10] Dressing K, Peterson T, Schmit-Neuerburg KP. Compartment pressure in the carpal tunnel in the distal fractures of
the radius. Arch Orthop Trauma Surg 1994;113:285–89.
[11] Gelberman RH, Szabo RM, Mortensen WW. Carpal tunnel pressures and wrist position in patients with Colles’
fractures. J Trauma 1984;24:747–9.
[12] Kongsholm J, Olerud C. Carpal tunnel pressure in the acute phase after Colles’ fracture. Arch Orthop Trauma Surg
1986;105:183–6.
[13] McClain EJ, Wissinger HA. The acute carpal tunnel syndrome: nine case reports. J Trauma 1976;16:75–8.
[14] Altissimi M, Antenucci R, Fiacca C, Mancini GB. Long-term results of conservative treatment of fractures of the
distal radius. Clin Orthop 1986;206:202–10.
[15] Lewis MH. Median nerve decompression after Colles’ fracture. J Bone Joint Surg 1978;60B:195–6.
[16] Aro H, Koivunen T, Katevuo K, Nieminen S, Aho AJ. Late compression neuropathies after Colles’ fractures. Clin
Orthop 1988;233:217–25.
[17] Wainapel SF, Davis L, Rogoff JB. Electrodiagnostic study of carpal tunnel syndrome after Colles fracture. Am J
Phys Med 1981;60:126–31.
Combined carpal tunnel and ulnar nerve release

Paul C. Dell, MD*, Dean W. Smith, MD
Department of Hand and Microsurgery, University of Florida Medical Center,
200B SW 62nd Boulevard, Gainesville, FL 32607, USA
An estimated 35% to 40% of patients presenting with documented carpal tunnel syndrome
also have concomitant symptoms of ulnar nerve compression at the wrist [1,2]. Sedal et al [1]
reported abnormalities of nerve conduction velocities of the ulnar nerve in ~40% of patients with
documented carpal tunnel syndrome. Silver [2] reported in 1985 that 34% of patients with carpal
tunnel syndrome had abnormalities in sensibility testing of both median and ulnar nerves by
Semmes-Weinstein monofilament testing. While some authors recommend release of the ulnar
nerve simultaneously in all cases of patients presenting with clinical abnormality, others recom-
mend release of the ulnar nerve only under specific instances [3,4].
Silver et al [2] evaluated 59 patients with documented carpal tunnel syndrome that underwent
carpal tunnel release. Twenty of the 59 patients had preoperative combined median and ulnar
nerve sensory abnormalities as determined by Semmes-Weinstein monofilament testing. With
electromyographic testing across the wrist, five of these patients had an abnormal sensory
latency of the ulnar nerve, and an additional seven had abnormal ulnar motor latencies. Follow-
ing release of the transverse carpal ligament 89% of patients reported a decrease in paresthesias
in the distribution of the ulnar nerve. With Semmes-Weinstein testing 94% had improved light
touch sensibility. The authors concluded that simultaneous median and ulnar nerve release was
not indicated, and that one might expect improvement of ulnar nerve dysfunction following car-
pal tunnel release. They felt that upon release of the transverse carpal ligament there were alter-
ations in Guyon’s canal, which decreased compression of the ulnar nerve (Fig. 1). These findings
were later confirmed by Ablove et al [5] through MRI studies. As part of a prospective study,
pre- and post-operative MRIs were performed to evaluate the effects of endoscopic release. The
mean increase in carpal canal volume was 1.4 cc. The shape of Guyon’s canal also changed post-
operatively from a triangular to a more rounded appearance, further substantiating that release
of the transverse carpal ligament does indeed alter the anatomy of the neighboring Guyon’s
canal. Despite these objective measurements, there still remains firm indication for the simulta-
neous release of both nerves at the wrist.
Ectopic calcification within the transverse carpal ligament as a result of metabolic abnormal-
ities [6] substantially alters its elasticity. In this instance, release of a symptomatic ulnar nerve
would be indicated. If Guyon’s canal is not released, improvement post-operatively in the ulnar
nerve symptoms can be unpredictable. Thermal burns involving the wrist area can also present
with clinical signs and symptoms of median and ulnar nerve compression neuropathy. In
patients presenting with sensory changes involving both nerves, 50% had abnormal EMGs of
the median nerve and 60% had an abnormality of the ulnar nerve [7]. In this case, both the
median and ulnar nerves should be released to improve predictable recovery. Because of changes
in elasticity within the transverse carpal ligament in cases involving ectopic calcification or thermal
injury, isolated release of the transverse carpal ligament would not predictably decrease pressure
within the canal of Guyon. Simultaneous release of both nerves is therefore indicated.
E-mail address: paul@ortho.ufl.edu (P.C. Dell).
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Fig. 1. Transverse section through carpal tunnel and Guyon’s canal. The ulnar nerve is variably overlying the carpal
tunnel.
Although large series report overall good results after carpal tunnel release [8], there exist a
group of patients who experienced either no relief or only transient relief after surgical treat-
ment. This persistence might be related to inaccurate diagnosis, incomplete release, or inappro-
priate incision. If the skin incision is placed too radially there is a tendency for invagination of
the cutaneous scar, which might cause adhesions of the nerve to the skin. Re-exploration is
indicated in individuals who have incomplete release or scar adhesions. During re-exploration
the authors routinely release the volar carpal ligament and Guyon’s canal. In situations in which
there is scarring between the nerve and the skin the fat pad transfer (as described by Strickland
[9]) or transfer of the abductor digiti minimi [10] might be indicated. The technique of simulta-
neous median and ulnar nerve releases at the wrist decrease the incidence of recurrence. The
authors have slightly modified the technique of surgical release as described by Taleisnik [11]
Fig. 2. Skin incision in palm can be extended across the wrist as needed.
Fig. 3. View through skin incision ulnar artery can be seen entering Guyon’s canal.
P.C. Dell, D.W. Smith / Atlas Hand Clin 7 (2002) 273–276 275
to decrease the incidence of injury to the palmar cutaneous nerves of both the ulnar and median
nerves. A 6 to 8 cm palmar curved longitudinal incision is made in midline of the axis of the
ring finger. The incision crosses the wrist in an ulnar direction at an angle of 45 for 1 to 2 cm
before turning back in a sharp 45 angle towards the midline of the forearm, where it can be
extended proximally in a longitudinal manner as needed (Fig. 2). Dissection is deepened
through the palmar subcutaneous fat and palmar fascia. The ulnar artery is easily identified
entering Guyon’s canal (Fig. 3) and the volar carpal ligament is released. Once the volar carpal
Fig. 4. (A, B) The volar carpal ligament has been incised and the ulnar artery and nerve retracted ulnarly to reveal the
transverse carpal ligament.
276 P.C. Dell, D.W. Smith / Atlas Hand Clin 7 (2002) 273–276
ligament is released the ulnar nerve and artery can be retracted ulnarly, exposing the transverse
carpal ligament. A longitudinal incision is then made in the transverse carpal ligament, just
radial to the hook of the hamate (Fig. 4A, B). Following release of the transverse carpal liga-
ment the tendons can be retracted and the nerve inspected by reflecting the transverse carpal
ligament radially. If there are adhesions within the carpal, a neurolysis is performed. An epi-
neurectomy is not performed on a routine basis. The skin is then closed with interrupted nylon
sutures. A compressive soft dressing is applied, a splint is incorporated, and the patient is
instructed on early range of motion of the fingers and wrist. The patient is advised to avoid
heavy lifting (>5 pounds) for the first 4 weeks post-operatively and to try to use the hand when
lifting with the wrist in neutral to avoid problems with subluxation of the flexor tendons.
In cases of re-operation for repeat carpal tunnel release in which the original surgery has been
done through a radial incision, the original incision is ignored and not incorporated into the sec-
ondary procedure. The more ulnar incision allows a generous flap to be developed over the me-
dian nerve to prevent a recurrent neurocutaneous adhesion. If an interposition of tissue between
the skin and nerve is deemed necessary, the proximally based abductor digiti minimi muscle flap
can be transferred directly over the median nerve, where it is splayed out. Clinically, the authors
have found this to be helpful in cases of revision carpal tunnel release.
The authors feel that in instances in which there is loss of elasticity of the transverse carpal
ligament—such as in burns, ectopic calcification, or repeat surgery—simultaneous release of
both nerves is more predictable than solely releasing the median nerve. In instances of primary
carpal tunnel surgery in which there are preoperative ulnar nerve, clinical, and even EMG
changes, release of the ulnar nerve is not indicated at the time of carpal tunnel release.
References
[1] Sedal L, McLeod JG, Walsh JC. Ulnar nerve lesions associated with the carpal tunnel syndrome. J Neurol
Neurosurg Psychiatry 1973;36:118–23.
[2] Silver MA, Gelberman RH, Gellman H, et al. Carpal tunnel syndrome: associated abnormalities in ulnar nerve
function and the effect of carpal tunnel release on these abnormalities. J Hand Surg 1985;10A:710–3.
[3] Shea JD, McClain EJ. Ulnar nerve compression syndromes at and below the wrist. J Bone Joint Surg 1969;
51A:1095–102.
[4] Dupont C, Cloutier GE, Prevost Y, et al. Ulnar tunnel syndrome at the wrist. A report of four cases of ulnar nerve
compression at the wrist. J Bone Joint Surg 1965;47A:757–61.
[5] Ablove R, Peimer C, Diao E, et al. Morphologic changes following endoscopic and two-portal subcutaneous carpal
tunnel release. J Hand Surg 1994;19A:821–6.
[6] Hecht O, Lipsker E. Median and ulnar nerve entrapment caused by ectopic calcification: report of two cases. J Hand
Surg 1980;5A:30–1.
[7] Fissette J, Onkelinx A, Fandi N. Carpal and Guyon tunnel syndrome in burns at the wrist. J Hand Surg 1981;
6A:13–5.
[8] Inglis AE, Straub LR, Williams CS. Median nerve neuropathy at the wrist. Clin Orthop 1972;83:48–54.
[9] Strickland JW, Idler RS, Lourie GM, et al. The hypothenar fat pad flap for management of recalcitrant carpal
tunnel syndrome. J Hand Surg 1996;21A:840–8.
[10] Dell PC. Unpublished data.
[11] Taleisnik J. The palmar cutaneous branch of the median nerve and the approach to the carpal tunnel. An
anatomical study. J Bone Joint Surg 1973;55A:1212–7.
Secondary carpal tunnel surgery

Jess Ting, MDa,*, Andrew J. Weiland, MDb
a
Division of Plastic and Reconstructive Surgery, Mount Sinai School of Medicine, Mount Sinai Hospital,
One Gustave Levy Place, New York, NY 10029, USA
b
Department of Orthopedic Surgery, Weill-Cornell Medical School, Hospital for Special Surgery,
525 East 71st Street, New York, NY 10021, USA
Carpal tunnel release is the most commonly performed hand operation in America. In
the majority of cases, surgery is successful and treatment of this condition remains a gratifying
pursuit for patient and surgeon alike. As the number of carpal tunnel surgeries increases, how-
ever, it has become apparent that a significant minority of patients have outcomes from primary
carpal tunnel surgery that are less than ideal. The incidence of secondary carpal tunnel syndrome
is difficult to quantify, due in part to variations in outcome measures and inclusion criteria.
Langloh and Linscheid reported a rate of 34 recurrences in 2053 median nerve decompressions
(1.6%) in 1972, but this was not a longitudinal study so a true incidence is difficult to extrapolate
[1]. Kulick et al published a retrospective study of the long-term effects of carpal tunnel release
in 130 hands in 1986 [2]. Their failure rate, with failure being defined as persistence of any pre-
operative symptoms, was 19% with an average of 4 years of follow-up. A review of the literature
reveals that the definition of a ‘‘failed’’ carpal tunnel release is highly variable, as there are no
universally accepted criteria for success or failure. Many patients obtain only partial relief of
symptoms, confounding outcome analysis. In addition, both the success rate and recurrence rate
will vary with the length of follow-up. In actuality, the term ‘‘recurrent carpal tunnel syndrome’’
is a misnomer, as the ‘‘syndrome’’ is actually a heterogeneous group of disorders. In very broad
terms, patients with poor outcomes after carpal tunnel surgery can be classified into different
categories based upon clinical presentation [3,4]. This classification, while somewhat arbitrary,
is helpful in guiding the diagnosis and treatment.
Classification
In overview, patients with recurrent carpal tunnel syndrome can be separated into three
broad categories: those who never obtain improvement in symptoms after surgery (persistent
symptoms), those who are improved for a period of time but then develop recurrent symptoms
(recurrent symptoms), and those who develop entirely new and different symptoms after their
surgery (new symptoms).
In the first group (persistent symptoms), a detailed history will reveal that there was no period
of time after surgery during which symptoms of pain, numbness, or paresthesias improved.
Post-operative symptoms are identical or very similar to preoperative ones. In this group of
patients, there are several possible modes of failure: incomplete decompression of the median
nerve (usually at the distal end of the transverse carpal ligament or at the antebrachial fascia of
the distal forearm) or incorrect diagnosis (eg, the patient diagnosed with carpal tunnel syndrome
is in fact suffering from pronator syndrome or cervical radiculopathy). In addition, some
patients have multiple focal compressions of the median nerve, the so-called ‘‘double-crush’’
syndrome, where relieving the more distal lesion unmasks the more proximal lesion and results
E-mail address: ting_jess@yahoo.com (J. Ting).
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in treatment failure. These proximal nerve compression syndromes can usually be diagnosed on
the basis of a provocative physical examination and focused history, but must be specifically
searched for. Electrophysiologic studies specifically examining more proximal regions of the
median nerve may help elucidate the diagnosis. Incomplete decompression of the median nerve
is a diagnosis of exclusion. If the physical exam and electrophysiological studies are negative
for more proximal nerve compression in a patient with persistent symptoms, one can assume that
the etiology of failure is incomplete decompression of the median nerve at the wrist and treat the
patient accordingly.
In the second group, patients have a period of improvement after surgery, but then develop
recurrent symptoms. The fact that these patients have improvement, no matter how short-lived,
indicates that the surgery was a technical success (ie, that the median nerve was successfully
decompressed). The recurrence of symptoms can result from a number of theoretical factors:
fibrosis and scarring of the nerve, reformation of the transverse carpal ligament, or traction
neuropathy, to name a few. In some patients there may be pathologic post-operative scarring
and fibrosis around the median nerve. Why some patients develop excessive amounts of scarring
and fibrosis after carpal tunnel release is unknown. Theoretical risk factors include occult hema-
toma in the carpal tunnel, subclinical infection, prolonged immobilization, or a genetic predis-
position to exuberant scar formation. In reality, it is probably some combination of these
factors. Alternatively, reformation of the transverse carpal ligament could account for recur-
rence of symptoms. It is common on secondary exploration of the carpal tunnel to note a struc-
ture similar in appearance to the intact transverse carpal ligament. This represents either a
healed ligament or well-organized scar tissue. In either case, it is a small conceptual leap to pos-
tulate that this structure, whatever its origin, could result in secondary compression of the
median nerve. In another possible explanation, Hunter espouses the theory of unrecognized
traction neuropathy as an etiology for recurrent carpal tunnel syndrome [5–7]. According to this
theory, the mechanism of recurrent symptoms in these patients is adhesion of the median nerve to
surrounding structures which prevents normal nerve gliding. This results in intermittent nerve
dysfunction during provocative wrist motion. Symptoms begin 6 weeks after carpal tunnel
release and become progressively worse with use and therapy. The recommended treatment in
these cases is, according to Hunter, carpal tunnel exploration through an extended incision,
extensive neurolysis and lysis of adhesions of the nerve, and reconstruction of the gliding sur-
face of the transverse carpal ligament and antebrachial fascia [5,6]. In an alternative approach,
Plancher et al [8] advocate the interposition of the vascularized hypothenar fat pad flap between
the median nerve and the radial leaf of the transverse carpal ligament to prevent adhesion
formation in secondary carpal tunnel surgery. Numerous other vascularized flaps have been
described and are discussed in the section below.
In the third group, patients develop distinctively new symptoms after carpal tunnel release.
The types of problems seen in this group are myriad, relating to nerve, tendon, and vascular
systems. Most of these injuries are iatrogenic and treatment should be tailored to the pathology.
The authors discuss specific complications by type below.
Nerve complications
Virtually every nerve of the hand has been implicated as a source of post-operative compli-
cations after carpal tunnel surgery. These include the palmar cutaneous branch of the median
nerve, the recurrent motor branch of the median nerve, the main trunk of the median nerve,
the ulnar nerve, and the superficial sensory branch of the radial nerve. The palmar cutaneous
branch of the median nerve, which runs between the tendons of the flexor carpi radialis and
palmaris longus in the distal forearm, is the most commonly injured nerve during carpal tunnel
release, especially with poorly planned incisions that extend radial to the palmaris longus ten-
don. Injuries can be partial with resultant neuromas, or complete transections. Compression of
the nerve, which runs in its own compartment, has also been reported [9]. Patients with palmar
cutaneous nerve injuries usually have an area of numbness in the palm and a positive Tinel’s
test over the area of injury. The area can be exquisitely sensitive to touch, out of proportion to
the apparent degree of injury and can serve as a ‘‘nidus’’ for the subsequent development of
J. Ting, A.J. Weiland / Atlas Hand Clin 7 (2002) 277–286 279
complex regional pain syndrome (RSD). The recurrent motor branch of the median nerve, which
supplies the thenar musculature, can be injured during carpal tunnel surgery. Its anatomy has
been the subject of considerable study and debate. Leaving the main trunk of the median nerve
approximately at the level of the first web space, its branching pattern is quite variable, passing
distal to the transverse carpal ligament or within the substance of the ligament itself. It is for this
reason that the authors advocate incising the transverse carpal ligament along its ulnar border
and avoiding a dissection of the motor branch unless specifically indicated. Injury to this nerve
manifests as profound weakness and atrophy of the abductor pollicis brevis muscle, or as failure
to recover thenar bulk and strength after surgery. The main trunk of the median nerve can also
be injured, with the severity of injury running the gamut from partial injuries with neuroma for-
mation to complete transection. Because of the internal topography of the nerve, with the most
superficial fibers being those supplying the third web space, partial injuries usually will affect
these fibers first and post-operative anesthesia of this area is sensitive marker for injury. Another
woeful complication of carpal tunnel surgery is the development of a painful scar. Most likely
related to aberrant re-innervation of palmar skin after damage to small sensory nerves, the
mainstay of treatment is desensitization techniques. Preventative techniques are aimed at avoid-
ing injury to the palmar cutaneous branches of the ulnar and median nerves. In intractable
cases, symptoms may be ameliorated by the interposition of tissue flaps between skin and under-
lying structures. This is discussed in detail below.
Vascular complications
The most commonly damaged vascular structure during carpal tunnel surgery is the superfi-
cial palmar arch [10]. Unrecognized injury to this structure can result in massive post-operative
hematoma and ischemia of the overlying palmar skin. Distal skin incisions and inappropriate
distal dissection can result in injuries to the common digital arteries. Unless frank hematoma
is noted, these injuries will commonly go undetected due to the redundant circulation at this
level. Nonetheless, the authors do not routinely release the tourniquet prior to closing the skin
incision unless there is a question of a vascular injury intraoperatively. Prevention of these
complications relies on adequate visualization of the operative field and the avoidance of blind
dissection in the palm. The surgeon must also be cognizant of possible arterial variations in the
hand, such as a patent median artery or aberrant palmar arch.
Tendon complications
The two most commonly cited tendon problems after carpal tunnel surgery are bowstringing
of the flexor tendons and trigger fingers. Both of these complications may be related to the loss of
the pulley effect of the transverse carpal ligament. In a cadaveric study of tendon excursion
following carpal tunnel release, Kiritsis et al found a 26% increase in FDP excursion and bow-
stringing of the tendons with the wrist in 20° to 30° of wrist flexion [11]. To prevent bowstring-
ing, many hand surgeons will immobilize the wrist for 1 to 2 weeks post-operatively to allow
partial healing of the ligament. Several early studies supported this practice on an empiric basis
[10,12], but two more recent prospective, randomized studies found no increased incidence of
bowstringing in patients treated without post-operative immobilization. Indeed, Cook et al
[13] found that the only significant differences between the experimental groups were a delay
in return to work and strength recovery, and increased pain and scar tenderness at the 1 month
visit in the immobilized group. Other authors advocate reconstruction of the transverse carpal
ligament, either by direct suture of the two ends of the transverse carpal ligament, by suturing
one end of the transverse carpal ligament to the other cut end of the palmar aponeurosis to cre-
ate a ‘‘neo-ligament,’’ or by any one of a number of step-lengthening or transposition techniques
[14–18]. Netscher et al found that patients having reconstruction of the transverse carpal liga-
ment by the transposition technique had an increased pinch and grip strength at 12 weeks com-
pared to patients without ligament reconstruction, although the improvement was modest [18].
Many authors have noted the association between carpal tunnel syndrome and trigger fingers
[10,19–22]. This association may be due to shared underlying risk factors, such as non-specific
flexor synovitis, or to alteration of tendon mechanics following carpal tunnel release. Some the-
orize that the loss of the transverse carpal ligament places more stress on the next most distal
pulley, the first annular pulley, resulting in the increased triggering. More than likely, it is a com-
bination of these and other factors that accounts for the association.
Minimally invasive carpal tunnel release
The advent of the minimally invasive carpal tunnel release has led to an in-depth examination
of the complications of this technique. While the incidence of certain complications after min-
imally invasive carpal tunnel release may differ from those seen with open release, the nature of
the complications and their treatment are similar. One of the most commonly cited complica-
tions is an incomplete release of the transverse carpal ligament. While overall success rates
are high and probably comparable to those obtained after open surgery, considerable attention
has been devoted to the development of secondary carpal tunnel syndrome after endoscopic
release. Because this is still a relatively new procedure, there are only a handful of studies on
revision surgery in this population. Hulsizer et al published their study of the success rate of
revision surgery after endoscopic versus open carpal tunnel release in 1998 [23]. In this study
13 wrists that had previous endoscopic release and 17 wrists with prior open release underwent
secondary carpal tunnel release. The success rate was significantly higher in the endoscopic
group (77%) than in the open group (47%), which the authors attributed to the higher incidence
of incomplete release in the endoscopic group. Of note, worker’s compensation patients had an
18% success rate versus 84% for privately insured patients. In another study, Varitimidis et al
operated on 22 patients (24 wrists) that had had previous endoscopic release [24]. Two patients
were found to have transactions of the median nerve, one partial and one complete at the time of
revision carpal tunnel surgery. The remaining 20 patients (22 wrists) were all found to have an
incomplete release. Of these, all 20 patients (22 wrists) had resolution of night pain, returned to
work, and had improved strength and two-point discrimination after secondary carpal tunnel
release.
Treatment
Secondary carpal tunnel release
The technique employed in secondary carpal tunnel release varies with the etiology of disease
and the precise pathology found. For example, in patients with persistent symptoms who do not
have evidence of a more proximal nerve lesion, the technique is limited to re-release of the
median nerve. If more proximal lesions exist (eg, pronator syndrome) they are addressed
separately. If a short-scar technique was used at the first surgery, the threshold for converting
to a long-scar technique is low. The incision is extended across the wrist crease with an ulnar
dart. This extension enables release of the distal antebrachial fascia under direct visualization.
The transverse carpal ligament, which may have reformed by the time of secondary carpal
tunnel release, is opened, paying particular attention to the distal end of the ligament. In these
patients with persistent symptoms, treatment limited to re-release of the transverse carpal liga-
ment and antebrachial fascia is usually successful.
Patients with recurrent symptoms are treated with a lower threshold for performing ancillary
procedures than patients with persistent symptoms. The re-release of the transverse carpal
ligament and antebrachial fascia is performed in a manner similar to that above. During re-
exploration, however, particular attention is paid to rule out other treatable causes of secondary
compression. If there is extensive synovitis, a synovectomy should be performed with specimens
sent for pathologic examination. This is particularly relevant in the chronic hemodialysis pop-
ulation, in whom deposition of b-2-microglobulin is a cause of secondary carpal tunnel syn-
drome [25]. The median nerve is inspected and its pathology staged. If there is extensive
perineural fibrosis and scarring, an external neurolysis, or epineurotomy is performed. After
epineurotomy, if there appears to be pathology within the median nerve itself, an internal neu-
rolysis should be considered.
Internal neurolysis
The authors define internal neurolysis as the incision or excision of epineurium followed by
an extrafascicular dissection of individual nerve fascicles, preserving the perineurium of individ-
ual fascicles (see Fig. 1). While the technique has its roots much earlier in the century, it was the
landmark paper by Curtis and Eversman in 1973 that sparked tremendous interest in the tech-
nique [26]. In their paper, Curtis and Eversman reported excellent results in the application of
internal neurolysis in patients with advanced carpal tunnel syndrome, with 94 of 95 patients
(99%) demonstrating improvement in sensory function and 37 of 39 patients (95%) showing
improvement in motor function. While several early reports from Europe were supportive of
the technique, these were non-controlled, retrospective studies [27]. The majority of prospective,
controlled studies have clearly refuted the benefit of internal neurolysis in primary carpal tunnel
release. In one of the largest studies, Mackinnon et al published their series of 59 patients ran-
domized to carpal tunnel release with and without internal neurolysis, failing to note any
improvement in outcomes. Because of the small numbers of patients undergoing secondary car-
pal tunnel release, it is difficult to study internal neurolysis in this setting. To date, no studies on
the efficacy of internal neurolysis during secondary carpal tunnel release have been published.
Nonetheless, some practitioners of secondary carpal tunnel surgery do routinely employ internal
neurolysis [3,4], perhaps based upon the assumption that secondary carpal tunnel syndrome is
more likely to be related to interfascicular fibrosis and scarring than primary cases.
Fig. 1. Comparison of normal nerve, epineurotomy and internal neurolysis.

Surgical technique
Internal neurolysis is performed after the release of the transverse carpal ligament. Optical
magnification, either with surgical loupes or the operating microscope, is critical. The operation
is performed under tourniquet control using standard microsurgical instruments. After the
nerve is freed from surrounding scar and soft-tissue adhesions, the epineurium is grasped with
forceps and split with fine-tipped dissecting scissors. Fine retention sutures may be employed to
hold the edges of the epineurium apart. Millesi advocates circumferential excision of the epi-
neurium; most feel it is sufficient to incise the epineurium. The interfascicular soft-tissues are
then meticulously teased apart using sharp and blunt dissection, until individual nerve fascicles
can be visualized. Care is taken not to violate the perineurium of individual nerve fascicles.
Injury to palmar cutaneous branch
The palmar cutaneous branch of the median nerve is the most commonly injured nerve dur-
ing carpal tunnel release [3,4,10,28,29]. Treatment is directed at managing the painful neuroma.
The neuroma is excised and the nerve stump is redirected away from skin incisions and super-
ficial areas of the forearm. Using optical magnification, the palmar cutaneous branch can be
dissected back to its takeoff from the median nerve. As the injury is usually distal, this results
in a sufficient length of nerve to allow the cut end to be buried between the superficial and deep
flexor muscles [3,4] or within the pronator quadratus muscle [30]. Good results have been re-
ported with simply excising the entire nerve at its origin from the median nerve [31].
Median nerve injuries
Partial transections of the median nerve can result in painful neuromas and loss of sensitivity
and function in the hand. When faced with neuromas-in-continuity of the median nerve, the
clinician must balance the need to treat the neuroma with the desire to not to damage intact
portions of the nerve. A microscopic, interfascicular dissection to isolate specific nerve fascicles
involved in the neuroma while preserving unaffected fascicles addresses both these goals. After
interfascicular nerve dissection, only those fascicles involved in the neuroma are excised and
repaired with interpositional nerve grafts. Various donor nerves in the same extremity have been
described in addition to the commonly used sural nerve grafts. These include the terminal
branch of the posterior interosseus nerve, the anterior interosseus nerve, and the medial or lat-
eral antebrachial nerves [4]. Injuries to the motor branch of the median nerve are less common.
With isolated transection of the motor branch noted at secondary exploration, return of thenar
muscle function has been reported after direct repair of the nerve [32].
Vascularized flaps
Flaps have several applications in secondary carpal tunnel surgery. In situations where there
has been loss of soft tissue coverage of the median nerve, as can occur in wound infection, hema-
toma, or dehiscence, flaps function as vascularized soft-tissue coverage. The apposition of well-
vascularized tissue to the median nerve can have other salutary effects as well. First, flaps can
provide padding around the median nerve and can decrease the incidence of pillar pain. Sec-
ondly, by providing a well-vascularized bed they can deliver enhanced nutrition to the median
nerve, possibly inhibiting fibrosis and helping to restore gliding of the median nerve. Some
authors believe it is critical to interpose vascularized tissue between the median nerve and the
radial leaf of the transverse carpal ligament to prevent adhesion formation and traction
neuropathy [8]. Thirdly, by providing a physical barrier between the median nerve and overlying
skin, interpositional flaps may inhibit aberrant innervation of overlying skin and prevent the
formation of painful scars. Finally, a number of local flaps also function as motors for tendon
transfers. A dizzying variety of local and distant flaps have been described, including the abduc-
tor digiti minimi flap, the hypothenar fat pad flap, the palmaris brevis flap [33,34], the synovial
flap [35], the pronator quadratus flap [36,37], the first and second radial lumbrical flaps [38], and
reversed radial forearm flaps, as well as a number of microvascular free flaps. In addition, some
authors advocate the use of nonvascularized dermal fat grafts instead of vascularized flaps in
these situations [39]. Selected techniques are described below.
Abductor digiti minimi flap
Described originally as a motor transfer for opponensplasty, Huber, Leslie, and Ruby [40]
used the abductor digiti minimi (ADM) muscle flap for the coverage of carpal tunnel release
wound dehiscence. Kleinart and Spokevicius [41] subsequently described a modification of this
technique incorporating a skin paddle on the muscle belly and obviating the need for a split
thickness skin graft. When used as a Huber transfer, the ADM also restores the bulk of the
thenar eminence and improves the hand’s appearance.
Surgical technique
The ADM muscle is the most superficial muscle of the hypothenar eminence (Fig. 2). It orig-
inates from the pisiform bone and FCU tendon and inserts on the proximal phalanx and exten-
sor apparatus of the little finger. It abducts the little finger. The neurovascular bundle originates
from the ulnar artery and nerve just distal to pisiform bone and enters the muscle proximally
along its deep radial aspect.
The operation is performed under tourniquet control. The ADM muscle is approached
through a longitudinal incision along the ulnar border of the hand. If a skin paddle is to be used,
it is centered over the proximal two thirds of the fifth metacarpal, starting just distal to the pisi-
form bone and extending for a length of 2 to 3 cm. After the skin incision is made, the most
superficial muscle is identified. This is the ADM muscle. The incision is extended to the meta-
carpophalangeal joint and the insertion on the proximal phalanx and extensor apparatus is
released. During this maneuver, care is taken to preserve the digital nerves the fifth finger. The
ADM muscle is then dissected free in a distal to proximal direction. Guyon’s canal may be
opened at this point to facilitate identification of the neurovascular pedicle and to prevent kink-
ing after the muscle is rotated. Once the neurovascular bundle is identified, the proximal attach-
ments to the pisiform bone are divided. If the ADM muscle is to be used for soft-tissue coverage
only, the motor nerve and proximal attachments to the FCU tendon are divided. In a Huber
transfer, they are preserved. The ADM muscle, thus islandized, is then tunneled under the
hypothenar skin bridge and delivered into the carpal tunnel incision. The muscle is inset around
Fig. 2. Abductor digiti minimi (ADM) transfers: (A) abductor digiti minimi (ADM) anatomy; (B) ADM used for Huber
transfer; (C) ADM used for soft-tissue coverage.
Fig. 3. An axial illustration of hypothenar fat raised by subcutaneous dissection in an ulnar direction. (Courtesy of Gary
Schnitz, Indiana Hand Center.)
the median nerve, or attached to the APB tendon through a separate counter-incision if it is to
be used as a Huber transfer. The tourniquet is released and the viability of the muscle is asses-
sed. If there is questionable blood supply at this point, the insetting stitches can be released.
Skin graft, if it is to be used, is applied at this time.
Hypothenar fat pad flap
A number of authors have published reports on the use of the hypothenar fat pad flap in sec-
ondary carpal tunnel surgery with favorable results, reporting improvements in pain relief, grip
strength and overall satisfaction [8,42–45]. The flap is based on a pad of adipose tissue overlying
the hypothenar eminence superficial to the muscle layer. The fat pad receives its blood supply
from segmental arteries arising from the ulnar border of the ulnar artery in Guyon’s canal.
Surgical technique
The flap is raised through a standard carpal tunnel incision (Fig. 3). With the hypothenar
skin retracted superiorly with skin hooks by the assistant, the hypothenar fat pad is held infe-
riorly by the operating surgeon and a plane between the skin and fat pad developed with a scal-
pel for a distance of 2 cm. A fine layer of adipose tissue should be left on underside of the
hypothenar skin flap to preserve its blood supply. The underside of the fat pad is then under-
mined by blunt and sharp dissection in the plane between the fat pad and the ulnar leaf of
the transverse carpal ligament, stopping when the ulnar neurovascular bundle is identified. A
portion of the ulnar leaf of the ligament can be resected to facilitate this dissection. The ulnar
digital nerve to the fifth finger passes in close contact to the underside of the distal third of the
fat pad and must be vigilantly protected. The fat pad is then mobilized gently and sutured to
the radial wall of the carpal tunnel. The skin is closed in the usual fashion and the wrist is im-
mobilized for 4 weeks. Unrestricted motion is allowed at 6 weeks.
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Vein wrapping with autologous graft for recalcitrant

median nerve compression
Ioannis K. Sarris, MD, Dean G. Sotereanos, MD*
University of Pittsburgh, Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery,
Kaufmann Building, Suite 911, 5th Avenue, Pittsburgh, PA 15213, USA
Carpal tunnel syndrome has an incidence of 99 per 100,000 and a prevalence of 10% in the
general population [1,2]. Despite the high success rates reported in the literature after transverse
carpal ligament release, compression symptoms can re-occur. The general complication rate for
open carpal tunnel release is 5% to 15% [3–5] and for endoscopic carpal tunnel release it is 2% to
35% [6].
If the primary decompression was adequate, cicatrix (Fig. 1) that develops at the site of de-
compression surrounding the nerve is postulated to be the main reason for failure [7]. The mech-
anisms by which scar tissue might cause nerve dysfunction include the following: mechanical
constriction by circumferential scarring, nerve ischemia due to decrease in blood flow, loss of
nerve gliding, and subsequent traction to the nerve with joint motion.
Because a second decompression is generally not efficacious in recurrent compression neurop-
athy due to scarring [8], investigators have developed supplementary techniques to improve the
outcome of a second surgical procedure. Theoretically, neurolysis and the application of a scar
tissue barrier would be beneficial. Examples of barrier tissues that have been studied include fat
[5,9], muscle [10], fascia, and vein.
The ideal wrapping material should protect the nerve from compression by scar tissue, inhibit
tissue adhesions to the nerve, improve the gliding of nerves during motion of the extremity, and
decrease the scarring within the nerve trunk. An appropriate material should also resist degra-
dation, minimize inflammatory reaction, not induce immunologic reaction, and should not be a
source of long-term compression of the nerve.
History
The technique of vein wrapping was first described by Gould [11] for the treatment of painful
neuroma in-continuity. Masear [12] was the first to report clinical results with the use of vein
wrapping for recurrent median nerve compression. Since then several authors have reported
good results using this method.
Koman et al [13] used allograft umbilical vein for median nerve dysfunction with good
results. Masear et al [14] found no significant difference in the results between allograft versus
autograft vein in their series, although they agree that allograft adheres to the nerve. Ruch
et al [15] found a significant increase of inflammatory cells and scar tissue associated with
glutaraldehyde-preserved allograft in a rat model.
In the authors’ series [16] a saphenous autograft was used in 15 patients with good results.
The authors have also performed the first experimental study (in rats) in the literature for assess-
ing compressive neuropathy with the use of autogenous vein graft [17], noting that all parame-
ters improved in the vein grafted nerve compared to the control.
E-mail address: dsoterea@uoi.upmc.edu (D.G. Sotereanos).
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Fig. 1. Scar tissue around the median nerve at the wrist.
Surgical technique
Exposure of the median nerve
The approach used is the standard surgical approach for carpal tunnel release, but slightly
extended proximally and distally to expose the median nerve in an unscarred environment
(Fig. 2). General anesthetic is used due to the need for upper and lower extremity surgery. A
tourniquet is applied and the median nerve is identified proximally and traced distally into
the scarred area. The nerve is carefully neurolysed with 3.5 magnification until completely
freed of adhesions. Internal neurolysis is performed only if indicated. Indications include severe
compression and thinning of the nerve, lack of epineural vascularity, muscle wasting, and loss of
two points of discrimination.
Harvesting and preparation of the saphenous vein autograft
The ipsilateral or contralateral lower extremity is used for harvesting of the greater saphe-
nous vein. A longitudinal incision is made anterior to the medial malleolus. The required length
Fig. 2. Extensive approach of the median nerve at the wrist.

I.K. Sarris, D.G. Sotereanos / Atlas Hand Clin 7 (2002) 287–293 289
Fig. 3. Preparation of the vein graft in three stages.
of the vein is 3 to 4 times the scarred length of the nerve. A vein length of 25 to 30 cm is usually
adequate, and an incision is made accordingly. The authors prefer to harvest the vein graft with
a vein stripper to minimize the length of the incision and the morbidity of the donor site. The
remaining greater saphenous vein is ligated both proximally and distally before the excision of
the graft.
With the help of sutures, or skin hooks, the graft is held straight and is incised longitudinally,
using a pair of sharp scissors, to form a rectangle (Fig. 3).
Attachment and vein wrapping technique around the median nerve
With use of loupe magnification or microscope, one end of the vein graft is tacked distal to
the scarred portion (Fig. 4) of the nerve on a tissue that is not mobile. Then with the vein intima
against the nerve, circumferential wrapping distal to proximal is performed (Fig. 5). Each loop
of vein is sutured with a 7-0 prolene stitch to the previous loop. One must be careful to avoid
wrapping too tightly and constricting the nerve. Finally, the other end of the vein graft is tacked
Fig. 4. Distal attachment of the graft.

Fig. 5. Circumflex wrapping of the vein graft around the median nerve.
proximal to the scarred segment of the nerve on unscarred tissue (Fig. 6). The coverage of the
scarred nerve segment must be complete to prevent recurrent compression. During the wrapping
procedure, care is taken to avoid nerve traction or suturing of the vein to the median nerve.
Post-operative treatment
The wrist is immobilized in slight extension with a light splint for 1 week followed by active
and passive motion exercises.
The authors’ results
Based on clinical and experimental studies, the treatment of recurrent median nerve compres-
sion with autologous vein graft wrapping has been very promising.
In the authors’ clinical study 19 patients (15 for median nerve and 4 for ulnar nerve compres-
sion neuropathy due to scarring) were treated with this technique by the senior author (D.G.
Sotereanos) [16,18], with a mean follow-up of 43 (range 24 to 78) months and previous average
Fig. 6. Vein graft wrapping completed.

number of surgeries 3.3. All patients reported reduction in pain and the sensory disturbances
secondary to the compression of the median nerve. Two points of discrimination and electro-
diagnostic findings also improved. All patients were happy they had their operations performed,
and only one patient required re-operation for a neuroma 2 years after the initial procedure.
This patient had a vein wrapping procedure of the ulnar nerve for cubital tunnel syndrome;
2 years later the authors re-operated on her to treat a medial antebrachial cutaneous nerve
neuroma (Fig. 7). During the surgery the authors noted that the vein was intact around the
ulnar nerve and there was no scarring between the vein and the nerve [19]. A Freer-elevator
could easily be passed between the vein and the nerve (Fig. 8).
The authors’ experimental studies [17,20] have shown that the technique of autologous vein
wrapping for compressive neuropathy is effective, and minimal scar tissue forms between the
trunk of the nerve and the vein graft. The vein grafts had no adverse effects on the nerves.
Discussion
Mobilization of the nerve followed by internal neurolysis cannot alleviate problems due to
recurrent scarring. Most authors agree that soft tissue coverage is necessary to prevent this phe-
nomenon, and several options have been suggested. For recurrent carpal tunnel syndrome the
hypothenar fat pad flap can produce good results and it is uncomplicated in most cases [5,9].
Pedicle or free flaps, including the groin flap, lateral arm flap, and posterior interosseous flap,
provide excellent protection of the nerve, but the technique is complex and the result is not al-
ways satisfying [5,11]. Small local flaps such as the abductor digiti minimi, the palmaris brevis,
and the pronator quadrus have also been used [10,22]. Discussion of these free flaps is not al-
ways easy, however; nerve coverage is sometimes inadequate and skin-closing problems might
occur. The use of implanted peripheral nerve stimulators has been suggested to relieve pain re-
sulting from compressed or injured peripheral nerves [23,24], but failures have been reported in
many cases because of complications such as nerve injuries, skin problems, and early formation
of scar tissue due to silicone [11,21,23].
Masear et al [14] first reported the successful use of a vein graft for recurrent symptoms sec-
ondary to scarring of the nerve. Koman et al [13] and Gould [11] have also shown that the vein
graft wrapping technique can improve the recovery of nerve function in patients with chronic
refractory nerve symptoms secondary to cicatrix. Schon et al [25] did revision nerve release
and vein wrapping in 58 patients to relieve intractable lower extremity nerve pain, and they re-
ported good results in 77% of patients.
Fig. 7. Exposure of the neuroma of the medial antebrachial cutaneous nerve and of the vein wrapped ulnar nerve.
Fig. 8. (A) A freer elevator or (B) a forcept can easily pass between the nerve and the vein graft 2 years after the vein
wrapping procedure.
Summary
The authors believe that this procedure works by insulating the peripheral nerve from
surrounding cicatrix, thereby preventing adhesion formation between the nerve trunk and sur-
rounding tissues. In addition, the autogenous vein graft with its smooth inner surface should
improve the gliding of the nerve trunk during motion of the joint, decreasing gliding friction.
The procedure itself is a simple technique that causes minimal complications in the donor
area. In addition, the donor vein is readily available and harvesting is easy. The use of auto-
genous vein graft wrapping is mainly recommended by the senior author for treatment of recal-
citrant median nerve compression in cases in which two or more previous surgical procedures
have failed to resolve the problem.
References
[1] Herbert P, Schroender V, Botte MJ. Carpal tunnel syndrome. Hand Clin 1996;12:752–6.
[2] Yu GS, et al. Preoperative factors and treatment outcome following carpal tunnel release. J Hand Surg 1992;17A:
646–50.
[3] Bande S, Desmet L, Fabry G. The results of carpal tunnel release: open versus endoscopic techniques. J Hand Surg
1994;19B:14–7.
[4] McDonald RL, Lichtman DM, Hanlon JJ, Wilson JN. Complications for surgical release for carpal tunnel
syndrome. J Hand Surg 1978;3:70–6.
[5] Urbaniak JR. Complications of treatment of carpel tunnel syndrome. In: Gelderman RH, editor. Operative nerve
repair and reconstruction. Philadelphia: J.B. Lippincott; 1991. p. 967–79.
[6] Urbanic JR, Desai SS. Complications of nonoperative and operative treatment of carpal tunnel syndrome. Hand
Clinics 1996;12:325–35.
[7] Hunter JM. Recurrent carpal tunnel syndrome, epineural fibrous fixation, and traction neuropathy. Hand Clinics
1991;7:491–504.
[8] Cobb TK, Amadio PC, Leatherwod DF, Schleck CD, Ilstrup DM. Outcome of reoperation for carpal tunnel
syndrome. J Hand Surg 1996;21A:347–56.
[9] Plancher DH, Idler RS, Lourie GM, Strickland JW. Recalcitrant carpal tunnel: the hypothenar flap. Hand Clinics
1996;12:337–49.
[10] Rose EH, Norris MS, Kowalski TA, Lucas A, Fleger EJ. Palmaris brevis turnover flap as an adjust to internal
neurolysis of the chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg 1991;16A:
191–201.
[11] Gould JS. Treatment of the painful injured nerve in-continuity. In: Gelderman RH, editor. Operative nerve repair
and reconstruction. Philadelphia: J.B. Lippincott; 1991. p. 1541–9.
[12] Mesear VR, Colgin S. The treatment of epineural scarring with allograft vein wrapping. Hand Clinics 1996;12:
773–9.
[13] Koman AL, Neal B, Santichen J. Management of the post-operative painful median nerve at the wrist. Orthop
Trans 1995;18:765–9.
[14] Masear VR, Tulloss JR, Mary ES, Meyer RD. Venous wrapping of a nerve to prevent scarring. J Hand Surg
1990;15A:817–8.
[15] Ruch DS, Spinner RM, Koman LA, Challa VR, O’Farrel D, Levin SL. The histologic effect of barrier vein
wrapping of peripheral nerves. J Recon Microsurgery 1996;12:291–5.
[16] Sotereanos DG, Giannakopoulos PN, Mitsionis GI, Xu J, Herdon J. Vein graft wrapping for the treatmant of
recurrent compression of the median nerve. Microsurgery 1995;16:752–6.
[17] Xu J, Sotereanos DG, Moller AR, et al. Nerve wrapping with vein grafts in a rat model: a safe technique for the
treatment of recurrent chronic compressive neuropathy. J Reconstr Microsurg 1998;14:323–58.
[18] Varitimides SE, Vardakas DG, Goebel F, Sotereanos DG. Treatment of recurrent compressive neuropathy of
peripheral nerves in the upper extremity with an autologous vein insulator. J Hand Surg 2001;26A:296–302.
[19] Vardakas DG, Varitimidis SE, Grim JS, Ferraz I, Sotereanos DG. Exploration of the ulnar nerve at the elbow two
years after vein-wrapping. Pittsburgh Orthopedic J 2001;12:67–8.
[20] Xu J, Varitimides SE, Fischer KJ, Tomaino MM, Sotereanos DG. The effect of wrapping scarred nerves with
autogenous vein graft to treat chronic nerve compression. J Hand Surg 2000;25A:93–103.
[21] Rhoades CE, Mowery CA, Gelderman RH. Results of internal neurolysis of the median nerve for severe carpal
tunnel syndrome. J Bone Joint Surg 1985;67A:253–6.
[22] Botte MJ, von Schroeder HP, Abrams RA, Gelman H. Recurrent carpal tunnel syndrome. Hand Clinics 1996;12:
731–43.
[23] Nashold BS Jr, Goldner JL, Mullen JB, Bright DS. Long-term pain control by dorect peripheral-nerve stimulation.
J Bone Joint Surg 1982;64A:1–0.
[24] Monsivais JJ, Monsivais DB. Managing chronic neuropathic pain with implanted anesthetic reservoirs. Hand
Clinics 1996;12:781–6.
[25] Schon LC, Lam PW, Easley ME, Anderson CD, Lumsden DB, Shanker J, Levin GB. Complex salvage procedures
for severe lower extremity nerve pain. Clin Orthop 2001;391:171–80.
Local and distant flaps in recalcitrant

carpal tunnel surgery
James W. Fletcher, MDa, Detlev Erdmann, MDb,
L. Scott Levin, MDb,*
a
Department of Orthopaedic Surgery, P.O. Box 3945, Duke University Medical Center, Durham, NC 27710, USA
b
Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center,
Durham, NC 27710, USA
Surgical decompression of the transverse carpal ligament affords relief for the vast majority
of patients, but there exists a population of patients that continue to suffer from persistent par-
aesthesias, dysesthetic pain, weakness, or focal irritability of the median nerve [1,2]. Estimates of
treatment failures are between 0.3% and 20% in large series. This difficult clinical problem usu-
ally results in prolonged non-surgical management, perhaps followed by repeat surgery. Causes
of discomfort include painful neuroma at the surgical site, incomplete release of structures com-
pressing the median nerve, scarring, or devascularization [3]. Repeat release in combination with
neurolysis helps the majority of these patients.
Even after repeat surgery, there exists a small population who continue to suffer from median
nerve dysesthesias. There is evidence that a subset of these patients have scarring of the nerve to
the volar and or radial surface of the carpal canal producing traction and pain with wrist move-
ment [4]. Numerous operations have been designed to ameliorate the problem of recalcitrant
carpal tunnel. Although diverse, they are all designed to provide additional vascular supply
to a region of relative chronic ischemia, allow for a gliding/non-adherent interface for the me-
dian nerve, and add a physical barrier between the nerve and adjacent anatomic structures.
Hypothenar fat pad flap
The hypothenar fat pad flap (HFPF) mobilizes a portion of fat from the hypothenar emi-
nence as a pedicle. The flap is then transposed to cover the median nerve and provide a gliding
surface for the nerve. First described by Cramer [16], the flap has subsequently been modified by
many surgeons. Numerous clinical experiences demonstrate its efficacy in selected patients [4–7].
Anatomy
The flap receives its vascular supply from multiple transverse branches of the ulnar artery
within Guyon’s canal. Latex arterial injections, cadaver dissections, and clinical experience have
all confirmed a rich plexus to the HFPF (Fig. 1).
Surgical technique
Performed under regional or general anesthesia, a linear/curvilinear incision is fashioned

through the previous release incision. After lysis of the median nerve, dissection is performed in
E-mail address: levin001@mc.duke.edu (L.S. Levin).
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296 J.W. Fletcher et al / Atlas Hand Clin 7 (2002) 295–307
Fig. 1. Latex arterial injection confirming multiple transverse branches arising from the ulnar artery in Guyon’s canal
providing a rich plexus to the hypothenar fat pad flap. (From Strickland JW. The hypothenar fat pad flap for
management of recalcitrant carpal tunnel syndrome. J Hand Surg 1996;21A:841; with permission.)
an ulnar direction just beneath the subdermal plexus overlying the hypothenar fat pad to the der-
mal insertion of the palmaris brevis. Dissection is then taken from the deep radial surface of the fat
pad in an ulnar direction. Care must be taken to identify and preserve the ulnar nerve and artery in
Guyon’s canal (Fig. 2). Mobilization of the fat pad continues until easy transposition over the me-
dian nerve is achieved (Fig. 3). Anchoring of the fat pad to the deep radial aspect of the carpal
canal may be performed with absorbable suture. Gentle and simultaneous mid-axial pressure
on the thenar and hypothenar eminence with the tying of these sutures facilitates closure (Fig. 4).
Abductor digiti minimi flap
The abductor digiti minimi (ADM) flap is a local muscle flap designed to provide additional
vascular supply and gliding surface for the nerve. The hand affords few options for local tissue
transfer due to the importance of structures and donor morbidity. Some authors contend, how-
ever, that the ADM is suitable for transfer because it does not significantly affect function or
appearance of the hand.
Fig. 2. The hypothenar fat is raised by subcutaneous dissection in an ulnar direction. The contents of Guyon’s canal are
just deep to the fat. (From Strickland JW. The hypothenar fat pad flap for management of recalcitrant carpal tunnel
syndrome. J Hand Surg 1996;21A:842; with permission.)
J.W. Fletcher et al / Atlas Hand Clin 7 (2002) 295–307 297
Fig. 3. Deep mobilization of fat pad is demonstrated. Ulnar segment of transverse carpal ligament is excised. (From
Strickland JW. The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome. J Hand Surg
1996;21A:842; with permission.)
The consistent neurovascular supply to the ADM, first described by Huber [8], has allowed
the use of the ADM as a motor unit for thumb adduction, as a local flap for coverage following
trauma or tumor extirpation, and as coverage for the carpal tunnel region.
Anatomy
The ADM acts to adduct the small finger. It occupies the most superficial portion of the
hypothenar eminence. The ADM takes its origin from the os pisiforme and inserts into the dorsal
aponeurosis of the small finger on the ulnar aspect. Consistent branches of the ulnar artery and
nerve just distal to the pisiform supply the muscle. The ADM motor branch is most often prox-
imal to the vascular supply.
Surgical technique
Incision is fashioned on the ulnar boarder of the hand (Fig. 5) and the most superficial muscle is
identified. Care is taken at this point to identify and protect the ulnar digital nerve to the small
Fig. 4. Mattress sutures are placed through the radial wall of the tunnel and back through the fat pad. (From Strickland
JW. The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome. J Hand Surg 1996;21A:843;
with permission.)
Fig. 5. Diagram of the hypothenar incision with skin island. Also shown: schematic transfer and donor site. (With
permission, The Christine M. Kleinert Institute for Hand and Microsurgery, Inc.)
finger and the artery to the ulnar small finger overlying the superficial and radial portion of the
muscle as well as the dorsal ulnar sensory nerve (Fig. 6). Attachment distally at the aponeurosis
is divided and the muscle is elevated in a proximal fashion. Guyon’s canal is opened with subse-
quent identification of the ulnar nerve and artery (Fig. 7). The ADM motor branch is readily iden-
tified and divided. Muscle is detached at its proximal origin from the pisiform, allowing a greater
arc of rotation. Passage of the ADM from ulnar incision to the opened Guyon’s canal by way of a
tunnel preserves the hypothenar skin. ADM viability is assessed after release of tourniquet and
muscle is inset. The bulk of the ADM often requires the use of a split-thickness skin graft for cover-
age. This is not required if a musculocutaneous flap is designed and elevated (Fig. 8).
Palmaris brevis flap
The palmaris brevis (PB) flap is a broad, thin vestigial sheet of muscle adjacent to the carpal
canal that, like the ADM flap, affords vascular coverage of the nerve while minimizing donor
deficit in the hand.
Fig. 6. Abductor digiti minimi muscle is most superficial in hypothenar eminence. Ulnar side digital nerve to the small
finger and dorsal ulnar sensory branch lies at the volar and dorsal aspect of the muscle. (From Spokevicius S. The
abductor digiti minimi flap. Hand Clinics 1996;12:352; with permission.)
Fig. 7. After elevation of the muscle, Guyon’s canal is opened and the ulnar nerve, artery, and concomitant veins are
dissected. (From Spokevicius S. The abductor digiti minimi flap. Hand Clinics 1996;12:352; with permission.)
Anatomy
The trapezoidal muscle originates from the transverse flexor retinaculum and inserts into
the fibro–fatty tissue of the ulnar aspect of the hypothenar eminence. It lies volar to Guyon’s
canal. Absent in only 2% of the population, the PB has consistent neurovascular supply. There
are two heads of the muscle, each with its own nutrient artery from the ulnar artery usually
distal to the bifurcation. The proximal nerve pedicle originates from the ulnar nerve trunk
and the distal motor branch is from the common sensory to the fourth or the small finger
(Fig. 9) [9,10].
Surgical technique
The initial incision follows the previous release scar and travels in the transverse wrist crease
(Fig. 10). The hypothenar flap is elevated in the subdermal plexus, taking care to avoid the
palmar cutaneous branch. The volar surface of the fibers of the palmaris brevis is exposed.
The dissection of the muscle begins at the ulnar aspect with care to avoid injury to the under-
Fig. 8. Closure of the donor site and inset of musculocutaneous flap. (From Spokevicius S. The abductor digiti minimi
flap. Hand Clinics 1996;12:354; with permission.)
Fig. 9. Dual arterial blood supply to palmaris brevis muscle. These arteries usually arise from the deep palmar branch of
the ulnar artery distal to bifurcation. The ulnar nerve supplying the muscle is depicted. (From Rose EH. Palmaris brevis
tunover flap as an adjunct to internal neurolysis of the chronically scarred median nerve in recurrent carpal tunnel
syndrome. J Hand Surg 1991;16A:193; with permission.)
lying ulnar nerve and artery (Fig. 11). Palmaris is elevated off the underlying hypothenar muscles
and flipped over its radial attachment containing the nutrient vessels to cover the carpal canal
(Fig. 12). The flap is secured at the radial aspect of the carpal canal to the remaining transverse
carpal ligament (Fig. 13).
Pronator quadratus
In addition to providing a well-vascularized bed for implantation of sensory nerves after neu-
roma resection, the pronator quadratus flap has been suggested for a nutritive interface between
an ‘‘internal lysed nerve and overlying dysestheic or adherent skin’’ [11].
Anatomy
In a study of 16 cadavers, the muscle is 5 cm in length by 4 cm in width. The neurovascular

bundle lies on the volar surface of the interosseous membrane with the neurovascular bundle
consistently arising from the anterior interosseous nerve and artery. The bundle lies over the
mid-longitudinal axis of the muscle and enters 1 cm to 2 cm proximal to the proximal edge
of the muscle (Fig. 14).
Surgical technique
Exposed by way of any existing volar incision, the incision is carried proximally 12 cm from
the wrist crease. The radial aspect of the muscle is dissected between the flexor profundus group
and the flexor pollicis longus tendons (Fig. 15A). The distal edge is divided and the terminal
Fig. 10. Incision in thenar and wrist crease. (From Rose EH. Palmaris brevis tunover flap as an adjunct to internal
neurolysis of the chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg 1991;16A:195;
redrawn with permission.)
branches of the anterior interosseous nerve and artery are divided (Fig. 15B). Insertion of the
pronator is elevated from the radius with a scalpel and carried across the interosseous mem-
brane with an elevator. Release of the origin on the ulna is accomplished from the interval be-
tween the profundus muscle and the flexor carpi ulnaris (Fig. 15C). The muscle is gently elevated
from distal to proximal (Fig. 15D) [11].
Reverse radial artery fascial flap
The reverse-flow vascularized radial artery forearm fascial flap has been described in the
successful treatment of series of patients with chronic median nerve symptoms after repeated
release of the transverse carpal ligament [12].
Anatomy
The antebrachial fascia overlying the intermuscular interval of the flexor carpi radialis and
the brachioradialis is supplied by segmental perforators from the radial artery.
Surgical technique
Prior to surgery, an Allen’s test confirms the presence of ulnar artery flow to the hand. The
proximal third of the forearm is incised and a pivot point 4 cm to 5 cm from the radial styloid
is marked. A 4 to 5 cm length of flap is marked and designed to pivot distally to cover the carpal
Fig. 11. Muscle exposed by lysis of dermal insertions. (From Rose EH. Palmaris brevis tunover flap as an adjunct to
internal neurolysis of the chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg
1991;16A:195; redrawn with permission.)
Fig. 12. Flap transposed as a ‘‘book leaf ’’ over carpal tunnel. (From Rose EH. Palmaris brevis tunover flap as an
adjunct to internal neurolysis of the chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg
Fig. 13. Turnover flap inset into radial edge of retinaculum. (From Rose EH. Palmaris brevis tunover flap as an adjunct
to internal neurolysis of the chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg
Fig. 14. The pronator quadratus muscle shown schematically supplied by the anterior interosseous neurovascular
bundle with vessels perforation the interosseous membrane. (From Dellon AL. The pronator quadratus muscle flap.
J Hand Surg 9A:424, 1984; with permission.)
Fig. 15. Elevation of the pronator quadratus muscle flap. Please refer to text for details. (From Dellon AL. The pronator
quadratus muscle flap. J Hand Surg 1984;9A:425; with permission.)
canal proximally. Dissection is carried through the skin to the antebrachial fascia. Skin and sub-
cutaneous tissue are elevated for 2 to 3 cm on either side of the intermuscular septum between
the flexor carpi radialis and the brachioradialis. The fascia is incised, the radial artery is divided
proximally, and flap dissection is carried distal to the pivot point preserving connections of the
radial artery to the fascia (Fig. 16). The median nerve is wrapped in the carpal canal by the flap
and secured with absorbable suture (Fig. 17).
Synovial flap
The use of a synovial flap after extensive neurolysis and mobilization of the medina nerve is
advocated to isolate the nerve from further scar [13].
Surgical technique
After mobilization of the median nerve, a wide ulnar-based pedicle of synovium is turned
radial to cover the nerve and secured with fine absorbable sutures (Fig. 18).
Fig. 16. (A) Radial artery fascial flap elevated with a hemostat securing the vascular pedicle. (B) Dissected fascial flap (a)
attached to ligated vascular pedicle (b). (From Tham SK. Reverse radial artery fascial flap: a treatment for the
chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg 1996;21A:851; with permission.)
Fig. 17. (A) Fascial flap surrounding a scarred median nerve. (B) Fascial flap (a) placed dorsal to the median nerve (b);
vascular pedicle (c) lying beneath the flexor carpi redialis (d ). (From Tham SK. Reverse radial artery fascial flap: a treatment
for the chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg 1996;21A:852; with permission.)
Fig. 18. (A) The scarred tissue around the median nerve and the flexor tendons is exposed. (B) The wide synovial flap on
ulnar pedicle is elevated. (C) The synovial flap is placed over the median nerve and secured to the radial and palmar
aspect of the carpal tunnel. (From Wulle C. The synovial flap as treatment of the recurrent carpal tunnel syndrome.
Hand Clincs 1996;12:381; redrawn with permission.)
Fig. 18 (continued )
Reconstruction of the transverse carpal ligament
Some authors justify the reconstruction of the transverse carpal ligament (TCL) in patients
with proven traction neuritis of the median nerve. The technique re-establishes the gliding flexor
sheath for the movement of flexors and the median nerve and restores strength to the hand by
providing transverse support at the level of the wrist. After extensive neurolysis, reconstruction
Fig. 19. (A) Painful hypertrophic scar of the volar wrist. (B) Elevation of the reverse radial forearm fasciocutaneous
flap. (C) Inset of flap and closure of donor site. (D) Patient after several weeks demonstrating healing of the flap and
donor site.
is accomplished by fasciotomy of Guyon’s canal and mobilization of the TCL from the origin of
the thenar muscles [14].
Dermal fat grafts/free flaps
The use of dermal fat grafts from the lower abdominal groin crease has been described for
coverage of the median nerve at the carpal canal [15]. Series also exist detailing the successful
use of microvascular transplantation of tissue including lateral arm, latissimus, scapular, and
free radial forearm to wrap the scarred median nerve [3].
Reverse radial forearm fasciocutaneous flap
The use of the reverse radial forearm fasciocutaneous flap has also been used for coverage of
recalcitrant median nerve neuritis. The patient had prior release with hypertrophic scarring and
painful neuritis at the level of the wrist (Fig. 19A). The reverse radial forearm flap including
cutaneous island is elevated (Fig. 19B). After transposition and inset, the donor site was
closed primarily (Fig. 19C). At follow-up 1 month after, symptoms of neuritis had improved
(Fig. 19D).
References
[1] Phalen GS. Reflections on 21 years’ experience with the carpal tunnel syndrome. JAMA 1970;212:1365–7.
[2] Mackinnon SE. Secondary carpal tunnel surgery. Neurosurgery Clin N Am 1991;2:75–91.
[3] Jones NF, Shaw WW, Katz RG, et al. Circumferential wrapping of a flap around a scarred peripheral nerve for
salvage of end-stage traction neuritis. J Hand Surg [Am] 1997;22:527–35.
[4] Plancher KD, Idler RS, Lourie GM, et al. Recalcitrant carpal tunnel. The hypothenar fat pad flap. Hand Clinics
1996;12:337–49.
[5] Jones SM, Stuart PR, Stothard J. Open carpal tunnel release. Does a vascularized hypothenar fat pad reduce wound
tenderness? J Hand Surg [Br] 1997;22:758–60.
[6] Giunta R, Frank U, Lanz U. The hypothenar fat-pad flap for reconstructive repair after scarring of the median
nerve at the wrist joint. Chirurgie de la Main 1998;17:107–12.
[7] Frank U, Giunta R, Krimmer H, et al. Relocation of the median nerve after scarring along the carpal tunnel with
hypothenar fatty tissue flap-plasty. Handchirurgie, Mikrochirurgie, Plastische Chirurgie 1999;31:317–22.
[8] Huber VE. Hilfsoperation bei mediannunslahmung. Deutsche Zeitschrift fur Chirurgie 1921;162:271–5.
[9] Rose EH, Norris MS, Kowalski TA, et al. Palmaris brevis turnover flap as an adjunct to internal neurolysis of the
chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg [Am] 1991;16:191–201.
[10] Rose EH. The use of the palmaris brevis flap in recurrent carpal tunnel syndrome. Hand Clinics 1996;12:389–95.
[11] Dellon AL, Mackinnon SE. The pronator quadratus muscle flap. J Hand Surg [Am] 1984;9A:423–7.
[12] Tham SK, Ireland DC, Riccio M, et al. Reverse radial artery fascial flap: a treatment for the chronically scarred
median nerve in recurrent carpal tunnel syndrome. J Hand Surg [Am] 1996;21:849–54.
[13] Wulle C. The synovial flap as treatment of the recurrent carpal tunnel syndrome. Hand Clinics 1996;12:379–88.
[14] Hunter JM. Reconstruction of the transverse carpal ligament to restore median nerve gliding. Hand Clinics
1996;12:365–78.
[15] McClinton MA. The use of dermal-fat grafts. Hand Clinics 1996;12:357–64.
[16] Cramer LM. Local fat coverage for the median nerve. In: Langford LL, editor. Correspondence Newletter for Hand
Surgery; 1985. p. 35.
Management of complications of carpal tunnel release

Michael Forseth, MD, Peter J. Stern, MD*
Mary S. Stern Hand Foundation & Department of Orthopaedic Surgery, University of Cincinnati College of Medicine,
2800 Winslow Avenue, Suite 401, Cincinnati, OH 45206, USA
Since Sir James Learmonth [1] performed the first reported carpal tunnel release (CTR) in
1933, countless carpal tunnels have been decompressed. CTR has become a reliable procedure
with a low complication rate and excellent results. More than 200,000 CTRs are performed
annually in the United States, making it the most common surgical procedure performed on
the hand. Despite CTR being a relatively safe procedure, complications do occur. The focus of
this paper will be on the management of the complications stemming from carpal tunnel release,
either performed openly or endoscopically.
Complications of CTR can be categorized either by technique (open CTR versus endoscopic
CTR), chronologically (intraoperative, early, or late post-operative), or by the tissues affected
(nerve, tendon, skin, or a combination thereof). Complications can range from transient digital
nerve contusion to the devastating loss of palmar skin requiring flap coverage. Below is a com-
prehensive inventory of noted complications.
• Nerve injury
Median nerve
Palmar cutaneous branch median nerve
Recurrent motor branch median nerve
Ulnar nerve
• Incomplete division of flexor retinaculum
• Tendon
Tendon laceration
Flexor tendon adhesions
Flexor tendon bow string
• Pain conditions
Pillar pain
Painful scar
Complex regional pain syndrome
• Infection
• Vascular
Superficial palmar arch laceration
Superficial palmar arch pseudoaneurysm
• Palmar skin necrosis
• Pisotriqutral subluxation
• Recurrence
Technique: open versus endoscopic
Multiple studies have been published outlining the complications of CTR. Palmer and
Toivonen [2] sent questionnaires to members of the American Society for Surgery of the Hand
E-mail address: pstern@handsurg.com (P.J. Stern).
PII: S 1 0 8 2 - 3 1 3 1 ( 0 2 ) 0 0 0 0 5 - 5
310 M. Forseth, P.J. Stern / Atlas Hand Clin 7 (2002) 309–316
regarding complications of open CTR and endoscopic CTR. After surveying the responses from
708 respondents, they found that the most common complication was median nerve laceration,
regardless of technique (Fig. 1). They also found a higher than expected number of tendon lac-
erations, usually the small finger profundus or superficialis. Tendon lacerations were much more
common after endoscopic CTR compared to open CTR. Other complications included super-
ficial palmar arch lacerations, ulnar nerve lacerations, and common digital nerve lacerations.
No attempt to calculate an incidence of the complications was made due to the retrospective,
voluntary nature of the study.
Jacobsen and Rahme [3] performed a prospective, randomized study comparing open CTR
and endoscopic CTR. An independent observer noted no significant differences between the two
groups regarding sick leave or overall results, but three patients in the endoscopic group had
transient numbness of the radial aspect of the ring finger.
Brown et al [4] published another prospective randomized study comparing open CTR and
endoscopic CTR. This multi-center study included 169 hands. Four complications were noted in
the endoscopic CTR group and none in the open CTR group. Complications included a partial
superficial palmar arch laceration, a digital nerve contusion, an ulnar nerve neurapraxia, and a
wound hematoma. An additional complication occurred in the pre-study trial period involving
transection of the common digital nerve of the ring and small fingers and the medial 20% of the
median nerve.
The two procedures have also been compared with respect to recurrence. Concannon et al [5]
found six recurrences after 88 endoscopic CTRs and no recurrences after 103 open CTRs.
Acute lacerations
Injuries to tendons, nerves, and arteries that are noted intra-operatively should be repaired.
Tendons should be repaired using standard methods and neurovascular structures should be re-
constructed using microsurgical techniques. Ligation of the superficial arch has been described,
but one must ensure adequate flow distally prior to ligation.
Laceration of the median nerve motor branch deserves special mention. The motor branch is
susceptible to injury secondary to its variable course. It most commonly arises just distal to the
Fig. 1. Complete median nerve laceration after open carpal tunnel release. (A) Physical examination post-operatively
demonstrated complete sensory loss in median nerve distribution. (B) Intraoperative photograph showing lacerated
median nerve.
M. Forseth, P.J. Stern / Atlas Hand Clin 7 (2002) 309–316 311
flexor retinaculum, taking a recurrent course to the thenar musculature. The nerve may also
arise proximal to the flexor retinaculum and exit distally (sub-ligamentous) or pass through
the flexor retinaculum (trans-ligamentous). It is this trans-ligamentous motor branch that is
at higher risk, as it pierces the retinaculum 2 to 6 mm from its distal edge [6]. If the laceration
is noted acutely, microsurgical repair is indicated. Delayed repair is an option; excellent func-
tional recovery has been reported as late as 14 months following injury [7]. Injuries presenting
later are best treated with an opposition transfer. There are many options for a motor; the
authors prefer the extensor indicis proprius [8].
Neuroma
Post-operative neuroma formation may occur after complete or partial nerve lacerations. The
palmar cutaneous branch of the median nerve is particularly vulnerable if one employs a trans-
verse incision that extends radial to the palmaris longus. Patients usually present with painful
paresthesias in the thenar eminence. Percussion of the scar with a positive Tinel’s test may help
localize the neuroma. Confirmation involves symptomatic relief following local anesthetic injec-
tion into the point where the Tinel’s test is maximally positive. Treatment entails dissecting the
neuroma free from surrounding scar. After the nerve branch is mobilized, it may then be buried
in surrounding deep tissues. Evans and Dellon [9] resected the neuroma and buried the nerve in
the pronator quadratus in 13 patients with good to excellent results in all cases.
Painful scar
Continued pain over the scar may be secondary to either superficial or deep causes. Trans-
ection of small, cutaneous nerve branches may be the etiology of pillar pain. Detailed anatomic
studies have shown that many small branches of the palmar cutaneous nerve lie in the superfi-
cial, loose connective tissue overlying the transverse carpal ligament [10]. Management of neural
scarring begins with ‘‘watchful waiting.’’ If the problem fails to improve with time and is second-
ary to superficial wound hypertrophy (Fig. 2), a z-plasty may be helpful, especially if the scar
runs perpendicular to the wrist flexion creases.
Fig. 2. Hypertrophic wound following open carpal tunnel release.

Deep scar formation may lead to adhesions around the median nerve. This is more likely to
occur following extensive surgery (eg, flexor tenosynovectomy or median nerve neurolysis).
These adhesions can cause a traction neuropathy or a neurodesis effect. Extension of the wrist
will cause severe pain in the wrist with radiation distally in the median nerve distribution.
Deep scarring leading to adhesions around the median nerve has been treated with internal
and external neurolysis combined with a variety of soft tissue coverage/interposition procedures
to be discussed later. The authors’ approach is to free the nerve from the surrounding scar fol-
lowed by soft tissue interposition, most often a fat pad flap from the hypothenar eminence. Mul-
tiple studies have found internal neurolysis to be of no benefit in the setting of recurrent or
primary carpal tunnel syndrome [11,12].
Complex regional pain syndrome
Complex regional pain syndrome (CRPS), formally known as reflex sympathetic dystrophy,
is an infrequent complication of carpal tunnel release. It may stem from complete or partial lac-
erations of the median nerve or one of its branches leading to neuroma formation. The clinical
hallmarks of early CRPS are pain, decreased range of motion of the digits, swelling, and vaso-
motor and autonomic dysfunction. Timely recognition and early treatment are the key elements
in aiding recovery.
Treatment involves a combination of interventions. These include physical [13] and occupa-
tional therapy, oral medications [14], regional anesthetic blocks, and (rarely) surgical interven-
tion. Therapy acts to restore functional activity. This may be through the use of splints, contrast
baths, or massage. Better alternative oral medications include amitriptyline, which helps reduce
the burning pain associated with CRPS. The anticonvulsive medications phenytoin and carba-
mazepine have been used, but their significant side effects require close monitoring. Nifedipine, a
calcium channel blocker, has been shown to be effective in the management of CRPS as well.
Oral medications are a key element in treating CRPS, but narcotics should be avoided to obvi-
ate the risk of dependence.
If therapy and oral medications fail to provide symptomatic relief, regional blocks are the next
step. Stellate ganglion blocks can be both diagnostic and therapeutic. Anterior scalene, axillary,
and brachial regional blocks may also be efficacious. If all non-operative methods fail, surgical
intervention may be considered. Surgery can be especially helpful where it is directed towards an
identifiable neuroma, a neuroma-in-continuity, or a secondary compression neuropathy [15].
Infection and wound problems
Infection is another uncommon complication. Early infection may be treated with antibiotics
alone, but close monitoring is required. If antibiotic treatment fails to improve the situation or
deep infection is suspected, a formal irrigation and debridement is indicated. Wide incisions are
advised, the proximal and distal ends of the incision left open to allow drainage. However, the
median nerve itself should remain covered to prevent its desiccation. There are case reports
in the literature of wound slough after carpal tunnel release, even large areas of palmar skin
necrosis requiring free flap coverage [16].
Persistence and recurrence
One of the most common complications after carpal tunnel release is failure to alleviate the
preoperative symptoms. A careful history and physical is crucial in determining the cause of the
continued symptomatology. Did the symptoms fail to improve immediately after surgery, or
even worsen? This is consistent with persistence, which refers to continued symptoms post-
operatively, with no intervening period of improvement. This suggests either an incomplete
release (Fig. 3) or that the wrong diagnosis was made preoperatively. Incomplete release should
be suspected when there is an incision at or proximal to the wrist flexion crease.
Persistence may also originate from an error in diagnosis. Alternative diagnoses to consider in-
clude a more proximal nerve compressions such as pronator syndrome or cervical radiculopathy.
Fig. 3. Persistent flexor retinaculum after open carpal tunnel release (arrow).
Peripheral neuropathy may occur with or without a concomitant entrapment neuropathy. Its
presence is established by electrodiagnostic studies. Underlying medical problems may mimic or
exacerbate carpal tunnel syndrome. These include upper motor neuron disease, spondylotic
myelopathy, syringomyelia, and multiple sclerosis [17]. If the underlying cause is not addressed,
treatment is unlikely to be successful.
True recurrence, as opposed to persistence, is defined as having a period of improvement
postoperatively followed by return of the symptoms. Recurrence may be related to a number
of factors. Rheumatoid arthritis patients as well as those undergoing hemodialysis are at partic-
ular risk of recurrence. Scar formation, as mentioned earlier, can lead to a traction neuropathy.
Return to heavy work may also have a causal relationship to recurrence.
Options for failed carpal tunnel release
Successful surgical management of either persistent or recurrent carpal tunnel syndrome

hinges on an accurate preoperative workup and a thorough exploration of the median nerve
at the time of surgery. If the transverse carpal ligament was incompletely released, complete de-
compression may be all that is necessary. Alternatively, if the median nerve is adherent to the
overlying transverse carpal ligament, some variation of soft tissue interposition is indicated. A
number of different procedures have been described to help cushion the nerve and allow it to glide
under the transverse carpal ligament. Options include placement of an autologous vein insulator
or ‘‘vein wrapping’’ [18], hypothenar fat pad flap [19], palmaris brevis flap [20], reverse radial
artery fascial flap [21], synovial flap [22], reconstruction of the TCL to restore median nerve gliding
[23], and dermal fat grafts [24]. The authors’ preference is the hypothenar fat pad flap (HTFPF)
as described by Strickland et al [19]. The HTFPF provides locally available tissue to prevent fur-
ther adhesions after the scarred median nerve has been freed from its surrounding tethers.
Technique of hypothenar fat pad flap
The procedure begins with assessment of the previous surgical incision. Wide exposure of the
median nerve is necessary to safely and adequately free the scarred nerve. Distal dissection is of
particular importance because failure to release the most distal aspect of the TCL is a common
reason for persistence of the symptoms. The median nerve is located proximally, away from the
scar, and meticulously followed distally (Fig. 4A). Adhesions are carefully lysed. After the nerve
has been adequately freed, elevation of the fat pad flap is begun. Dissection is carried out in an
ulnar direction, deep to the subdermal plexus. Caution is taken not to excessively thin the over-
lying skin. The flap is superficially dissected just ulnar to the insertion of the palmaris brevis.
The flap is then carefully separated from the hypothenar muscles. After the superficial dissection
is completed, the deep dissection starts between the ulnar leaf of the TCL and the overlying fat
pad. The deep dissection continues ulnarly until the ulnar neurovascular bundle is visualized.
After the flap has been sufficiently mobilized, traction sutures (Fig. 4B) are placed in the radial
aspect (free margin) of the flap. The radial leaf of the TCL is gently retracted radially and the
Fig. 4. Vessel loop around (A) scarred median nerve, (B) sutures placed through hypothenar fat pad, (C) hypothenar fat
pad being brought over median nerve.
Fig. 5. Z-plasty of linear scar across volar wrist crease. (A) Post-operative scar. Note proximal location of scar in
addition to linear nature across wrist crease. (B) Z-plasty post-operatively.
flap is secured to the undersurface of the radial leaf of the TCL (Fig. 4C). In this manner the fat
pad becomes interposed between the median nerve and overlying TCL. After the flap has been
sutured in place skin closure is addressed. If the previous incision crossed the wrist flexion crease
at a right angle, a z-plasty is indicated (Fig. 5A, B). Post-operatively, the patient is placed in a
transversely compressing plaster splint to minimize tension on the repair. This remains in place
for 2 weeks, at which time sutures are removed and gentle wrist motion is started. Unrestricted
use of the wrist is allowed at 6 weeks.
Strickland et al [19] reported a 95% satisfaction rate in patients undergoing HTFPF for re-
current carpal tunnel syndrome. This included workers’ compensation and non-workers’ com-
pensation patients. Dysesthesia and paresthesias were relieved in 89%.
References
[1] Learmonth JR. The principles of decompression in the treatment of certain diseases of peripheral nerves. Surg Clin
N Am 1933;13:905–13.
[2] Palmer AK, Toivonen DA. Complications of endoscopic and open carpal tunnel release. J Hand Surg 1999;
24A:561–5.
[3] Jacobsen MB, Rahme H. A prospective, randomized study with an independent observer comparing open carpal
tunnel release with endoscopic carpal tunnel release. J Hand Surg 1996;21B:202–4.
[4] Brown RA, Gelberman RH, Seiler JG, et al. Carpal tunnel release. J Bone Joint 1993;75A:1265–75.
[5] Concannon MJ, Brownfield ML, Puckett CL. The incidence of recurrence after endoscopic carpal tunnel release.
Plast Reconstr Surg 2000;105:1662–5.
[6] Lanz U. Anatomical variations of the median nerve in the carpal tunnel. J Hand Surg 1977;2A:44–53.
[7] Lilly CJ, Magnell TD. Severance of the thenar branch of the median nerve as a complication of carpal tunnel
release. J Hand Surg 1985;10A:399–402.
[8] Burkhalter W, Christensen RC, Brown P. Extensor indicis proprius oppensplasty. J Bone Joint Surg 1973;55A:
725–32.
[9] Evans GR, Dellon AL. Implantation of the palmar cutaneous branch of the median nerve into the pronator
quadratus for treatment of painful neuroma. J Hand Surg 1994;19A:203–6.
[10] DaSilva MF, Moore DC, Weiss AP, et al. Anatomy of the palmar cutaneous branch of the median nerve: clinical
significance. J Hand Surg 1996;21A:639–43.
[11] Gelberman RH, Pfeffer GB, Galbraith RT, et al. Results of treatment of severe carpal tunnel syndrome without
internal neurolysis of the median nerve. J Bone Joint Surg 1987;69A:896–903.
[12] Mackinnon SE, McCabe S, Murray JF, et al. Internal neurolysis fails to improve the results of primary carpal tunnel
decompression. J Hand Surg 1991;16A:211–8.
[13] Watson HK, Carlson L. Treatment of reflex sympathetic dystrophy of the hand with an active ‘‘stress loading’’
program. J Hand Surg 1987;12A:779–85.
[14] Koman LA, Smith TL, Smith BP, et al. Reflex sympathetic and other dystrophies. In: Peimer CA, editor. Surgery of
the hand and upper extremity. New York: McGraw-Hill; 1996. p. 2302–3.
[15] Jupiter JB, Seiler III JG, Zienowicz R. Sympathetic maintained pain (causalgia) associated with a demonstrable
peripheral nerve lesion. Operative treatment. J Bone Joint Surg 1994;76A:1376–84.
[16] Cartotto RC, McCabe S, Mackinnon SE. Two devastating complications of carpal tunnel surgery. Ann Plast Surg
1992;29:380–1.
[17] Witt JC, Stevens JC. Neurologic disorders masquerading as carpal tunnel syndrome: 12 cases of failed carpal tunnel
release. Mayo Clin Proc 2000;75:409–13.
[18] Varitimidis SE, Vardakas DG, Goebel F, et al. Treatment of recurrent compressive neuropathy of peripheral nerves
in the upper extremity with an autologous vein insulator. J Hand Surg 2001;26A:296–302.
tunnel syndrome. J Hand Surg 1996;21A:840–8.
[20] Kelly MBH, Bosmans L, Gault D. Use of the palmaris brevis flap for preventing recurrent median nerve
compression in mucolipidosis. J Hand Surg 1999;24B:300–2.
[21] Tham SKY, Ireland DCR, Riccio M, et al. Reverse radial artery flap: a treatment for the chronically scarred median
nerve in recurrent carpal tunnel syndrome. J Hand Surg 1996;21A:849–54.
[22] Wulle C. The synovial flap as treatment of the recurrent carpal tunnel syndrome. Hand Clin 1996;12:379–88.
[23] Hunter JM. Reconstruction of the transverse carpal ligament to restore median nerve gliding. Hand Clin 1996;
12:365–78.
[24] McClinton MA. The use of dermal-fat grafts. Hand Clin 1996;12:357–64.

2002, Vol. 7, Issues 2, Techniques in Carpal Tunnel Surgery

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2002, Vol. 7, Issues 2, Techniques in Carpal Tunnel Surgery

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Atlas of the Hand Clinics

Copyright © 2006 Saunders, An Imprint of Elsevier

Volume 7, Issue 2 (September 2002)

Techniques in carpal tunnel surgery

Techniques in carpal tunnel surgery

Barry Katzman, MD Edward Akelman, MD

Open carpal tunnel release

Limited-open carpal tunnel release using

Fig. 2. Exposed transverse carpal ligament.

17 months). Fifteen patients had a recurrence of symptoms post-operatively, a rate of 1.9%.

Carpal tunnel release using the carpal tunnel tome

* Corresponding author. c/o Lyn Camire.

Fig. 1. The single pilot, palmar stripper, and double pilot.

Carpal tunnel release using the carpal tunnel tome

The blunt pilot

Fig. 6. The blunt pilot.

The palmar stripper

The double pilot

The cutting tome

Fig. 9. The palmar stripper.

Fig. 11. The double pilot.

Fig. 13. The carpal tunnel tome.

Fig. 14. Closeup of blade housing of the cutting tome.

Endoscopic carpal tunnel release: Chow technique

E-mail address: ocsijc@charter.net (J.C.Y. Chow).

Indications and contraindications

Setup and portals

Common mistakes and checkpoints

Ligament cutting technique

Fig. 9. The endoscope is placed in the proximal opening of the tube.

Fig. 10. The carpal ligament is identiﬁed by the transverse ﬁbers.

Single distal portal endoscopic carpal tunnel release

E-mail address: mmurphy@chesapeakehand.com (M.S. Murphy).

Fig. 5. (A, B) Passage of the endoscope from proximal to distal.

Fig. 6. Proximal extent of the TCL, which is often

Fig. 9. Endoscopic visualization of the transected

Single-portal endoscopic carpal tunnel release

* E-mail address: skozin@shrinenet.org (S.H. Kozin).

Fig. 2. Transligamentous recurrent branch that perforated the TCL.

Indications for endoscopic carpal tunnel release

muscles, which is indicative of denervation. Endoscopic carpal tunnel release is contraindicated

The beneﬁt of transverse carpal ligament

Methods of TCL reconstruction

Rationale and indications for transposition ﬂap TCL reconstruction

Carpal tunnel syndrome in rheumatoid

Fig. 1. Radiograph of a bone spur on the scaphoid (arrow).

Fig. 2. Rice bodies (arrow) seen at the time of tenosynovectomy.

Median nerve injuries associated with distal radius

Median nerve contusion

Acute carpal tunnel syndrome

Carpal tunnel syndrome

Late or delayed injuries

Tardy carpal tunnel syndrome

Pre-existing median neuropathy

Pediatric epiphyseal fracture dislocations

The growing understanding of the pathoanatomy of distal radius fractures is inclusive of

Combined carpal tunnel and ulnar nerve release

Secondary carpal tunnel surgery

Minimally invasive carpal tunnel release

Secondary carpal tunnel release

Fig. 1. Comparison of normal nerve, epineurotomy and internal neurolysis.

Injury to palmar cutaneous branch

Median nerve injuries