Traditional or standard OCTR involved a large incision across the palm, wrist and extends into the forearm. With the advent of ECTR it has become common to perform OCTR with a modified 2-3 centimeter incision that is confined to the palm of the hand. Through either incision, the skin and subcutaneous tissue is divided, followed by the palmar fascia, and ultimately the flexor retinaculum.
Operative plan for OCTR with a modified incision.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Operative plan for OCTR with standard incision. This operative plan may be chosen if the patient has had a recurrence of symptoms following OCTR with a modified incision and the physician needs to make a larger incision to ensure that all of the flexor retinaculum has been divided.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Application of local anaesthesia. Here a nerve block is performed on the median nerve.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Application of local anaesthesia. Here tumescence of the carpal tunnel. A mixture of lidocaine and epinephrine is preferred by this physician. The lidocaine has immediate effects, whereas the epiphrine takes 10-15 minutes to achieve full effect. The epiphrine's vasoconstricting effects allow for better visualization of the flexor retinaculum following division of the overlying structures.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Prepping the area.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Creating the surgical field.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Dividing the structures overlying the flexor retinaculum.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Dividing the flexor retinaculum. Note that the skillful use of the retractor allows for the complete division of the transverse carpal ligament despite poor visualization of the proximal and distal boundaries with a modified incision.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Closing the wound.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Closed wound.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Splinting of wrist in a neutral position. NB: this is the treating physician's preference. Evidence suggests no benefit to splinting following surgical release in terms of symptom and function improvement1. However, splinting may protect the wound and reduce wound associated discomfort.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Operative plan for OCTR with a modified incision.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Operative plan for OCTR with standard incision. This operative plan may be chosen if the patient has had a recurrence of symptoms following OCTR with a modified incision and the physician needs to make a larger incision to ensure that all of the flexor retinaculum has been divided.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Application of local anaesthesia. Here a nerve block is performed on the median nerve.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Application of local anaesthesia. Here tumescence of the carpal tunnel. A mixture of lidocaine and epinephrine is preferred by this physician. The lidocaine has immediate effects, whereas the epiphrine takes 10-15 minutes to achieve full effect. The epiphrine's vasoconstricting effects allow for better visualization of the flexor retinaculum following division of the overlying structures.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Prepping the area.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Creating the surgical field.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Dividing the structures overlying the flexor retinaculum.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Dividing the flexor retinaculum. Note that the skillful use of the retractor allows for the complete division of the transverse carpal ligament despite poor visualization of the proximal and distal boundaries with a modified incision.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Closing the wound.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Closed wound.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
Splinting of wrist in a neutral position. NB: this is the treating physician's preference. Evidence suggests no benefit to splinting following surgical release in terms of symptom and function improvement1. However, splinting may protect the wound and reduce wound associated discomfort.
Image Source: Victoria Squissato, courtesy of Dr. John S.D. Davidson
1Ashworth N. Carpal tunnel syndrome. Clinical Evidence Database. BMJ Publishing Group. 2010;03:1114-1142.