Patients › Wrist
Liberación del túnel carpiano
Carpal tunnel release surgery relieves median nerve compression—when it’s needed and what to expect.
¿Por qué se ha recomendado esta operación?¶
El Dr. Kieran Hirpara, cirujano de extremidades superiores en el Mater Private Hospital Rockhampton, comienza por ofrecer las opciones menos invasivas adecuadas para su condición. Por lo general, los pacientes son derivados a nuestra clínica por su médico de cabecera; si un fisioterapeuta le ha sugerido que nos consulte, igualmente necesitará una derivación de su médico de cabecera para poder acceder al reembolso de Medicare. En su consulta, tomamos su historia clínica, examinamos su mano y, si es necesario, solicitamos estudios de imagen o pruebas nerviosas. El síndrome del túnel carpiano se produce cuando un nervio de la muñeca queda comprimido, lo que provoca hormigueo, entumecimiento y dolor en la mano. Normalmente iniciamos con tratamientos no quirúrgicos como el uso de férulas, terapia de la mano o inyecciones. La cirugía se considera únicamente cuando dichos tratamientos no logran mejorías suficientes. La operación se denomina liberación del túnel carpiano; consiste en cortar una banda tensa en la muñeca para aliviar la presión sobre el nervio. Independientemente de la edad, otras condiciones médicas o del estado de compensación laboral, se pueden esperar mejoras significativas en la intensidad de los síntomas y en la función de la mano tras esta operación. Analizaremos juntos todas las opciones y decidiremos si la cirugía es adecuada para usted.
Antes de la operación¶
Su cirujano le dará instrucciones claras, pero esto es lo que puede esperar. Deberá dejar de comer y beber siete horas antes de la cirugía. Pedimos que sea siete horas en lugar de seis para poder adelantar su turno si la lista de quirófanos se agiliza. Lleve una lista de los medicamentos que toma actualmente y coméntele al cirujano si toma anticoagulantes, ya que algunos podrían necesitar ser suspendidos previamente. Organice que alguien lo lleve a casa después de la intervención. Use ropa holgada y cómoda, cuyas mangas se puedan quitar fácilmente. Es posible que se requieran estudios de imagen, como radiografías, resonancia magnética o ecografías, para planificar la operación. Si padece otras enfermedades, es posible que necesite análisis de sangre o una evaluación con el anestesista; sin embargo, la mayoría de las personas no requieren esto.
El día de la cirugía¶
El día de la operación, acude a la unidad de admisiones quirúrgicas del hospital. El personal allí le registrará y le preparará para el quirófano. A continuación, conocerá al anestesista, el médico encargado de administrar la anestesia y de cuidarle durante la intervención. Esta operación puede realizarse con anestesia local (una inyección que adormece únicamente la zona de la cirugía, mientras usted permanece despierto) o con anestesia general (quedando completamente dormido). La mayoría de los pacientes optan por la anestesia local, ya que la recuperación es más rápida y puede volver a casa poco después. Si prefiere permanecer dormido, también es una opción válida; hable al respecto con su cirujano y anestesista. Luego será conducido al quirófano, donde se realiza la operación. Posteriormente, despertará en la sala de recuperación, donde las enfermeras le vigilarán mientras la anestesia va desapareciendo. Una vez que su estado sea estable, podrá volver a casa o permanecer un breve tiempo en la sala de hospitalización, según el tipo de intervención y su evolución.
Descripción del procedimiento quirúrgico¶
El procedimiento se denomina liberación del túnel carpiano. El cirujano realiza una única incisión en la zona a operar, en la muñeca y la palma de la mano. A través de dicha incisión, el cirujano accede a la banda de tejido tensa que forma el techo del túnel carpiano, un canal estrecho en la muñeca por donde pasa el nervio. Al cortar esa banda, se abre el túnel y se elimina la presión sobre el nervio. No es necesario reparar dicha banda; esta cicatriza dejando más espacio para el nervio.
Posteriormente, la incisión se cierra con puntos de sutura. Luego se coloca un vendaje grueso y acolchado alrededor de la mano y la muñeca. Deberá mantener este vendaje durante unos 10 días, tal como se describe en la siguiente sección.
El procedimiento en sí es breve y usted podrá volver a casa el mismo día. Antes de que firme el formulario de consentimiento, el cirujano le explicará nuevamente todos los pasos del proceso; además, podrá plantear cualquier pregunta en cualquier momento.
Después de la operación¶
Despertará en la sala de recuperación, donde las enfermeras lo vigilarán mientras el efecto de la anestesia desaparece. Su mano estará cubierta con un vendaje grueso y acolchado; además, le administraremos analgésicos para mantenerlo cómodo. Se trata de una intervención ambulatoria, por lo que podrá volver a casa el mismo día. Por favor, asegúrese de que alguien permanezca con usted durante las primeras 24 horas. Dejamos el vendaje puesto durante unos 10 días; no lo retire antes de ese plazo, a menos que se lo indiquemos. Lo cambiaremos o lo retiraremos cuando venga a la consulta. Mantenga la mano elevada cuando descanse, y úsela con cuidado para tareas ligeras en cuanto se sienta capaz. La mayoría de los pacientes vuelven a conducir en una o dos semanas, una vez que la herida no les molesta y pueden agarrar el volante y girarlo sin proteger la mano operada. Consulte Conducción después de una cirugía de miembro superior.
Recuperación¶
Durante los primeros días, su mano estará adolorida e hinchada, y el vendaje acolchado le parecerá voluminoso. Mantenga la mano elevada cuando esté descansando, ya que esto reduce la hinchazón y el malestar. Por lo general, un analgésico sencillo es suficiente; muchas personas no necesitan medicamentos fuertes para el dolor tras esta cirugía.
En cuanto se sienta capaz, podrá usar la mano con cuidado para tareas ligeras. El vendaje se mantiene puesto hasta su próxima consulta; una vez retirado, podrá lavarse y ducharse con normalidad. Los puntos de sutura se retiran en esa misma visita de seguimiento. La terapia de mano posterior a la cirugía la llevará a cabo Ruby Doolan en Extend Rehabilitation; ella le guiará en los ejercicios y confeccionará una férula si es necesario para su comodidad. Los movimientos suaves ayudan a que el nervio se estabilice, por lo que irá utilizando más la mano con el paso de las semanas.
A medida que la hinchazón disminuya, notará que el hormigueo y el entumecimiento se reducen y que recupera la fuerza de agarre. Cuando pueda agarrar y girar objetos sin dolor, las actividades cotidianas volverán a ser normales. El alivio oportuno de la presión sobre el nervio permite que la sensibilidad y la función de la mano se restauren. Si presentaba síntomas en ambas manos, podremos analizar la posibilidad de operarlas en la misma sesión.
La recuperación varía según cada persona; su cronograma puede ser distinto. Su cirujano y terapeuta lo guiarán durante todo el proceso.
Qué puede salir mal¶
La mayoría de los pacientes evolucionan bien, pero en ocasiones pueden surgir problemas. Su cirujano y el equipo lo vigilarán de cerca para detectar cualquier anomalía a tiempo.
Infección. Una infección de la herida puede manifestarse como enrojecimiento que se extiende desde el corte, calor en la zona o secreción de líquido. Es posible que sienta un dolor profundo y palpitante que no mejora con analgésicos comunes, o que le suba la fiebre. Si nota alguno de estos síntomas, llame a la clínica ese mismo día. Si se siente mal o el enrojecimiento se extiende rápidamente, acuda a urgencias. Hay factores que aumentan el riesgo de infección, como una inyección de esteroides en la muñeca poco antes de la cirugía o ciertas condiciones médicas. Hablaremos de todo lo relevante para usted antes de la operación.
Problemas de la herida. En algunas ocasiones, los bordes de la herida tardan más en cicatrizar o se abren ligeramente; también puede acumularse sangre bajo la piel, provocando hinchazón. Es posible que vea que los puntos de sutura se separan o note un bulto duro y sensible cerca del corte. Comente esto en su visita de seguimiento, o llame a la clínica antes si la situación empeora.
Irritación nerviosa. El nervio que se libera se encuentra cerca de la zona operatoria, por lo que puede sufrir hematomas o irritación durante la cirugía. Esto suele manifestarse como hormigueo, entumecimiento o sensación de pinchazos en la mano, o como una zona de la piel que se siente distinta a antes. La mayoría de las irritaciones nerviosas desaparecen con el tiempo, aunque algunos cambios pueden persistir. Informe a su cirujano en la siguiente revisión si nota entumecimiento nuevo que no mejora.
Síntomas que reaparecen o no desaparecen por completo. En ocasiones la presión sobre el nervio no se elimina por completo, o el túnel se estrecha de nuevo con el paso de los meses o años. Es posible que vuelva a notar el hormigueo, el entumecimiento o el dolor nocturno iniciales. Si esto ocurre, mencione el tema en su revisión. En algunos casos es necesaria una cirugía adicional; su cirujano ordenará las pruebas pertinentes para determinar el motivo.
En la tabla de complicaciones de esta página se detallan las tasas típicas, por si desea conocer los datos específicos.
¿Cuándo deben contactarnos?¶
La mayoría de las personas se recuperan sin problemas; sin embargo, existen ciertos síntomas que requieren atención inmediata. Llámenos si presenta fiebre, enrojecimiento creciente o secreción en la herida, o si el dolor empeora progresivamente. Comuníquese con nosotros si nota entumecimiento nuevo en la mano que no mejora, o si no puede mover los dedos. Acuda a urgencias si experimenta dolor intenso y repentino, hinchazón o dolor en la pantorrilla, o dificultad para respirar. Si tiene dudas, llame a la clínica y le brindaremos orientación.
¿Dónde leer más sobre esta afección?¶
Esta página trata sobre la operación en sí. La afección que se trata con ella, incluyendo lo que demuestran las evidencias sobre cuándo la cirugía es útil y cuándo no, se explica con mayor detalle en la página de Síndrome del túnel carpiano.
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Overview¶
- Symptoms of pain, numbness, and tingling in the hands are common in the general population [1].
Anatomy & Pathophysiology¶
Epidemiology & Symptoms¶
- Carpal tunnel syndrome with compression of the median nerve at the wrist is the most commonly diagnosed site of nerve compression in the upper extremity [10].
- Symptoms include paresthesia or numbness (or both) in the median nerve distribution, specifically the thumb, index finger, middle finger, and radial side of the ring finger [10].
- Nocturnal paresthesias in the radial three digits of the hand is nearly pathognomonic for carpal tunnel syndrome [10].
- Paresthesias occur characteristically in "fixed wrist activities" such as reading a book or a newspaper, driving, or use of a computer keyboard or mouse [10].
- Patients rarely describe aching in the thenar eminence [10].
- With advanced nerve compression, weakness and atrophy of the abductor pollicis brevis and opponens pollicis muscles occur [10].
- Because of the slow onset of thenar weakness, patients typically adapt to this loss without functional impairments [10].
Pathogenesis¶
- Bony abnormalities of the carpal bones can decrease the size of the carpal tunnel [5].
- Acromegaly can decrease the size of the carpal tunnel [5].
- Flexion or extension of the wrist can decrease the size of the carpal tunnel [5].
- Forearm and wrist fractures, including Colles fracture and scaphoid fracture, can increase the contents of the carpal canal [5].
- Dislocations and subluxations, including scaphoid rotary subluxation and lunate volar dislocation, can increase the contents of the carpal canal [5].
- Posttraumatic arthritis with osteophytes can increase the contents of the carpal canal [5].
- Musculotendinous variants can increase the contents of the carpal canal [5].
- Aberrant muscles, including lumbrical, palmaris longus, and palmaris profundus, can increase the contents of the carpal canal [5].
- Local tumors, including neuroma, lipoma, multiple myeloma, and ganglion cysts, can increase the contents of the carpal canal [5].
- A persistent medial artery, whether thrombosed or patent, can increase the contents of the carpal canal [5].
- Hypertrophic synovium can increase the contents of the carpal canal [5].
- Hematoma resulting from hemophilia, anticoagulation therapy, or trauma can increase the contents of the carpal canal [5].
- Diabetes mellitus is a neuropathic condition involved in the pathogenesis of carpal tunnel syndrome [5].
- Alcoholism is a neuropathic condition involved in the pathogenesis of carpal tunnel syndrome [5].
- Double-crush syndrome is a neuropathic condition involved in the pathogenesis of carpal tunnel syndrome [5].
- Exposure to industrial solvents is a neuropathic condition involved in the pathogenesis of carpal tunnel syndrome [5].
- Rheumatoid arthritis is an inflammatory condition involved in the pathogenesis of carpal tunnel syndrome [5].
- Gout is an inflammatory condition involved in the pathogenesis of carpal tunnel syndrome [5].
- Nonspecific tenosynovitis is an inflammatory condition involved in the pathogenesis of carpal tunnel syndrome [5].
- Infection is an inflammatory condition involved in the pathogenesis of carpal tunnel syndrome [5].
- Pregnancy involves alterations of fluid balance in the pathogenesis of carpal tunnel syndrome [5].
- Menopause involves alterations of fluid balance in the pathogenesis of carpal tunnel syndrome [5].
- Eclampsia involves alterations of fluid balance in the pathogenesis of carpal tunnel syndrome [5].
- Thyroid disorders, especially hypothyroidism, involve alterations of fluid balance in the pathogenesis of carpal tunnel syndrome [5].
- Renal failure involves alterations of fluid balance in the pathogenesis of carpal tunnel syndrome [5].
- Long-term hemodialysis involves alterations of fluid balance in the pathogenesis of carpal tunnel syndrome [5].
- Raynaud disease involves alterations of fluid balance in the pathogenesis of carpal tunnel syndrome [5].
- Obesity involves alterations of fluid balance in the pathogenesis of carpal tunnel syndrome [5].
- Lupus erythematosus involves alterations of fluid balance in the pathogenesis of carpal tunnel syndrome [5].
- Scleroderma involves alterations of fluid balance in the pathogenesis of carpal tunnel syndrome [5].
- Amyloidosis involves alterations of fluid balance in the pathogenesis of carpal tunnel syndrome [5].
- Paget disease involves alterations of fluid balance in the pathogenesis of carpal tunnel syndrome [5].
- Vibration is an external force involved in the pathogenesis of carpal tunnel syndrome [5].
- Direct pressure is an external force involved in the pathogenesis of carpal tunnel syndrome [5].
Anatomical Structures & Surgical Landmarks¶
- The palmar cutaneous sensory branch of the median nerve lies in the interval between the palmaris longus and the flexor carpi radialis tendons [4].
- The palmar cutaneous branch of the median nerve is located deep to the thenar crease and radial to the palmaris longus [11].
- The superficial palmar arterial arch is 5 to 8 mm distal to the distal margin of the transverse carpal ligament [4].
- The flexor retinaculum includes the distal deep fascia of the forearm proximally, the transverse carpal ligament, and the aponeurosis between the thenar and hypothenar muscles [4].
- Fibers of the transverse carpal ligament can extend distally farther than expected [4].
- The recurrent branch of the median nerve may perforate the transverse carpal ligament and leave the median nerve on the volar side [4].
- Potential anatomical anomalies include connections between the flexor pollicis longus and the index flexor digitorum profundus tendons [4].
- Potential anatomical anomalies include anomalous flexor digitorum superficialis [4].
- Potential anatomical anomalies include palmaris longus, hypothenar, and lumbrical muscle bellies [4].
- Potential anatomical anomalies include median and ulnar nerve branches and interconnections [4].
- The thenar crease takes a variable course [4].
- A crossing cutaneous branch from the ulnar nerve is identified in a distal portion of the incision about 15% of the time [11].
Diagnostic & Prognostic Factors¶
- Carpal tunnel syndrome is a clinical diagnosis based on a combination of symptoms and characteristic physical findings [10].
- Electrodiagnostic studies are useful to stage the degree of nerve compression and assist in anticipating the time needed for recovery of nerve function [10].
- Patients with long-standing symptoms, severe atrophy of the thenar musculature, and dense sensory loss should be cautioned that release may not lead to complete recovery of sensation or thenar strength [10].
- Ultrasound sensitivity for carpal tunnel syndrome has been reported to be over 97% when the median nerve diameter is greater than 10 mm² at the level of the pisiform [5].
- In patients with negative electrodiagnostic studies but a clinical diagnosis of carpal tunnel syndrome, high-resolution ultrasonography has a sensitivity of 73% if the cutoff of 9.4 mm² at the inlet of the carpal tunnel is used [5].
- The diagnosis of carpal tunnel syndrome should be based on clinical acumen and physical examination in the vast majority of patients [5].
- Ancillary tests should be reserved for patients without clear presentations [5].
- MRI is not routinely used for diagnosis of carpal tunnel syndrome [5].
- A major advantage of MRI is its high soft-tissue contrast, which gives detailed images of bones and soft tissues [5].
- Reported false-negative rates of electrodiagnostic testing are 10% [5].
- Postoperative electrodiagnostic testing may be helpful in assessing recurrent symptoms [5].
Clinical Presentation¶
Epidemiology and Risk Factors¶
- Carpal tunnel syndrome is the most common compression neuropathy of the upper extremity [9].
- The mean age at diagnosis for carpal tunnel syndrome is 50 years [9].
- Carpal tunnel syndrome is more common in women than men by nearly four times [9].
- By the age of 65 years, the prevalence of carpal tunnel syndrome is approximately 5.1% for women and 1.3% for men [9].
- Risk factors for carpal tunnel syndrome include obesity, pregnancy, hypothyroidism, diabetes mellitus, and menopause [9].
- The American Academy of Orthopaedic Surgeons guidelines list body mass index (BMI) and high hand repetition rate as factors with strong evidence of increased risk for development of carpal tunnel syndrome [9].
Clinical Symptoms and Signs¶
- Classically, carpal tunnel syndrome presents with nocturnal paresthesias in a median nerve distribution that gradually worsen as nerve injury progresses [9].
- Late in the disease course, carpal tunnel syndrome leads to sensory loss and thenar muscle atrophy [9].
- Many patients report pain in the hand and may report symptoms that are not directly referable to the median nerve [9].
- A positive Tinel sign at the wrist can aid in the diagnosis of carpal tunnel syndrome [9].
- Development of symptoms after a provocative Phalen maneuver can aid in the diagnosis of carpal tunnel syndrome [9].
- The reported specificity of the Tinel sign at the wrist varies from 55% to 100% [9].
- The reported specificity of the Phalen test varies from 54% to 98% [9].
- Tinel sign and Phalen maneuver are most reliable as adjuncts to other diagnostic tests [9].
Diagnostic Testing¶
- Nerve conduction studies are a useful diagnostic tool for carpal tunnel syndrome, assessing focal demyelination by delayed conduction velocities of the median nerve at the wrist [9].
- Needle electromyography is considered an optional adjunct to nerve conduction studies and is mostly used to differentiate carpal tunnel syndrome from other possible causes [9].
- Documenting muscle atrophy and fibrillations on needle EMG can assist with identifying severity of the disease and help with prognostication [9].
- Thenar atrophy and abductor pollicis brevis weakness can often be detected on physical examination [9].
- Ultrasonography allows rapid diagnosis of carpal tunnel syndrome by identification of enlarged, hypoechoic median nerve fascicles proximal to the carpal tunnel [9].
- Controversy remains as to whether ultrasonography evaluation could replace electrophysiology in the diagnosis of carpal tunnel syndrome [9].
- MRI and/or ultrasonography imaging should be considered in patients who have new, persistent, or recurrent symptoms after surgery to delineate the etiology of the symptoms [9].
- Ancillary tests for carpal tunnel syndrome should be reserved for patients without clear presentations [5].
- Reports of MRI in carpal tunnel syndrome are promising, especially with newer techniques such as diffusion tensor imaging [5].
Pathogenesis Factors¶
- Bony abnormalities of the carpal bones are a factor involved in the pathogenesis of carpal tunnel syndrome [5].
- Acromegaly is a factor involved in the pathogenesis of carpal tunnel syndrome [5].
- Flexion or extension of the wrist is a factor involved in the pathogenesis of carpal tunnel syndrome [5].
- Forearm and wrist fractures, such as Colles fracture and scaphoid fracture, are factors involved in the pathogenesis of carpal tunnel syndrome [5].
- Dislocations and subluxations, such as scaphoid rotary subluxation and lunate volar dislocation, are factors involved in the pathogenesis of carpal tunnel syndrome [5].
- Posttraumatic arthritis with osteophytes is a factor involved in the pathogenesis of carpal tunnel syndrome [5].
- Musculotendinous variants are a factor involved in the pathogenesis of carpal tunnel syndrome [5].
- Aberrant muscles, including lumbrical, palmaris longus, and palmaris profundus, are factors involved in the pathogenesis of carpal tunnel syndrome [5].
- Local tumors, including neuroma, lipoma, multiple myeloma, and ganglion cysts, are factors involved in the pathogenesis of carpal tunnel syndrome [5].
- A persistent medial artery, whether thrombosed or patent, is a factor involved in the pathogenesis of carpal tunnel syndrome [5].
- Hypertrophic synovium is a factor involved in the pathogenesis of carpal tunnel syndrome [5].
- Hematoma from hemophilia, anticoagulation therapy, or trauma is a factor involved in the pathogenesis of carpal tunnel syndrome [5].
- Pregnancy is an alteration of fluid balance involved in the pathogenesis of carpal tunnel syndrome [5].
- Menopause is an alteration of fluid balance involved in the pathogenesis of carpal tunnel syndrome [5].
- Eclampsia is an alteration of fluid balance involved in the pathogenesis of carpal tunnel syndrome [5].
- Thyroid disorders, especially hypothyroidism, are alterations of fluid balance involved in the pathogenesis of carpal tunnel syndrome [5].
- Renal failure is an alteration of fluid balance involved in the pathogenesis of carpal tunnel syndrome [5].
- Long-term hemodialysis is an alteration of fluid balance involved in the pathogenesis of carpal tunnel syndrome [5].
- Raynaud disease is an alteration of fluid balance involved in the pathogenesis of carpal tunnel syndrome [5].
- Obesity is an alteration of fluid balance involved in the pathogenesis of carpal tunnel syndrome [5].
- Lupus erythematosus is an alteration of fluid balance involved in the pathogenesis of carpal tunnel syndrome [5].
- Scleroderma is an alteration of fluid balance involved in the pathogenesis of carpal tunnel syndrome [5].
- Amyloidosis is an alteration of fluid balance involved in the pathogenesis of carpal tunnel syndrome [5].
- Paget disease is an alteration of fluid balance involved in the pathogenesis of carpal tunnel syndrome [5].
Investigations¶
Clinical Presentation and Prevalence¶
- The American Academy of Orthopaedic Surgeons (AAOS) guidelines list body mass index (BMI) and high hand repetition rate as factors with strong evidence of increased risk for development of carpal tunnel syndrome [9].
Physical Examination¶
Electrodiagnostic Testing¶
- Nerve conduction studies remain a useful diagnostic tool in carpal tunnel syndrome [9].
- Focal demyelination in carpal tunnel syndrome can be assessed by delayed conduction velocities of the median nerve at the wrist [9].
- Needle electromyography is currently considered an optional adjunct to nerve conduction studies [9].
- Needle electromyography is mostly used to differentiate carpal tunnel syndrome from other possible causes [9].
- Pre-operative electrodiagnostic testing predicts time to resolution of symptoms after carpal tunnel release [3].
- Reported false-negative rates of 10% limit the usefulness of electrodiagnostic testing to determine treatment [5].
- Electrodiagnostic testing does not increase the diagnostic value of the four commonly used clinical tests (abnormal hand diagram, abnormal Semmes-Weinstein, positive Durkan compression, and night pain) [5].
- Electrodiagnostic testing does not predict functional recovery or reemployment after carpal tunnel release [5].
Imaging¶
- MRI is not routinely used for the diagnosis of carpal tunnel syndrome [5].
- Advances in ultrasonography technology have allowed rapid diagnosis of carpal tunnel syndrome by identification of enlarged, hypoechoic median nerve fascicles proximal to the carpal tunnel [9].
- Imaging can help identify causes of postoperative symptoms such as incomplete ligament division, iatrogenic injury, or other causes [9].
Diagnostic Principles¶
- The diagnosis of carpal tunnel syndrome is made by clinical history, physical examination, and supportive diagnostic testing with exclusion of other possible disorders [9].
Treatment¶
Operative Technique¶
- Palmar incisions for carpal tunnel release should be placed well ulnar to the thenar crease to avoid injury to the median nerve palmar cutaneous branch [4].
- A curved incision ulnar and parallel to the thenar crease is not advisable because the palmar cutaneous branch of the median nerve may be at higher risk of injury proximally [4].
- The incision should be extended proximally to the wrist flexion crease and angled toward the ulnar side of the wrist to avoid crossing flexor creases at a right angle [4].
- The palmar cutaneous sensory branch lies in the interval between the palmaris longus and the flexor carpi radialis tendons [4].
- If the palmar sensory branch is severed, it frequently causes a painful neuroma that may later require excision from the scar [4].
- When the palmar sensory branch is severed, repair is not attempted; instead, the nerve is sectioned more proximally to be covered by the middle finger sublimis muscle [4].
- The transverse carpal ligament (TCL) must be carefully divided while avoiding damage to the median nerve and its recurrent branch, which may perforate the ligament and leave the median nerve on the volar side [4].
- Fibers of the TCL can extend distally farther than expected [4].
- The flexor retinaculum includes the distal deep fascia of the forearm proximally, the TCL, and the aponeurosis between the thenar and hypothenar muscles [4].
- A successful carpal tunnel release usually requires division of all components of the flexor retinaculum [4].
- Potential anatomical anomalies to be aware of include connections between the flexor pollicis longus and index flexor digitorum profundus tendons, anomalous flexor digitorum superficialis, palmaris longus/hypothenar/lumbrical muscle bellies, and median/ulnar nerve branches and interconnections [4].
- The superficial palmar arterial arch is located 5 to 8 mm distal to the distal margin of the TCL and must be avoided [4].
- Tenosynovectomy is occasionally indicated, especially in patients with rheumatoid arthritis [4].
- Closure involves only the skin, with wound drainage as needed [4].
Postoperative Care¶
- A light compression dressing and a volar splint may be applied postoperatively [4].
- The hand is actively used as soon as possible after surgery, but the dependent position is avoided [4].
- The dressing can usually be removed by the patient at home 2 or 3 days after surgery [4].
- Gentle washing and showering of the hand are permitted after dressing removal [4].
- Gradual resumption of normal hand use is encouraged [4].
- Sutures are removed after 10 to 14 days [4].
- A splint may be continued for comfort as needed for 14 to 21 days [4].
Complications¶
- Transection of the motor branch of the ulnar nerve is a complication of two-portal endoscopic carpal tunnel release [2].
- Scar discomfort can occur after carpal tunnel surgery [2].
- Recurrent carpal tunnel syndrome is a recognized clinical entity following carpal tunnel release [2].
- Poor outcome is associated with neural surgery (epineurotomy or neurolysis) for carpal tunnel syndrome compared with carpal tunnel release alone [2].
- Symptoms may return after carpal tunnel surgery [2].
- Complications related to carpal tunnel release are a documented clinical concern [2].
- Carpal tunnel release in patients with diabetes results in poor outcomes in long-term study [3].
Key Evidence¶
- [L4] Symptoms of pain, numbness, and tingling in the hands are common in the general population. [1] (10.1001/jama.282.2.153)
References¶
[1] Prevalence of Carpal Tunnel Syndrome in a General Population. JAMA. 1999. DOI: 10.1001/jama.282.2.153
[2] Campbell S Operative Orthopaedics 4 Volume Set. COMPRESSIVE NEUROPATHIES OF THE HAND, FOREARM, AND ELBOW > CARPAL TUNNEL SYNDROME.
[3] Campbell S Operative Orthopaedics 4 Volume Set. COMPRESSIVE NEUROPATHIES OF THE HAND, FOREARM, AND ELBOW > REFERENCES > CARPAL TUNNEL SYNDROME.
[4] Campbell S Operative Orthopaedics 4 Volume Set. COMPRESSIVE NEUROPATHIES OF THE HAND, FOREARM, AND ELBOW > EXTENDED OPEN CARPAL TUNNEL RELEASE.
[5] Campbell S Operative Orthopaedics 4 Volume Set. COMPRESSIVE NEUROPATHIES OF THE HAND, FOREARM, AND ELBOW > CARPAL TUNNEL SYNDROME > BOX 77.1.
[9] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Neuropathies, Vascular Conditions: Buerger’s, Raynaud’s; Degenerative Conditions > Upper Extremity Neuropathies > Carpal Tunnel Syndrome.
[10] Green S Operative Hand Surgery. Median Nerve Compression at the Elbow and Forearm > COMPRESSION OF THE MEDIAN NERVE > Median Nerve Compression at the Wrist: Carpal Tunnel Syndrome.
[11] Green S Operative Hand Surgery. Median Nerve Compression at the Elbow and Forearm > AUTHORS’ PREFERRED METHOD OF TREATMENT: OPEN CARPAL TUNNEL RELEASE.