Complications of carpal tunnel surgery

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✓ During a 12-year period, the authors treated 25 patients with 26 complications of previous carpal tunnel surgery. Twenty-four of these patients were referred following initial surgery elsewhere. The most frequent complication identified was neuroma of the palmar cutaneous branch of the median nerve in 14 of the cases. Other complications were hypertrophic scars, dysesthesias after multiple procedures to release the carpal tunnel, joint stiffness, failure to relieve symptoms, and neuromas of the dorsal sensory branch of the radial nerve. All of these complications are potentially preventable. With a properly placed incision, exposure carried out under magnification, and surgery under direct vision the majority of these complications may be prevented. It is further noted that the technique of transverse incision at the wrist for release of the carpal tunnel is potentially dangerous and should be abandoned.

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Address reprint requests to: Dean S. Louis, M.D., C4500 Outpatient, University of Michigan Hospitals, Ann Arbor, Michigan 48109.

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    Left: Case 1. The interthenar portion of this incision is appropriate. The area where it is marked is just distal to the wrist flexion creases. This is the point at which the palmar cutaneous branch of the median nerve was divided across the interthenar area. This was successfully treated by ligating this branch where it exited from the median nerve proper in the distal forearm. Right: The palmar cutaneous branch of the median nerve is marked in this specimen with black marker as it is seen to exit from the radial side of the median nerve proper approximately 4 inches proximal to the wrist flexion creases. In this instance, it arborized between the thenar muscle masses and certainly would be prone to injury at this level. This illustrates the need for magnification and great care to protect these branches during the course of carpal tunnel surgery.

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    Left: In most circumstances release of the carpal tunnel can be done satisfactorily with the incision depicted here. The confluence of the transverse carpal ligament and antebrachial fascia can be seen under direct vision by appropriate retraction of the proximal edge of the skin, thus avoiding crossing the wrist flexion creases. Right: When it is necessary to cross the wrist flexion creases, it is best done in the fashion shown, with the incision crossing the wrist flexion creases at approximately 45°. This avoids tension on the incision line and hypertrophic scar formation. In addition, it deviates away from the palmar cutaneous branch of the median nerve. The palmar sensory branch of the ulnar nerve may be visualized with this incision, and should be looked for.

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    Left: Case 7. Neuromas of the dorsal sensory branch of the radial nerve and of the palmar cutaneous branch of the median nerve are visualized in this clinical surgical photograph. The neuroma of the dorsal sensory branch of the radial nerve was left intact and translocated deep to the muscle belly of the flexor carpi radialis, thus eliminating the symptoms. The neuroma of the palmar cutaneous branch of the median nerve was ligated at its exit from the median nerve and the nerve was relocated deep to the superficialis muscle belly of the long finger. The anticipated areas of numbness resulted; however, the painful symptoms that were due to the neuromas were eliminated, much to the patient's satisfaction. Right: The dorsal sensory branch of the radial nerve in this specimen has been marked with an opaque ink, illustrating that the branches of its volar division may proceed in a path that will leave them vulnerable to a radially directed incision at the wrist.

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