Operative Technique in Plastic Surgery – Kevin C.Chung

2B,C).
■ Pain with loss of wrist ROM compared to the contralateral side is indicative of
wrist arthritis.
■ Provocative testing of the distal radioulnar joint (DRUJ) with dorsal and
palmar stress (a shuck test) may indicate DRUJ involvement.
IMAGING
■ Standard three-view radiographs of the hand and wrist are typically sufficient
for evaluation of OA.
■ Further imaging such as CT scan or MRI is usually not routine but may be
useful in select situations, such as evaluating the wrist for midcarpal arthritis.
■ OA is characterized by narrowed joint spaces due to loss of radiolucent
articular cartilage.
■ In addition, osteophytes and loose bodies may be present.
■ Subchondral cysts and sclerosis are signs of more advanced disease (see FIG
1).
■ Patient symptoms do not always correlate with the radiographic severity of
disease. As such, interventions should be based on patient complaints and
general goals.
PATHOGENESIS AND ETIOLOGY
■ In primary, or idiopathic, OA, there is no identifiable cause.
■ In secondary OA, articular loss is a result of traumatic injury, such as intra-
articular fractures, ligamentous injuries that lead to unfavorable articular load-
bearing characteristics, or joint infections.
■ Generally, OA develops as a result of an imbalance between the destruction
and repair of articular cartilage.

FIG 1 • Radiograph of bilateral hands displays typical
characteristics of osteoarthritis, including joint space
narrowing (yellow arrowheads), osteophyte formation
(blue arrowhead), and subchondral cyst and associated
sclerosis (red arrowhead).

FIG 2 • A. Example of Heberden nodes (red
arrowheads) and Bouchard nodes (yellow arrowheads).
B. Mucous cyst on dorsal DIPJ of ring finger
(arrowhead). C. A circular incision was used to excise
the cyst down to the joint. An osteophyte was removed
at the base of the cyst. A skin flap (marked) was
advanced to close the remaining defect.
■ Clefts in the articular surface and a decrease in cartilage thickness eventually
progress to exposure of the subchondral bone.
■ Bone density increases, as demonstrated by sclerotic changes seen on
radiographs, and overly exuberant bone formation may produce osteophytes
at the joint periphery. In addition, the synovial membranes become inflamed
as cartilage fragments are embedded within them.
■ Because of these mechanical factors and pain, joint motion is progressively
lost, leading to joint stiffness as the capsule and associated ligaments
contract.
■ Hand
■ In the hand, OA most commonly affects the DIPJs of the fingers and the
CMCJ of the thumb.

■ OA then affects the PIPJs and metacarpophalangeal joints (MCPJs),
respectively.
■ Wrist
■ Scaphotrapeziotrapezoid (STT) joint arthritis is one of the most common
presentations of idiopathic OA of the wrist.
■ Other causes of primary wrist OA include avascular necrosis of the lunate
(Kienbock disease) or the scaphoid (Preiser disease), which can lead to
degenerative changes later on.
■ Congenital conditions, including Madelung deformity, can also alter the
articular load, leading to wrist OA.
■ Secondary OA is usually trauma related and most frequently develops after
distal radius fractures (DRFs), scaphoid fractures, and scapholunate
ligamentous injuries.
■ Intra-articular DRFs can lead to a 91% incidence of arthritis if any degree of
articular step-off remains after fracture reduction, but only an 11% incidence
if a congruent articular reduction is achieved.
• Extra-articular DRFs can also lead to wrist OA due to the development of
abnormal load-bearing patterns across the wrist.
• Up to 11% of DRFs are associated with instability of the DRUJ, leading to
DRUJ arthritis.2
• Of note, rheumatoid arthritis is the most common inflammatory arthritis to
involve the DRUJ.
■ Scaphoid fractures may fail to heal in 5% to 10% of cases, leading to a pattern
of carpal instability termed scaphoid nonunion advanced collapse (SNAC)
arthritis.
■ SNAC wrist typically starts with arthritis at the radial styloid-scaphoid
articulation (stage 1) and progresses to the radioscaphoid and scaphocapitate
articulations (stage 2) and finally the lunocapitate articulation (stage 3).
■ Similarly, a scapholunate ligament injury can initiate progressive carpal
instability and arthritis starting at the radial styloid (stage 1) and progressing to
the proximal scaphoid and scaphoid fossa of the radius (stage 2) and finally the
midcarpal joint at the lunocapitate articulation (stage 3).
■ This is cumulatively known as scapholunate advanced collapse (SLAC)
arthritis.
■ The radiolunate joint is typically spared in the SLAC wrist because of the
unique congruency of this joint.

NONOPERATIVE MANAGEMENT
■ Because there is no cure for OA and no effective method to alter disease
progression, the mainstay of treatment is nonoperative and focuses on symptom
management.
■ Patients may engage in lifestyle modifications, hot and cold therapy, splinting,
oral or topical anti-inflammatory medications such as nonsteroidal anti-
inflammatory drugs (NSAIDs), or alternative methods such as acupuncture or
electrostimulation.
■ Steroid injections into the affected joints may provide short-term relief.
SURGICAL MANAGEMENT
Preoperative Planning
■ As OA patients are typically older with multiple comorbid conditions, a full
medical workup is recommended prior to surgery.
Positioning
■ The patient is positioned supine on the operative table and padded
comfortably.
■ The upper extremity is abducted onto the attached hand table.
■ A tourniquet is placed on the upper arm.
Approach
■ The indications for surgery in OA patients include refractory pain, loss of
motion, and/or joint instability leading to decreased function.
■ Surgical methods for the treatment of OA generally involve joint debridement,
arthrodesis, arthroplasty, and load-altering procedures.
Fingers
■ Because the DIPJs are the most commonly affected joints in OA, surgery
typically involves the removal of an enlarged osteophyte and/or excision of a
mucous cyst.
■ If the joint is destroyed, arthrodesis at about 5 to 10 degrees of flexion is
preferred.
■ The PIPJs are treated with arthrodesis or arthroplasty.
■ For the radial digits, arthrodesis of the PIPJs with K-wires, screws, or tension
banding is preferred in order to provide a strong post for pinch.

■ The PIPJ of the index finger should be fused at 25 degrees of flexion,
advancing by 5 degrees with each finger ulnarly, if required, for the most
functional posture.
■ The PIPJs of the ulnar digits require more motion for grip, however, and
should be considered for arthroplasty.
■ Silicone arthroplasty provides limited motion to the PIPJs (30–60 degrees)
and has a high fracture rate but can easily be revised.
■ Pyrocarbon implants provide greater motion, but implant dislocation may
occur, and high complication rates have led to this approach falling out of
favor for PIPJs.
■ We have abandoned the pyrocarbon implant in favor of the silicone implant
using the volar approach for the PIPJ.
Thumb
■ As the second most commonly affected joint in OA, the thumb CMCJ (ie, the
trapeziometacarpal [TM] joint) is surgically treated with volar ligament
reconstruction, arthroplasty, or arthrodesis.
■ Although the initial treatment may consist of splinting or steroid injections,
most patients presenting to surgeons already have sufficient joint destruction
to warrant surgery.
■ The Eaton classification3,4 (Table 1) of TM osteoarthritis describes and
categorizes the radiographic progression of the disease. However, surgical
planning is based on patient symptoms and complaints, not Eaton
classification.
■ For early OA (Eaton stage I), which may be characterized symptomatic
instability or laxity of the thumb TM joint, volar ligament reconstruction is
indicated (Eaton-Littler procedure).
■ For Eaton stage II to IV disease, loss of articular cartilage precludes the
possibility of joint salvage. Surgical options fall into four major categories:
Table 1 Eaton Classification of Trapeziometacarpal (TM) Osteoarthritis3,4
Stage
Radiographic Characteristics
I
• Normal or slightly widened TM joint
• TM subluxation up to 1/3 of articular surface
• Normal articular contours
II

• Decreased TM joint space
• TM subluxation up to 1/3 of articular surface
• Osteophytes or loose bodies less than 2 mm
III
• Decreased TM joint space
• TM subluxation greater than 1/3 of articular surface
• Osteophytes or loose bodies greater than or equal to 2 mm
• Subchondral cysts or sclerosis
IV
• Pantrapezial arthritis with stage III features
• Involvement of the scaphotrapezial, trapeziotrapezoid, and/or
the trapezio-index metacarpal joints
■ Trapeziectomy alone
■ Trapeziectomy with soft tissue arthroplasty via ligament reconstruction and
tendon interposition (LRTI) or an abductor pollicis longus (APL)
suspensionplasty
■ Arthrodesis
■ Prosthetic arthroplasty
■ Because of high complication rates with prostheses and lack of outcomes data
to show their effectiveness over autologous options, we do not advocate the use
of a prosthesis for the thumb TM joint.
■ For heavy laborers, thumb TM arthrodesis is preferred for joint stability and
strength.5 In these cases, the thumb TM joint should be fused at 30 to 40
degrees of abduction, 15 to 20 degrees of extension, and 15 degrees of
pronation to allow tip-to-tip pinch.
■ In any case, the presence of thumb MCPJ instability or hyperextension
greater than 30 to 45 degrees may also warrant concomitant volar plate
advancement or MCPJ fusion to avoid failure of the reconstructed TM joint.
Wrist
■ Surgical treatment of wrist OA is focused on pain reduction. The specific
treatment is formulated based on the patient’s symptoms, arthritic pattern, and
functional demands.
■ The selected approach should always account for future additional
procedures should the most current option fail.
■ In general, surgical options include joint debridement, denervation,
arthroplasty, partial vs total wrist arthrodesis, or a combination thereof.

■ A radial styloidectomy can be performed for arthritis at the radial styloid.
■ Wrist denervation is an option that has been shown to provide partial pain
relief in patients and can be considered if selective blocks of the anterior
interosseous nerve (AIN) and posterior interosseous nerve (PIN) prove
favorable.
■ A proximal row carpectomy (PRC), in which the scaphoid, lunate, and
triquetrum are removed, is an option when there is no arthritis at the midcarpal
joint or radiolunate joint.
■ Midcarpal and radiocarpal arthritis can be treated with a scaphoidectomy and
four-corner fusion, in which the scaphoid is removed and fusion of the lunate,
capitate, triquetrum, and hamate is performed.
■ For the arthritic DRUJ, surgical options include resection arthroplasties,
including the Darrach procedure, hemiresection ulnar arthroplasty, the Sauve-
Kapandji procedure, and prosthetic replacement of the ulnar head or DRUJ.2
■ The Darrach procedure involves resection of the entire distal ulna and has
been advocated for low-demand elderly patients.
■ The Sauve-Kapandji procedure preserves the head of the ulna while fusing
the DRUJ to prevent ulnar translocation of the carpus.
■ Hemiresection ulnar arthroplasty, in which the radiocarpal joint surface of
the ulna is resected while maintaining the triangular fibrocartilage complex
(TFCC), is often preferred over the Darrach procedure because of improved
postoperative wrist stability. Prosthetic replacement of the ulnar head or
DRUJ is a less common option for the arthritic DRUJ.
■ In cases of significantly advanced arthritis, wrist arthroplasty or fusion may be
the only remaining surgical options.
■ Wrist arthroplasty provides motion at the expense of strength and is
considered only in select patients with low-demand wrists or who have fusion
of the contralateral wrist. Patients with OA tend to fit this profile, as opposed
to those with OA.
■ Total wrist fusion is the ultimate salvage option for all types of wrist arthritis,
achieving both pain relief and strength.
T E C H N I Q U E S

■ Distal Interphalangeal Joint Arthrodesis
■ The distal interphalangeal joint (DIPJ) is exposed dorsally with a T-shaped
incision (TECH FIG 1A).
■ The extensor tendon is transversely divided, leaving a 5-mm distal stump for
later repair.
■ The radial and ulnar collateral ligaments are divided, allowing the joint to
hinge open.
■ Joint debridement is performed using a small rongeur, removing inflamed
capsule, ganglions, osteophytes, and residual cartilage.
■ A rongeur is used to fashion a concave “trough” at the base of the distal
phalanx and a convex “crest” at the head of the middle phalanx until the
surfaces align (TECH FIG 1B).
■ With the joint reduced and compressed at 5 to 10 degrees of flexion, a K-
wire is driven through the joint from distal to proximal in a retrograde
fashion.
■ A second K-wire is inserted to prevent rotation.
■ The angle is checked with fluoroscopy.
■ A third K-wire may be inserted for further stabilization.
■ The extensor tendon is then repaired with a 5-0 absorbable suture, and the
skin is closed with interrupted nonabsorbable suture (TECH FIG 1C).
■ Soft bulky dressings are applied.
■ The fused joint is supported in a splint for about 6 to 8 weeks until
radiographs show bony union (TECH FIG 1D,E).
• At that point, strengthening exercises may be initiated.

TECH FIG 1 • A. Skin incision. B. Bur is used to
create a crest and trough. C. Skin closure with K-wires
in place. D,E. Postoperative radiographs show K-wires
in place, fusing the DIPJs of the index and long
fingers.
■ Volar Approach to Proximal Interphalangeal Joint
Arthroplasty
Silicone Implant
■ Patients who do not want proximal interphalangeal joint (PIPJ) fusion for
their osteoarthritic pain may consider silicone PIPJ arthroplasty with the
understanding that a limited range of motion of 30 to 60 degrees is expected
postoperatively.
■ Important prerequisites to PIPJ arthroplasty include good bone quality for
implant insertion, supple soft tissue coverage, adequate finger sensibility
and blood flow, and normal tendon gliding. The best candidate for surgery
is a patient with painful PIPJ motion but good stability and normal tendon
function.

■ We prefer using silicone over pyrocarbon implants given the lower
complication rate and the ability to revise the joint more easily if
complications arise.
■ A V incision over the volar PIPJ is made (TECH FIG 2A).
■ Skin flaps are elevated, identifying and preserving the ulnar and radial
neurovascular bundles (TECH FIG 2B).
■ The A3 pulley is incised and elevated. The flexor tendons are retracted
volarly.
■ The volar plate is then incised proximally to expose the arthritic head of
the proximal phalanx (TECH FIG 2C).
■ The head of the proximal phalanx and the base of middle phalanx are
excised with an oscillating saw (TECH FIG 2D–F).
■ The medullary cavity is broached and reamed (TECH FIG 2G).
■ An appropriately sized implant is then placed (TECH FIG 2H).
■ Motion at the joint is checked.
■ The volar plate is reattached using 4-0 absorbable braided suture.
■ The A3 pulley is repaired.
■ After skin closure (TECH FIG 2I), the hand is placed in a volar splint.
■ The patient is seen in the clinic 3 or 4 days after surgery to initiate gentle
active range of motion exercises at the PIPJ.
■ Splint protection is maintained for approximately 3 weeks to preserve joint
alignment and encourage joint encapsulation for additional stability.
Pyrocarbon Implant
■ Steps for PIPJ pyrocarbon arthroplasty through a dorsal incision are shown
in TECH FIG 3.

(Trang không có chữ)

TECH FIG 2 • PIPJ silicone arthroplasty—volar
approach. A. A V incision. B. Skin flap elevation. C.
Exposure of the arthritic head of the proximal phalanx.
D–F. Excision of head of proximal phalanx and base of
middle phalanx with oscillating saw. G. The medullary
cavity is broached and reamed. H. Placement of
implant. I. Skin closure.

TECH FIG 3 • A. Incision. B,C. Excision of head of
proximal phalanx and base of middle phalanx. D,E.
Medullary cavity of proximal phalanx is broached. F,G.
Fluoroscopy. H,I. Implant is seated into the medullary
cavity. J,K. Fluoroscopy.

■ Thumb Metacarpophalangeal Joint Fusion for
Osteoarthritis
■ Patients with instability and pain at the thumb metacarpophalangeal joint
(MCPJ) due to osteoarthritis are candidates for arthrodesis.
■ A plate is used to achieve long-lasting joint stability for patient comfort.
■ A 4-cm incision over the dorsum of the thumb MCPJ is made (TECH FIG
4A).
■ The interval between the extensor pollicis longus (EPL) and the extensor
pollicis brevis (EPB) tendons is entered (TECH FIG 4B).
■ The joint capsule is incised to expose the joint.
■ The articular surfaces are removed with a rongeur.
■ A low-profile T-plate is selected and bent to fit the MCPJ with about 30
degrees of flexion.
■ As the bony surfaces are compressed, the T-plate is fixed to the plate with
screws (TECH FIG 4C).
■ Fluoroscopy is used to check hardware placement.
■ The capsule is closed with 4-0 absorbable suture, and the skin is closed with
4-0 nonabsorbable suture.
■ A thumb spica splint is placed.
■ The patient is immobilized for 6 to 8 weeks or until radiographic union
occurs (TECH FIG 4D,E).
■ At 2 weeks, the patient can start engaging in light activities of daily living
while wearing the splint.

TECH FIG 4 • Joint fusion for thumb MCPJ instability.
A. Skin incision. B. Interval between EPL and EPB. C.
Plate placement. D. Radiograph of fused MCPJ (AP
view). E. Radiograph of fused MCPJ (lateral view).
■ Reconstruction for Thumb Trapeziometacarpal
Instability Using Flexor Carpi Radialis: Eaton-
Littler Procedure
■ The Eaton-Littler procedure is reserved for thumb trapeziometacarpal (TM)
instability in the setting of intact articular surfaces.
■ A modified Wagner incision is made at the junction of glabrous and
nonglabrous skin along the border of the thenar eminence (TECH FIG 5A).
■ The radial edge of the thenar musculature at its insertion on the metacarpal
is identified and elevated to expose the metacarpal base and trapezium
(TECH FIG 5B).
■ The dorsal cortex of the metacarpal base is further exposed through the
interval between the EPL and EPB.

■ Using a small bur, a hole is made at the base of the metacarpal, from dorsal
to volar, starting at about 1 cm from the joint in a plane perpendicular to the
axis of the thumbnail (TECH FIG 5C).
■ The exit site should be at the apex of the volar beak of the metacarpal.
■ For harvest of the flexor carpi radialis (FCR), short transverse incisions
centered over the tendon are made at 2- to 3-cm intervals proximal to the
volar wrist crease.
■ The FCR sheath is entered through these incisions to isolate the radial half
of FCR, which is transected at about 6 cm proximal to the wrist crease and
separated longitudinally from the other half of the tendon (TECH FIG 5D).
■ At the wrist crease, the FCR slip is traced to its insertion at the base of the
index metacarpal.
■ The free end of the FCR is brought out through the thenar incision (TECH
FIG 5E).

TECH FIG 5 • Reconstruction for thumb
trapeziometacarpal instability using FCR (Eaton-
Littler). A. Skin incision. B. The trapeziometacarpal
joint is exposed. C. A hole is drilled through first
metacarpal base (arrow). D. Harvest of radial half of
FCR. E. The FCR slip is traced to its insertion at the
base of the index metacarpal and brought out the
thenar incisions. F,G. The tendon is directed through
the hole at the base of the first metacarpal, from volar
to dorsal, using a wire-loop tendon passer. H. The
FCR is passed through the first metacarpal. I. Final

reconstruction. J. Skin closure.
■ Using a wire-loop tendon passer, the tendon is directed through the hole at
the base of the thumb metacarpal, from volar to dorsal (TECH FIG 5F,G).
■ Under direct vision, the joint is reduced and held in extension and abduction,
seating the metacarpal well against the trapezium.
■ The tendon is pulled taut and sutured to the dorsal periosteum with a 3-0
braided nonabsorbable suture.
■ The tendon is then passed around the metacarpal base, deep to EPB and
abductor pollicis longus (APL), through a small spit in the intact FCR tendon
proximal to its insertion, and finally back across the joint and sutured to the
APL tendon (TECH FIG 5H,I).
■ Additional sutures are placed at the junction through the FCR tendon.
■ The thenar musculature is reattached using 3-0 braided absorbable suture.
■ The skin is closed with 4-0 nylon horizontal mattress sutures (TECH FIG
5J).
■ A thumb spica splint is placed and worn for 4 weeks, at which point gentle
active ROM exercises are initiated.
■ At 8 weeks, strengthening exercises are begun.
■ Trapeziectomy and Abductor Pollicis Longus
Suspensionplasty
■ A trapeziectomy with APL suspensionplasty is our preferred technique for
thumb TM (carpometacarpal joint [CMCJ]) arthroplasty, as it is faster and
technically easier than the Eaton-Littler procedure yet provides comparable
outcomes.6
■ The first incision is made over anatomic snuffbox and TM joint (TECH FIG
6A).
■ The radial sensory nerve branches are identified and retracted. The EPL
tendon is found at the ulnar aspect of the anatomic snuffbox.
■ The radial artery is identified in close proximity to the TM joint capsule
and is mobilized and retracted inferiorly (TECH FIG 6B).
■ The TM joint capsule is incised and sharply elevated to expose the
scaphotrapezial joint, the trapezium, and the thumb metacarpal base

(TECH FIG 6C).
■ The trapezium is cut longitudinally into three pieces using an oscillating saw
followed by an osteotome.
■ The pieces are removed with a rongeur (TECH FIG 6D,E).
■ Osteophytes and loose bodies embedded in the surrounding soft tissues
must also be removed meticulously.
■ Care is taken to avoid injury to the FCR tendon as it passes volar to the
trapezium at its proximal radial corner.
■ The surface of the trapezoid that articulates with the scaphoid is inspected,
and if arthritis is present, a partial proximal trapezoidal resection is
performed.
■ The second incision is made over the first extensor compartment to identify
the musculotendinous junction of the APL, which has multiple slips (TECH
FIG 6F).
■ The most radial slip of APL is divided at this junction (TECH FIG 6G),
passed under the skin bridge into the thumb incision with a hemostat, and
traced to its insertion at the thumb metacarpal base (TECH FIG 6H).
■ The extensor carpi radialis longus (ECRL) tendon is identified ulnarly where
it inserts into the base of the index metacarpal, deep to the EPL tendon.
■ A small incision is made longitudinally in the ECRL tendon (TECH FIG
6I).
■ The APL tendon is then passed volar to EPL and through the hole in the
ECRL into a tendon weave (TECH FIG 6J).
■ The tension is set such that the thumb metacarpal base is suspended at the
level of the index metacarpal base.
■ The tendon weave between APL and ECRL is secured using 3-0 braided
nonabsorbable horizontal mattress sutures (TECH FIG 6K,L).
■ The remaining tendon is cut, fashioned into a ball with 4-0 absorbable
suture, and placed in the trapeziectomy space (TECH FIG 6M).
■ The joint capsule is closed with 4-0 braided absorbable suture.
■ The skin is closed with 4-0 absorbable monofilament dermal sutures and a
4-0 absorbable monofilament running subcuticular suture (TECH FIG
6N,O).
■ A thumb spica splint is placed and worn for 4 weeks.
■ Hand therapy is then initiated for passive and active ROM exercises, with
the splint worn between exercises.

■ At 6 weeks, light strengthening exercises are begun. At 8 weeks, the splint
is weaned and heavy strengthening with grip and pinch exercises is
initiated.
■ Studies show that patients experience significant improvements in
activities of daily living, work, satisfaction, and pain at 1 year
postoperatively.

G Radial slip of APL- APL- EPB K • Tendon weave of APL slip into ECRL ECRL

TECH FIG 6 • Trapeziectomy and APL
suspensionplasty. A. First skin incision. B. Radial
artery is preserved. C. Trapezium is exposed. D. A
rongeur is used to remove the trapezium. E.
Trapezium has been removed. F. APL is identified via
second incision. G. The radial slip of APL is divided at
the musculotendinous junction. H. The slip of APL is
brought into the thumb incision and traced to its
insertion on the thumb metacarpal base. I. A small
incision is made in the ECRL tendon. J,K. The slip of
APL is passed volar to EPB and EPL and through the
hole in the ECRL into a tendon weave. L. Completed
APL tendon weave with ECRL. M. The excess APL

tendon is cut, sutured into a ball, and inserted into the
trapeziectomy space. N. Skin closure. O.
Postoperative x-ray.
■ Arthrodesis of the Thumb TM Joint (Thumb
CMCJ Arthrodesis)
■ Osteoarthritis of the thumb TM joint (ie, CMCJ) can be addressed with joint
fusion, particularly in manual laborers who require greater stability than can
be achieved with trapeziectomy and ligament reconstruction.
■ Arthrodesis is also indicated in patients with substantial joint laxity and
deformity. In the past, nonunion rate is high using the traditional plating
system.
■ We have applied the locking plate and screw design for this joint to provide
even more rigid fixation that may enhance fusion.
■ Using locking system is the preferred approach to fuse the thumb CMCJ.
■ A 4- to 6-cm dorsal longitudinal incision is made over the TM joint at the
base of the thumb metacarpal (TECH FIG 7A).
■ The interval between the EPL and EBP tendons is entered, exposing the
joint capsule. Care is taken to preserve and retract the radial artery.
■ The joint capsule and periosteum are incised, and periosteal flaps are
elevated off the trapezium and metacarpal (TECH FIG 7B,C).
■ Using a combination of rongeur and osteotome, the articular cartilage and
subchondral bone are resected (TECH FIG 7D).
■ A 2.3-mm locking T-plate is selected and positioned with the T-portion
centered on the trapezium and the longitudinal portion centered along
metacarpal.
■ Screws are applied with the joint in compression (TECH FIG 7E).
■ Plate position is confirmed with fluoroscopy.
■ If any bony gaps exist, cadaveric bone graft is applied.
■ The periosteal flaps and joint capsule are closed over the plate using 4-0
absorbable braided suture (TECH FIG 7F).
■ After skin closure, a thumb spica splint is placed.
■ The patient is immobilized in a thumb spica splint for 6 weeks to allow for
bony fusion, after which gentle active ROM exercises are initiated (TECH

FIG 7G–I).

G

TECH FIG 7 • Thumb CMC arthrodesis. A. Incision.
B,C. Radial artery retracted and thumb CMC joint
identified. D. Chevron-type osteotomy made through
base of metacarpal and trapezium. E. Thumb CMC
fusion with Synthes locking T-plate. F. Interval
between EPB and EPL closed over plate. G–I. Six
weeks postoperative x-rays. J–L. Results 6 weeks
postoperatively.

■ Darrach Procedure for Distal Radioulnar Joint
Arthritis
■ A dorsal incision is made longitudinally over the distal ulna, just proximal to
the extensor retinaculum, taking care to preserve the dorsal ulnar sensory
nerve (TECH FIG 8A).
■ The interval between the extensor carpi ulnaris (ECU) and extensor digiti
minimi (EDM) is entered (TECH FIG 8B).
■ The periosteum is incised, and radial and ulnar periosteal flaps are raised.
■ An oscillating saw is used to resect 2 cm of distal ulna at a 45-degree angle,
such that the long end of the oblique cut is in the ulnar border to minimize
impingement against the radius.
■ The loose ulnar head is sharply excised from its soft tissue attachments
(TECH FIG 8C).
■ Sharp edges of bone and synovitis within the sigmoid notch are removed
with a rongeur.
■ Ulnar stump stability is then assessed.
■ If stable, the tourniquet is release, and hemostasis is achieved with cautery.
■ If unstable, an ECU tenodesis is performed.
■ Then, with the wrist fully supinated, the dorsal wrist capsule is imbricated
with 2-0 braided nonabsorbable horizontal mattress sutures, ensuring that the
ulnar is not dorsally prominent in this position.
■ The skin is closed with 3-0 absorbable monofilament dermal sutures and a 4-
0 nonabsorbable (TECH FIG 8D).
■ A sugar-tong splint is applied with the forearm fully supinated for 4 weeks,
keeping the fingers free for ROM.
■ Gentle active ROM is started at 4 weeks, but if an ulna-stabilizing
procedure has been performed, pronation and supination are delayed until 6
weeks (TECH FIG 8E).
■ Full activities may be resumed as tolerated at 6 to 8 weeks.

TECH FIG 8 • Darrach procedure. A. Skin incision. B.
Interval between ECU and EDM is entered. C.
Excised ulnar head (arrow). D. Skin closure. E.
Postoperative x-ray.
■ Hemiresection Arthroplasty of the Distal Ulna
■ We prefer hemiresection ulnar arthroplasty over the Darrach procedure for
patients with wrist pain due to distal radioulnar joint (DRUJ) osteoarthritis, as
it is associated with less postoperative wrist instability7 and better wrist range
of motion, grip strength, and pain relief.8
■ In this procedure, the ulnar attachments of the TFCC (triangular
fibrocartilage complex) are preserved.
■ Resection of the radial and dorsal margins of the distal ulna is performed
such that the resected bone corresponds with the articular surface of the

sigmoid notch.
■ This “matched resection” is performed to prevent radioulnar impingement
during forearm rotation.9
■ The distal ulna is exposed in a similar manner as for the Darrach procedure
(see above for details) while maintaining the ulnar TFCC (TECH FIG 9A–
C).
■ Using a miniature C-arm, a Freer is used to delineate the dorsal radial cut of
the distal ulna to match the curvature of the sigmoid notch.
■ An oscillating saw is used to remove this portion of the ulna (TECH FIG
9D–F).
■ Pronation and supination are checked to ensure no impingement of the distal
ulna on the radius.
■ The dorsal capsular sheath over the ulna is imbricated to further stabilize the
distal ulna using buried 2-0 nonabsorbable braided horizontal mattress
sutures.
■ After skin closure (TECH FIG 9G,H), the extremity is splinted with the
forearm in supination.
■ The postoperative supination splint is maintained for approximately 4 weeks
to stabilize the DRUJ.
■ After 4 weeks, gentle pronation and supination exercises are initiated.

TECH FIG 9 • Hemiresection ulnar arthroplasty. A.
Incision. B. Sheath incision. C. Exposure of arthritic
distal ulna. D–F. Freer and oscillating saw is used to
remove distal ulna. G. Fluoroscopy. H. Skin closure.
■ Total Wrist Fusion
■ A dorsal midline incision is made, centered at the radiocarpal joint and

extending from the third metacarpal neck to about 5 cm proximal to Lister
tubercle (TECH FIG 10A).
■ The skin flaps are elevated, taking care to preserve the cutaneous nerves.
■ The third extensor compartment is entered, and the EPL tendon is
transposed.
■ The extensor retinaculum is incised, exposing the second through fifth
extensor compartments.
■ The posterior interosseous nerve (PIN) is identified on the floor of the
fourth compartment and excised.
■ The dorsal wrist capsule is incised along the dorsal intercarpal and dorsal
radiocarpal ligaments, creating a radially based capsular flap and elevating
it off the dorsal triquetrum.

TECH FIG 10 • Total wrist fusion. A. Skin incision. B.
Dorsal wrist anatomy showing areas decorticated and
removed of cartilage in preparation for fusion: third
CMC, radioscaphoid joint, radiolunate joint,

scaphocapitate joint, lunocapitate joint. C. Fusion
plate placed. D. Wrist capsule and extensor
retinaculum are repaired. E. Skin closure. F,G. PA and
lateral postoperative x-rays.
■ The dorsal radius, carpus, and third metacarpal are then exposed via a
subperiosteal dissection and further decorticated with an osteotome.
■ Lister tubercle is removed to allow the plate to seat well on the radius.
■ The articular cartilage and subchondral bone are removed from the
radioscaphoid, radiolunate, scaphocapitate, lunocapitate, and third
carpometacarpal joints to prepare them for fusion (TECH FIG 10B).
■ Care is taken to maintain carpal height by avoiding over-resection of bone.
■ Soft tissues are released as needed to permit joint reduction and alignment at
about 10 degrees of extension and slight ulnar deviation.
■ The surface of the radius is contoured to fit the curvature of the fusion plate.
■ The prepared joint spaces are filled with the bone graft.
■ For healthy patients, we use cadaveric bone graft, whereas for smokers or
those at risk for wound healing delay, we prefer using bone autografts from
the iliac crest.
■ The fusion plate is applied, spanning from the distal radius to the third
metacarpal.
■ A screw affixing the plate to the third metacarpal is placed in a neutral,
unrotated position.
■ With the wrist joint compressed, the plate is further affixed to the radius
(TECH FIG 10C).
■ The remaining screws are placed.
■ Hardware placement is check with fluoroscopy.
■ Full forearm rotation and passive digital ROM should be intact.
■ Once the plate is secured, additional bone graft is packed into the prepared
joint spaces.
■ The wrist capsule is closed over the plate.
■ The extensor retinaculum is repaired, leaving the EPL transposed over the
retinaculum.
■ The skin is closed with absorbable monofilament dermal and subcuticular
running sutures (TECH FIG 10E–G), and a bulky volar wrist splint is

applied.
■ Typically, at 2 weeks postoperatively, a removable wrist splint is provided
for full-time wear and may be removed transiently for personal hygiene.
■ The splint is worn for 3 months.
■ However, if the fixation is tenuous or patient compliance is questionable, a
postoperative cast should be placed.
■ Digital ROM and edema control are encouraged throughout this time
frame.
■ Upon surgical recovery, patients should expect pain relief, full digital
ROM, full forearm rotation, and the ability to complete most activities of
daily living.
PEARLS AND PITFALLS
DIPJ ARTHRODESIS
Exposure
■ Avoid injury to the germinal matrix of the nail fold.
■ If the joint deformity is fixed, adequate soft tissue release
must be performed to reduce the joint in an optimal position.
This includes release of the volar plate, if necessary.
Shaping the
bone
■ As an alternative to burring a “crest-and-trough”
configuration, the bone ends can be cut with the distal bone at
0 degrees and the proximal bone at the desired angle of fusion.
■ Avoid excessive bony removal to preserve length and retain
good quality bone for healing.
Other techniques
for DIPJ
arthrodesis
■ The two other most commonly reported techniques for DIPJ
fusion include the use of headless compression screws or
interosseous cerclage wires. Although evidence is insufficient
to support any particular technique, the technique with the
least reported complications is K-wiring.10
■ If a headless compression screw is placed across the joint, it
should be aimed from proximal to distal and slightly palmar to
avoid the nail matrix.
SILICONE PIPJ ARTHROPLASTY
Preoperative
assessment of
collateral
■ The collateral ligaments of the PIPJ must be assessed for
stability preoperatively.

ligaments
■ If deficient, the patient may require collateral ligament
reconstruction at the time of surgery or may eliminate patient
candidacy for arthroplasty.
Finger selection
■ Avoid the use of silicone implants at the index and long finger
PIPJs, particularly in young, active patients, because repetitive
stresses on the radial collateral ligaments during key or chuck
pinch can result early implant failure.
Alternative
implants:
pyrocarbon
■ Pyrocarbon, or pyrolytic carbon, implants have enhanced
lateral stability that makes implantation into the index finger
PIPJ more attractive compared to silicone.
■ However, pyrocarbon implants have fallen out of favor due to
complication rates as high as 30%.
■ If performed, pyrocarbon PIPJ arthroplasty can be done
through a lateral or dorsal approach (see TECH FIG 3A–K).
THUMB MCPJ FUSION
Techniques for
thumb MCPJ
fusion
■ Thumb MCPJ fusion can be accomplished with a variety of
techniques, depending on surgeon preference:
■ Tension band wiring
■ Crossed K-wire fixation
■ Plate fixation
■ Intramedullary implant placement
■ For patients with RA, K-wire placement is the author’s
preferred technique given that thumb MCPJ fusion is often
combined with a number of other procedures dealing with the
rheumatoid hand.
Angle of fusion
■ The fused position of the thumb MCPJ should be at about 5–
15 degrees of flexion for optimal functionality.
■ Slightly more flexion at 20–40 degrees may be considered in
patients at risk for developing/worsening OA at the thumb
CMCJ.
THUMB TM LIGAMENT RECONSTRUCTION WITH FCR
Anatomy of the
thumb CMCJ
■ The thumb CMCJ is the articulation between the trapezium
and the thumb metacarpal. It is also known as the
trapeziometacarpal (TM) joint.
■ It is a biconcave saddle-shaped joint that permits thumb
flexion, extension, abduction, adduction, and opposition.
■ The volar beak ligament is the primary stabilizer of the thumb
CMCJ. It extends from the ulnar base of the thumb metacarpal
onto the trapezium.

Harvest of FCR
■ The radial half of the FCR tendon is harvested.
■ The radial artery and sensory nerve branches must be
identified and protected.
■ Injury to the palmar cutaneous branch of the median nerve,
which lies 1 mm ulnar to the FCR tendon, must be avoided.
■ Care should be taken to separate the radial half of FCR from
the ulnar half as to avoid accidental transection. Scissors
should not be used to slide down the tendon and instead to
make deliberate cuts from proximal to distal.
Postoperative
course
■ Thumb CMCJ stiffness is expected for 4–6 wk after surgery
but can last up to 4 mo.
■ Patients can expect near-complete pain relief and minimal
progression of degenerative arthritis at the CMCJ provided
that the surgery is performed prior to onset of articular
cartilage destruction.
TRAPEZIECTOMY WITH APL SUSPENSIONPLASTY
MCPJ laxity
■ Remember to assess the patient’s thumb MCPJ for
hyperextensibility during pinch.
■ If laxity greater than 30–40 degrees is present and
unaddressed, ligament reconstruction will be stressed by
obligatory metacarpal adduction.
■ Hyperextensibility at the MCPJ can be addressed with joint
capsulodesis, volar plate advancement, or fusion. We advocate
MCPJ fusion in these cases because soft tissue imbrication
tends to attenuate over time, whereas fusion has a more
predictable outcome.
Carpal tunnel
syndrome
■ Up to 43% of patients with TM joint arthritis have
concomitant carpal tunnel syndrome. If present, a carpal
tunnel release should be performed as well.
Eaton
classification
■ The Eaton classification of TM osteoarthritis (see Table 1),
which is based on radiographic findings, often does not
correlate with patient symptoms.
Radiographs
■ A stress view of the TM joint is useful to assess joint space
loss and subluxation in patients with symptomatic joint laxity
(Eaton stage I). This is obtained by pressing the thumb tips
together with a 30-degree posteroanterior view.
Arthritic
involvement of
the trapezoid
■ If degenerative changes are present between the trapezoid and
the scaphoid, concomitant partial resection of the trapezoid is
recommended. This is done to ensure that no contact between

the scaphoid and trapezoid occurs with axial loading.
■ Traction on the index and long fingers after trapeziectomy will
allow visualization and assessment of the scaphotrapezoid
joint.
Exposure of the
trapezium
■ A dorsal approach provides easy access to the trapezium.
■ Identify and protect these four structures:
■ Radial sensory nerve branches
■ Extensor pollicis longus (EPL) tendon
■ APL tendon
■ Radial artery (located deep to the fatty tissue between EPL
ulnarly and APL radially)
■ Thumb traction can help facilitate exposure of the trapezium.
THUMB TM JOINT ARTHRODESIS
Anatomy
■ One must protect the radial sensory nerve during exposure of
the thumb TM joint.
■ The radial artery must be protected in the interval between the
EPL and EPB tendons where it lies deep to the subcutaneous
fat.
Plate selection
■ A 2.3-mm locking T-plate is preferred, with the T-portion
centered on the trapezium.
■ Utilization of a locking plate is important in the setting of
poor bone stock. The trapezium is often devoid of strong
cortical bone necessary to secure traditional screws and plates.
Functional
thumb position
■ The thumb should be fixed at 30–40 degrees of palmar
abduction, 15–20 degrees of extension, and 15 degrees of
pronation.
■ This functional position facilitates tip-to-tip pinch.
DARRACH PROCEDURE
Indications
■ Post-traumatic DRUJ arthritis, rheumatoid arthritis, or
osteoarthritis without pre-existing radiocarpal instability in
patients who are older and sedentary
■ Caput ulna syndrome with TFCC destruction and painful
pronation-supination of the DRUJ
■ Preferred in patients with no ulnar translation of carpus who
are at low risk of translation in the future
■ Can be performed concomitantly with partial or total wrist
fusion in setting of radiocarpal instability
■ Notably, we tend to avoid the Darrach procedure in
osteoarthritis, as it weakens the wrist. We prefer hemiresection

arthroplasty of the distal ulna (see Technique no. 8).
Caput ulna
syndrome
■ Combination of ulnar head dorsal dislocation, ECU volar
subluxation, and carpal supination seen in patients with
rheumatoid arthritis
■ The fifth extensor compartment (containing EDM) crosses the
ulnar head.
Extent of ulnar
head resection
■ The pronator quadratus (PQ) is a dynamic stabilizer of the
distal ulna, originating at the distal radius and inserting on the
distal ulna.
■ Ulnar head excision should be performed at the level of the
sigmoid notch in order to preserve the ulnar attachments of the
PQ.
Ulna-stabilizing
procedure
■ Prior to closing the wrist capsule, the distal ulna stump is
tested for stability with pronation-supination.
■ If unstable, an ulnar stabilizing procedure is indicated (ECU
tenodesis):
■ A hole in the dorsal cortex of the distal ulnar stump is drilled
with a 3-mm bur.
■ The distally based ulnar half of the ECU is harvested and
brought from inside the ulnar canal and out the hole dorsally.
■ The ECU is then sutured to itself with the ulnar stump reduced
palmarly and wrist in 15-degrees of extension and 15-degrees
of ulnar deviation.
■ The wrist capsule is then closed as described in the text.
HEMIRESECTION ARTHROPLASTY OF THE DISTAL ULNA
Relative
contraindications
■ Hemiresection ulnar arthroplasty should be considered with
caution in younger patients because it may lead to loss of
support for the ulnar carpus over time.
■ Ulnar-positive variance is a relative contraindication for
hemiresection ulnar arthroplasty because it increases the risk
of impingement between the ulnar styloid and triquetrum.
■ Other contraindications to hemiresection ulnar arthroplasty
include pre-existing ulnar carpal translation (may exacerbate
the ulnar translation) and irreparable damage to the TFCC (no
benefit over a Darrach procedure).
Technical points
■ Avoid excessive resection of the ulnar head.
■ Preserve the foveal attachments of the TFCC.
■ If necessary, debride the TFCC.
■ Consider ulnar shortening if positive variance is present.

TOTAL WRIST FUSION
Indications
■ Painful wrist with limited ROM due to osteoarthritis,
inflammatory arthritis, and post-traumatic arthritis
■ Multiple joint involvement
■ Failed partial wrist fusions or soft tissue reconstructions
■ Carpal instability patterns (eg, SLAC/SNAC arthritis)
■ Contraindications for joint arthroplasty or failed arthroplasty
■ Desire for a one-stage definitive treatment.
Dorsal wrist
capsule
■ The wrist capsule can be elevated as a radially based flap (as
described in the text) or via a straight midline longitudinal
incision.
■ A thick capsular flap should be maintained for good coverage
of the fusion plate.
■ The ECRL and ECRB tendons can be released from their
metacarpal insertions and used to augment soft tissue coverage
of the hardware.
The fusion mass
■ Bony fusion involves the radius, scaphoid, capitate, lunate,
and third metacarpal bones.
■ Not included in the fusion mass are the ulnar joints
(lunotriquetral and triquetrohamate joints).
Proximal row
carpectomy
(PRC)
■ Performing a PRC may help to facilitate joint alignment
before fusion, particularly in cases of chronic and severe
carpal deformity.
Fusion plate
■ A dynamic compression plate is used for wrist fusion and
must be contoured appropriately to allow for 10 degrees of
wrist extension and slight ulnar deviation.
■ In patients with poor bone stock, locking screw fixation can
be used.
Postoperative
splinting
■ A supportive wrist splint is applied at the end of the case.
■ Avoid MCPJ extension in the splint, which may result in
intrinsic tightness and loss of digital ROM.
COMPLICATIONS
■ Inadequate pain relief
■ Wound healing delay
■ Nonunion
■ Hardware failure

■ Failure of reconstruction
■ Infection
■ Need for further surgery
REFERENCES
1. Kozlow JH, Chung KC. Current concepts in the surgical management of
rheumatoid and osteoarthritic hands and wrists. Hand Clin. 2011;27(1):31-41.
2. Nacke E, Paksima N. The evaluation and treatment of the arthritic distal
radioulnar joint. Bull Hosp Joint Dis (2013). 2015;73(2):141-147.
3. Eaton RG, Glickel SZ. Trapeziometacarpal osteoarthritis: staging as a
rationale for treatment. Hand Clin. 1987;3:455-471.
4. Eaton RG, Littler JW. Ligament reconstruction for the painful thumb
carpometacarpal joint. J Bone Joint Surg Am. 1973;55:1655-1666.
5. Rizzo M. Thumb arthrodesis. Tech Hand Up Extrem Surg. 2006;10(1):43-46.
6. Chang EY, Chung KC. Outcomes of trapeziectomy with a modified abductor
pollicis longus suspension arthroplasty for the treatment of thumb
carpometacarpal joint osteoarthritis. Plast Reconstr Surg. 2008;122(2):505-
515.
7. Sauerbier M, Fujita M, Hahn ME, et al. The dynamic radioulnar convergence
of the Darrach procedure and the ulnar head hemiresection interposition
arthroplasty: a biomechanical study. J Hand Surg Br. 2002;27(4):307-316.
8. Minami A, Iwasaki N, Ishikawa J, et al. Treatments of osteoarthritis of the
distal radioulnar joint: long-term results of three procedures. Hand Surg.
2005;10(2-3):243-248.
9. Watson HK, Ryu JY, Burgess RC. Matched distal ulnar resection. J Hand Surg
[Am]. 1986;11(6):812-817.
10. Dickson DR, Mehta SS, Nuttall D, Ng CY. A systematic review of distal
interphalangeal joint arthrodesis. J Hand Microsurg. 2014;6(2):
74-84.

26
CHAPTER
Section VIII: Nerve
Conditions
Carpal Tunnel Release
Angelo B. Lipira and Jason H. Ko
DEFINITION
■ Compression of the median nerve at the level of the wrist is the most common
compression neuropathy, with a prevalence of 1% to 3%.1
■ Patients present with numbness or paresthesias in the distribution of the
median nerve (thumb, index finger, middle finger, radial half of ring finger).
■ Long-standing carpal tunnel syndrome (CTS) can result in weakness and
atrophy of the thenar musculature; sensory fibers are preferentially affected
earlier in the process.
■ CTS is diagnosed clinically. It is often confirmed with electrodiagnostic
studies, which can also indicate the severity of nerve injury.
ANATOMY
■ The median nerve provides sensation to the thumb, index finger, middle finger,
and radial half of the ring finger, as well as the skin of the thenar eminence via
the palmar cutaneous branch. It provides motor function to the thenar
musculature via the recurrent motor branch and radial two lumbricals via the
proper (first lumbrical) and common (second lumbrical) digital nerves (FIG
1A).
■ The carpal tunnel is an anatomic space bounded by the transverse carpal
ligament (TCL) volarly; the hamate, triquetrum, and pisiform ulnarly; the
scaphoid and trapezium radially; and the lunate and capitate dorsally (FIG 1B).
■ The carpal tunnel contains the median nerve and nine flexor tendons (four
flexor digitorum superficialis [FDS], four flexor digitorum profundus, and

flexor pollicis longus).
■ The recurrent motor branch innervates the abductor pollicis brevis, opponens
pollicis, and superficial head of flexor pollicis brevis. Most commonly, it arises
from the median nerve distal to the TCL (extraligamentous, 46%) but may be
subligamentous (31%) or transligamentous (23%). Variants that arise from the
ulnar aspect of the median nerve and cross over the TCL are at highest risk of
injury, particularly in endoscopic techniques.2
■ The palmar cutaneous branch usually branches from the radial aspect of the
median nerve 5 to 8 cm proximal to the wrist crease and travels distally
between the flexor carpi radialis (FCR) and palmaris longus.
■ Therefore, thenar sensation is typically preserved in CTS.
■ However, the palmar cutaneous branch can also show variation, including a
variant where it branches from the ulnar aspect of the median nerve.2 The
branch becomes superficial at the wrist level and is vulnerable during
incisions.
PATHOGENESIS
■ Increased pressures within the carpal tunnel lead to vascular congestion,
edema, and ischemia of the median nerve.
■ Demyelination occurs first, followed by axonal degeneration in more severe
cases. Sensory nerve fibers are affected earlier than motor fibers.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient history
■ Patients will often report numbness of the entire hand, rather than localizing
it to the median nerve distribution.3
■ Classically, patients will report being awakened by paresthesias and pain, as
symptoms often worsen at night because during sleep, the wrist relaxes and is
often flexed for prolonged periods of time, leading to elevated pressure in the
carpal tunnel. Furthermore, many will sleep with their hands and wrists under
the head, which also contributes to nerve compression.
■ They may report weakness or clumsiness in more advanced presentations
with motor weakness.
■ Investigate associated conditions including diabetes mellitus, rheumatoid
arthritis, obesity, gout, hypothyroidism, and pregnancy.1,4
■ Take a good occupational history, identifying predisposing and repetitive
tasks that may contribute to increased carpal tunnel pressure.

■ Inquire about past therapies including splinting and steroid injections.
■ Physical examination
■ Inspect the hand, looking for atrophy of the thenar musculature and
differences in temperature and sweat patterns in the median nerve distribution.
■ Test and document two-point discrimination (static and dynamic) on both the
radial and ulnar aspects of all digits (normal values: static less than 6 mm,
moving 2–3 mm).
■ Provocative maneuvers are used in an attempt to reproduce the patient’s
symptoms4:
• Phalen test: The wrists are held in a flexed position for up to 1 minute.
Record the time it takes to precipitate their usual symptoms.
• Tinel sign: The examiner percusses over the median nerve at the wrist. If
tingling paresthesias are elicited in the fingers, the test is considered
positive.
• Durkan carpal compression test: Direct pressure is applied over the carpal
tunnel with the examiner’s thumb. Apply just enough pressure to blanch the
overlying skin. Record the time it takes to precipitate their usual symptoms.5

Lateral two lumbrical muscles Digital nerves Flexor pollicis brevis Palmar cutaneous branch Recurrent motor branch Abductor pollicis brevis Median nerve - Flexor digitorum superficialis tendons - Median nerve Transverse carpal ligament Flexor carpi radialis tendon Flexor pollicis longus tendon Flexor digitorum profundus tendons Trapezium Triquetrum Lunate Scaphoid

FIG 1 • A. Structures at risk during carpal tunnel release
include the palmar cutaneous sensory branch, typically
arising ulnarly just proximal to the transverse carpal
ligament (TCL), and the recurrent motor branch,
typically arising radially just distal to the TCL. B.
Anatomic boundaries of the carpal tunnel include the
TCL volarly; hamate, triquetrum, and pisiform ulnarly;
lunate and capitate dorsally; and the scaphoid and
trapezium radially. The carpal tunnel contains nine
flexor tendons—four flexor digitorum superficialis, four
flexor digitorum profundus, and flexor pollicis longus—
and the median nerve.
IMAGING AND OTHER DIAGNOSTIC STUDIES
■ The diagnosis of CTS is usually made clinically, and electrodiagnostic studies
are frequently employed to confirm the diagnosis and rate the severity.
■ Imaging is not routinely performed for CTS but may be indicated if there is
suspicion of a mass lesion or other rarer presentations.
■ Electrodiagnostic studies focus on assessing the conduction velocities and
amplitude of the median nerve across the wrist. The ulnar and radial nerve are
also often evaluated to compare values in a nerve outside the carpal tunnel and
rule out effects of temperature, polyneuropathy, and other factors.
■ Nerve conduction studies may demonstrate increased sensory or motor latency
(demyelination) and decreased sensory and/or motor amplitude (loss of
axons).4 Sensory latencies are compared to an unaffected nerve (ulnar or
radial) and are generally considered abnormal if the difference exceeds 0.3 to
0.5 ms. Motor conduction is assessed by stimulating the median nerve at the
wrist and measuring at the abductor pollicis brevis. Latency of over 4.5 ms is
generally considered abnormal.6
■ The combined sensory index (CSI) is a useful composite value that is obtained
by measuring the difference in latency between the thumb, palm, and ring
fingers and the ulnar or radial nerve and summing these three values together.
A CSI of 1 ms or more is considered abnormal.7 Higher CSIs have been
associated with greater frequency of symptom resolution following carpal

tunnel release (CTR).6
■ There is evidence that preoperative electrodiagnostic studies may increase
costs and delay time to surgical treatment. Although the American Association
of Orthopaedic Surgeons (AAOS), in a prior proactive guideline,
recommended electrodiagnostic studies if surgery is being considered, a
substantial portion of hand surgeons do not routinely obtain them.8
DIFFERENTIAL DIAGNOSIS
■ Proximal median nerve lesion (eg, compression from pronator teres, FDS arch,
or an accessory muscle such as Gantzer muscle)
■ Polyneuropathy
■ Central nervous system lesion (tumor, CVA, multiple sclerosis)
■ Arthritis
NONOPERATIVE MANAGEMENT
■ Nonoperative therapies for CTS include avoidance of provocative maneuvers,
wrist immobilization (splinting), nonsteroidal anti-inflammatory drugs
(NSAIDs), and corticosteroid injection.
■ Wrist braces should hold the wrist in a neutral position. Wrist flexion or
extension increases pressure in the carpal tunnel. However, the active position
of the wrist is 30 degrees of extension, so neutral splints can make tasks more
difficult.
■ Although corticosteroid injection leads to transient relief in many patients, the
majority will recur within 1 year.9 Some surgeons believe that relief with
steroid injection is predictive of relief with operative CTR and thus holds
diagnostic value.
■ Dexamethasone is the preferred corticosteroid, as it appears to be less
deleterious than hydrocortisone or triamcinolone if inadvertently injected into
the nerve substance.10
SURGICAL MANAGEMENT
■ CTR is commonly performed using both open and endoscopic techniques.
■ There is currently no consensus supporting the superiority of one technique
over the other.
Preoperative Planning
■ Preoperative planning is based on the patient’s history and physical exam, as

well as review of electrodiagnostic studies, if available.
■ Considerations include conducting unilateral vs bilateral releases, anesthesia
plan (local, regional block, sedation), and special considerations in the case of
recurrent CTS (see below).
■ A recent study showed that patients undergoing bilateral simultaneous CTR
have increased difficulties with certain activities compared with unilateral
CTR, but self-care was unaffected, and the differences did not persist past two
postoperative days.11
■ Open CTR can be performed under local anesthetic block with or without
sedation or regional block such as Bier intravenous block (FIG 2).
■ General anesthesia is not typically required.
■ Endoscopic CTR can be difficult to perform under local anesthetic, as the
liquid in the carpal tunnel can obscure visualization, so one of the other
anesthetic techniques is recommended.
■ In cases of recurrent or persistent CTS following CTR, be sure to rule out
other etiologies of symptoms, such as cervical radiculopathy, proximal median
nerve or brachial plexus lesions, and polyneuropathy.
■ If the patient has hypersensitivity directly over the carpal tunnel without
evidence of palmar cutaneous branch injury, or if the median nerve is found to
be adherent to the TCL intraoperatively, we consider the interposition of a
hypothenar fat pad flap at the time of reoperation.12
Positioning
■ The patient is positioned supine on an OR table or stretcher, with the operative
extremity on a hand table.
■ A well-padded, nonsterile tourniquet is placed on the upper arm prior to prep
and drape.
■ The surgeon is seated with his or her dominant hand more proximal relative to
the operative extremity so that they are working distally down the carpal
tunnel.
■ A sterile folded towel is placed under the wrist to slightly extend the wrist (15–
20 degrees), which moves the median nerve away from the TCL.
■ For positioning considerations specific to endoscopic CTR, see section below.

FIG 2 • Typical setup for Bier block anesthesia. Note the
intravenous line in the dorsum of the hand and the
double tourniquet.
Approach
■ Techniques can be broadly divided into open or endoscopic. Open approaches
include numerous described incisions, including limited incision and minimally
invasive approaches.
■ Although numerous variations of incisions for open CTR have been described,
most agree that it should be in line with the ring finger, thus slightly ulnar to
the axis of the median nerve and less likely to cause injury to the palmar
cutaneous branch.
■ We prefer a 2- to 3-cm longitudinal curvilinear incision, staying 2 mm ulnar
to the thenar crease to avoid the palmar cutaneous branch. The distal extent is
well short of Kaplan cardinal line, which identifies the location of the palmar
arterial arch (FIG 3).
■ Endoscopic approaches include single-portal13 and two-portal14 techniques.
■ We prefer the single-portal (Agee) technique, and the proximal incision is
typically a 1- to 1.2-cm transverse incision placed in the distal flexion crease
of the wrist, just ulnar to the palmaris longus tendon (halfway between FCR
and flexor carpi ulnaris [FCU] tendons).