Carpal tunnel syndrome surgical approach.pptx

In this slide, we will delve into the surgical technique for carpal tunnel release, a common procedure aimed at alleviating symptoms of carpal tunnel syndrome (CTS)

1. Surgical approach Carpal tunnel syndrome release

2. Carpal tunnel syndrome CTS is the compressive neuropathy of median nerve in the carpal tunnel  The most common nerve compression syndromes

3. ANATOMY Palmar Cutaneous Branch of Median Nerve: Originates from median nerve 6–11 cm proximal to wrist crease Travels distally with median nerve Passes volar to carpal ligament Divides into branches to palmar skin Supplies sensation to radial and lateral aspect of palm at base of thumb Recurrent Motor Branch and Common Digital Nerves: Recurrent motor branch wraps around transverse carpal ligament Innervates thenar muscles: abductor pollicis brevis, superficial head of flexor pollicis brevis, opponens pollicis Terminal branches divide into digital nerves Provide sensation to thumb, index, middle, and radial half of ring finger

4. ANATOMY Other Neurovascular Structures in Palmar Wrist: Ulnar Nerve: Passes superficial and ulnar to transverse carpal ligament Bifurcates into sensory and deep motor branches in Guyon’s canal Sensory branches: Ulnar aspect of hand, small finger, ulnar aspect of ring finger Deep motor branches: Interosseous muscles, third and fourth lumbricals, hypothenar muscles, adductor pollicis, medial head of flexor pollicis brevis Radial and Ulnar Arteries: Arterial supply to hand Dominant blood supply: Ulnar artery via superficial arch (88%), deep palmar arch as continuation of radial artery (12%) Deep palmar arch anastomoses with deep branch of ulnar artery Location estimated by Kaplan’s cardinal line: 1 cm proximal to superficial arch, approximately one finger breadth superficial from line drawn from distal edge of abducted thumb to hook of hamate

5. Anatomy variant Variations of the recurrent motor branch of the median nerve: Extraligamentous (a), subligamentous (b), intraligamentous (c), branch from ulnar aspect (d), and traversing over transverse carpal ligament (e) Extraligamentous : 50%   Subligamentous: 30%  Transligamentous : 20%

6. preoperative Position: supine with forearm rest on armboard , palm facing upward Can use exsanguinating bandage Wallant solution is preferred for LA Antibiotic not required

7. incision Standard Longitudinal Incision: Straight or curvilinear at base of palm Straight incision: Begins distally at Kaplan cardinal line Extends proximally toward distal wrist crease along axis defined by radial aspect of ring finger (3–4 cm) Passes 3–5 mm ulnar to thenar crease Curvilinear incision: Parallel and ulnar to thenar crease Avoids crossing distal wrist crease to prevent hypertrophic scar For more proximal exposure: Incision can be extended in zigzag fashion across wrist in ulnar direction

8. Ctr release 1. Mark the incision landmark

9. Ctr release Mark the incision landmark Injection of LA along the incision site. Wallant solution can be used to minimize bleeding

10. Ctr release Mark the incision landmark Injection of LA along the incision site. Wallant solution can be used to minimize bleeding Incision is made with a scalpel through skin and subcutaneous tissue.

11. Ctr release Mark the incision landmark Injection of LA along the incision site. Wallant solution can be used to minimize bleeding Incision is made with a scalpel through skin and subcutaneous tissue. Beneath the subcutaneous fat, the palmar fascia is exposed. The fibers of the palmar fascia run longitudinally and can be distinguished from the fibers of the transverse carpal ligament which run transversely.

12. Ctr release 5. A small incision in the transverse carpal ligament is made exposing the median nerve (seen here at proximal aspect of wound).

13. Ctr release 5. A small incision in the transverse carpal ligament is made exposing the median nerve (seen here at proximal aspect of wound). 6.  The transverse carpal ligament is transected proximally until the volar fat pad is visible. Dissection distal to this risks injuring the superficial palmar arch. 

14. Ctr release 5. A small incision in the transverse carpal ligament is made exposing the median nerve (seen here at proximal aspect of wound). 6.  The transverse carpal ligament is transected proximally until the volar fat pad is visible. Dissection distal to this risks injuring the superficial palmar arch.  7. The transverse carpal ligament is released proximally using tenotomy scissors and a  Ragnell retractor to ensure adequate visualization.

15. Ctr release 5. A small incision in the transverse carpal ligament is made exposing the median nerve (seen here at proximal aspect of wound). 6.  The transverse carpal ligament is transected proximally until the volar fat pad is visible. Dissection distal to this risks injuring the superficial palmar arch.  7. The transverse carpal ligament is released proximally using tenotomy scissors and a  Ragnell retractor to ensure adequate visualization. 8. A bulb syringe can be used to inject saline into the proximal aspect of the incision. A visible collection of fluid underneath the skin indicates adequate release of the antebrachial fascia 

16. Ctr release 5. A small incision in the transverse carpal ligament is made exposing the median nerve (seen here at proximal aspect of wound). 6.  The transverse carpal ligament is transected proximally until the volar fat pad is visible. Dissection distal to this risks injuring the superficial palmar arch.  7. The transverse carpal ligament is released proximally using tenotomy scissors and a  Ragnell retractor to ensure adequate visualization. 8. A bulb syringe can be used to inject saline into the proximal aspect of the incision. A visible collection of fluid underneath the skin indicates adequate release of the antebrachial fascia  9. Excellent exposure of the median nerve after complete release of transverse carpal ligament 10. Inspect carpal tunnel for any SOL or irregularities of nerve 11. Close skin with nylon

17. Post operatively STO 10, No need for antibiotics Start nerve and tendon gliding exercises early ROM of elbow, wrist and digits

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