A practical guide written from the perspective of an Operating Room Nurse.

The workflows, surgeon preferences, and nursing tips presented in this article are based on the author’s real clinical experience. Surgical techniques and operating room practices may vary depending on the surgeon, hospital, and institutional protocols.

What is Carpal Tunnel Syndrome?

Carpal Tunnel Syndrome (CTS) is the most common compressive neuropathy of the upper extremity. It occurs when the median nerve becomes compressed beneath the transverse carpal ligament (flexor retinaculum) within the carpal tunnel.

Typical symptoms include:

Numbness and tingling of the thumb, index, middle, and radial half of the ring finger
Night pain
Weak grip strength
Thenar muscle atrophy in advanced cases

When conservative treatment such as splinting or corticosteroid injection fails, Carpal Tunnel Release (CTR) is performed to decompress the median nerve.

📌Quick Facts

Item	Details
Procedure	Open Carpal Tunnel Release
Specialty	Hand Surgery / Orthopedic Surgery
Incision	Longitudinal palmar incision just ulnar to the thenar crease
Anesthesia	Local, Regional, or General
Position	Supine with arm on arm board
Tourniquet	Upper arm or forearm
Average Time	15–30 minutes
Goal	Release the transverse carpal ligament and decompress the median nerve

Indications

Carpal tunnel release is indicated for patients with:

Persistent symptoms despite conservative treatment
Progressive median nerve compression
Thenar muscle weakness or atrophy
Severe electrodiagnostic findings
Recurrent symptoms after injection therapy

Contraindications

Relative contraindications include:

Active infection at the surgical site
Poor soft tissue condition
Uncontrolled systemic illness requiring optimization before surgery

Surgical Anatomy

Understanding the anatomy is essential to avoid nerve injury.

Key structures include:

Median nerve
Palmar cutaneous branch of the median nerve
Motor (recurrent) branch of the median nerve
Transverse carpal ligament (Flexor Retinaculum)
Palmaris longus tendon
Flexor digitorum superficialis tendons
Flexor digitorum profundus tendons
Flexor pollicis longus tendon

Patient Position

Supine position
Arm placed on an arm board
Forearm supinated
Palm facing upward
Tourniquet applied
Standard sterile preparation and draping

This position provides excellent exposure of the volar wrist and palm.

🕒Procedure Timeline

1. Skin Marking

The incision begins just ulnar to the thenar crease and extends proximally toward the wrist crease.

The incision should avoid crossing the wrist flexion crease at a right angle to reduce scar discomfort.

2. Skin Incision

A longitudinal palmar incision is made through the skin and subcutaneous tissue.

Care is taken to identify and preserve the palmar cutaneous branch of the median nerve.

3. Superficial Dissection

The palmar fascia is divided.

The palmaris longus tendon and flexor retinaculum are exposed.

Small retractors are used to improve visualization.

4. Identification of the Median Nerve

The median nerve is identified deep to the flexor retinaculum.

Special attention is given to the recurrent motor branch, which may have anatomical variations and is at risk during ligament division.

5. Transverse Carpal Ligament Release

A protective elevator or spatula is placed beneath the ligament.

The transverse carpal ligament is divided longitudinally under direct vision from distal to proximal.

Complete release is confirmed before proceeding.

6. Median Nerve Inspection

After decompression:

The median nerve is inspected.
Any residual constricting fibers are released.
The nerve should lie freely without compression.

7. Irrigation

The wound is irrigated thoroughly with normal saline.

Meticulous hemostasis is achieved.

8. Skin Closure

The skin is closed using interrupted nylon or absorbable sutures.

A soft compressive dressing is applied while avoiding excessive pressure over the carpal tunnel.

Surgical Workflow

Patient positioning
Skin preparation
Tourniquet inflation
Skin incision
Palmar fascia dissection
Identify flexor retinaculum
Identify median nerve
Protect recurrent motor branch
Divide transverse carpal ligament
Confirm complete decompression
Irrigation
Hemostasis
Skin closure
Dressing

Mayo Stand Setup

Cutting

#15 Blade
Scalpel Handle

Dissection

Metzenbaum Scissors
Tenotomy Scissors

Grasping

Adson Forceps
Toothed Forceps

Hemostasis

Mosquito Hemostat

Retraction

Senn Retractor
Skin Hooks

Protection

Freer Elevator or Small Spatula

Needle Holder

Webster Needle Holder

Back Table Setup

Prepare:

Sterile towels
Saline irrigation
Local anesthetic syringe
Bulb syringe
Gauze
Suction tubing (if required)
Sutures
Dressing materials

Closure

Typical closure consists of:

Final irrigation
Hemostasis
Interrupted skin sutures
Sterile gauze
Soft compressive dressing

Postoperative Care

Encourage gentle finger motion immediately after surgery.
Elevate the hand to reduce swelling.
Avoid heavy gripping for several weeks.
Remove sutures according to surgeon preference (commonly 10–14 days).
Begin gradual return to normal activities as symptoms improve.

Potential Complications

Potential complications include:

Infection
Hematoma
Incomplete ligament release
Persistent or recurrent symptoms
Injury to the median nerve
Injury to the recurrent motor branch
Injury to the palmar cutaneous branch
Pillar pain
Hypertrophic scar formation

⚠️Common Pitfalls

Incomplete Release of the Transverse Carpal Ligament

The most common cause of persistent or recurrent symptoms is incomplete division of the transverse carpal ligament.

Injury to the Recurrent Motor Branch

The recurrent motor branch of the median nerve is the most critical structure at risk during carpal tunnel release. Injury may result in permanent thenar muscle weakness and loss of thumb opposition.

Injury to the Palmar Cutaneous Branch

A skin incision placed too far radially may injure the palmar cutaneous branch of the median nerve, leading to painful scars or sensory disturbances.

Blind Division of the Ligament

Dividing the transverse carpal ligament without adequate visualization increases the risk of damaging the median nerve.

Excessive Retraction

Overly aggressive retraction can place unnecessary tension on the median nerve and surrounding soft tissues.

💎OR Nurse Pearls

✔ Verify the surgical side and affected hand before draping.

✔ Keep the incision slightly ulnar to the thenar crease to reduce the risk of injuring the palmar cutaneous branch.

✔ Always anticipate the recurrent motor branch before ligament division.

✔ Ensure a protective elevator is placed beneath the transverse carpal ligament before cutting.

✔ Confirm complete release of the ligament under direct visualization.

✔ Prepare delicate hand instruments and fine retractors to facilitate safe dissection.

✅30-Second OR Checklist

✅ Correct patient and operative side confirmed

✅ Tourniquet functioning

✅ #15 Blade available

✅ Senn Retractor prepared

✅ Freer Elevator or Spatula available

✅ Fine scissors ready

✅ Saline irrigation prepared

✅ Skin sutures available

✅ Soft dressing prepared

Frequently Asked Questions

Why is the transverse carpal ligament released?

The transverse carpal ligament forms the roof of the carpal tunnel. Dividing it relieves pressure on the median nerve and restores nerve function.

What is the most important structure to protect?

The recurrent motor branch of the median nerve is the most critical structure at risk because injury can result in permanent thenar muscle dysfunction.

Why is a spatula or elevator placed beneath the ligament?

It protects the median nerve while the transverse carpal ligament is divided under direct vision.

How long does the procedure usually take?

Most open carpal tunnel release procedures are completed within 15–30 minutes.

Conclusion

Open Carpal Tunnel Release is one of the most commonly performed hand surgeries and remains the gold standard for treating persistent carpal tunnel syndrome. For operating room nurses, a thorough understanding of the volar wrist anatomy, careful preparation of fine hand instruments, and awareness of critical structures such as the median nerve and its recurrent motor branch are essential. Meticulous protection of these structures and confirmation of complete transverse carpal ligament release contribute to safe surgery and excellent patient outcomes.