Charles Carroll IV and David M. Kalainov

1. Persistent pain, numbness, or weakness in the median nerve distribution that is not due to cervical radiculitis, brachial plexopathy, pronator syndrome, or nerve laceration and

2. Positive findings on physical examination (Tinel, Phalen, carpal compression) and

3. Failure of nonoperative management (splinting, steroid injections)

1. Inconsistent clinical history and/or equivocal physical examination

2. Negative electrodiagnostic study (relative)

3. Psychological and socioeconomic issues that may preclude a good surgical outcome

1. Appropriate history and physical examination

2. AP and lateral wrist X-rays

3. Consider electrodiagnostic testing.

1. Position patient supine with the hand on a table extension.

2. Upper extremity padded tourniquet(s) set to 250-mm Hg

3. Hand instruments and low-power loupe magnification

4. Microscope if neurolysis is anticipated

5. Local or regional block with intravenous sedation

1. Obtain hemostasis during exposure.

2. Identify the superficial palmar arch, Guyon’s canal, and carpal tunnel before releasing the transverse carpal ligament.

3. Dissect beneath the transverse carpal ligament with a smooth curved clamp and divide the tissue sharply. Use curved blunt-tipped scissors to release proximal ligament/forearm fascia.

4. Dissect ulnar to the median nerve to minimize the risk of injury to the motor branch. The motor branch may vary in position beneath the ligament.

6. If the incision is carried proximally across the wrist creases, stay ulnar to the palmaris longus tendon to minimize the risk of injury to the palmar cutaneous branch of the median nerve. The incision should cross the wrist crease obliquely to minimize the risk of skin contracture.

7. Loosely reapproximate the skin edges.