19

Carpal Tunnel
AN\1oMv
This is a presentation of the surgical anatomy and anatomical entities related
to the carpal tunnel syndrome through illustrations and tables (Figs. 19.1 - 19.8 ;
Tables 19.1 - 19.3 ).
665
L.J. Skandalakis et al., Surgical Anatomy and Technique,
DOI: 10.1007/978-0-387-09515-8_19, © Springer Science+Business Media LLC 2009
666 19. CarpaI TunneI
CarpaI TunneI 667
Figure 19.1. A-F (By permission of JE Skandalakis, GL Colborn, PN Skanda-
lakis, et al. Am Surg 58(1):72-76, 1992.)
668 19. CarpaI TunneI
Figure 19.2.
the motor branches of the median nerve. (By permission of JE Skandalakis, GL
Colborn, PN Skandalakis, et al. Am Surg 58(1):72-76, 1992.)
Figure 19.3.
sion of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(2):77-
81, 1992.)
Figure 19.4.
of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(2):77-81,
1992.)
Figure 19.5. The canals within the carpal tunnel (the middle surgical zone).
(By permission of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg
58(2):77-81, 1992.)
670 19. CarpaI TunneI
Figure 19.6. The proximal surgical zone. (From EW Lampe. Clin Symp
21(3):66-109, 1969. Copyright by Ciba-Geigy.)
Figure 19.7. The distal surgical zone. (By permission of JE Skandalakis, GL
Colborn, PN Skandalakis, et al. Am Surg 58(3):158-166, 1992.)
Figure 19.8. A. Palmar cutaneous branches of the ulnar, musculocutaneous,
radial, and median nerves. B. Palmar cutaneous branch of the median nerve.
(By permission of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg
58(3):158-166, 1992.)
672 19. CarpaI TunneI
TabIe 19.1 Upper Proximal Zone Divisions
Ulnar side

ulnar nerve
ulnar artery
Central (median) area

Median duo: palmaris longus
median nerve
Radial side
Radial trio: radial artery


By permission of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(2):77-81,
1992.
TabIe 19.2 Central Zone (Carpal Tunnel) Divisions
Ulnar side
Ulnar bursa: eight tendons (sublimis and profundus)
Central area
Median nerve and its branches (with possible variations)
Radial side

By permission of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(2):77-81,
1992.
TabIe 19.3 Distal Zone Divisions
Ulnar side
Ulnar nerve branches

Ulnar bursa: four profundus tendons

Central (median) side
Median nerve branches
Recurrent branch thenar muscles
One or two digital nerves for thumb

Radial side
Flexor pollicis longus with radial bursa
Median nerve palmar cutaneous branch
By permission of JE Skandalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(2):77-81,
1992.
SurgicaI Treatment of CarpaI TunneI Syndrome 673
TichNioUi
SURGICAL TREATMENT OF CARPAL
TUNNEL SYNDROME
Anatomical variations of the median nerve in the carpal tunnel are shown in
Figure 19.9
surgical intervention is the procedure of choice.
Step 1. Apply an upper arm tourniquet. Elevate the upper extremity. Use
elastic bandages for exsanguination. Inflate the tourniquet.
Step 2. Make a curved skin incision at the ulnar side of the palm across the
thenar crease and along the long axis of the ring finger, from the
lower border of the flexor retinaculum to the proximal wrist crease
(Fig. 19.10 ).
Step 3. Carefully separate the subcutaneous fat. Find and protect the palmar
cutaneous branch of the median nerve. It is located close to the pal-
maris longus, flexor carpi radialis, and flexor pollicis longus at the
thenar side of the median nerve (Figs. 19.11A,B ). Incise the palmar
fascia in a longitudinal fashion, starting at the proximal part of the
incision.
Step 4. Open the superficial transverse carpal ligament (antebrachial fascia)
in a similar fashion and identify the median nerve (Fig. 19.12 ). Dis-
sect, observe, and isolate the median nerve and the recurrent branch.
Use magnification glasses, if necessary. Incise the epineurium lon-
gitudinally. Take care to divide only the volar carpal ligament.
Step 5. Divide the flexor retinaculum at the ulnar side close to the hamate
bone. Locate and protect the motor branch of the recurrent nerve
(Fig. 19.13 ).
Step 6. Evaluate the canal and anatomical entities for any other patholo-
gy-congenital or acquired.
Step 7. Close the wound, skin only, with interrupted 4-0 or 5-0 nylon. A
volar plaster splint is applied for 2 weeks.
674 19. CarpaI TunneI
Figure 19.9. Anatomical variations of the median nerve in the carpal tunnel. A.
Regular branching of the median nerve, 55 percent. B. Thenar branch leaving the
median nerve within the carpal tunnel (subligamentous), 31 percent. C. Trans-
ligamentous course of the thenar branch, 14 percent. (By permission of JE Skan-
dalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(3):158-166, 1992.)
Figure 19.10. Skin incision. This incision follows the natural crease and not
Skandalakis, et al. Am Surg 58(3):158-166, 1992.)
SurgicaI Treatment of CarpaI TunneI Syndrome 675
Figure 19.11. A. Three possible sites of penetration of the palmar cutaneous
nerve. B. Note the palmar cutaneous branch of the median nerve that parallels
the palmaris longus tendon. (By permission of JE Skandalakis, GL Colborn, PN
Skandalakis, et al. Am Surg 58(3):158-166, 1992.)
676 19. CarpaI TunneI
Figure 19.12. Division of the volar carpal ligament. (By permission of JE Skan-
dalakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(3):158-166, 1992.)
Figure 19.13.
lakis, GL Colborn, PN Skandalakis, et al. Am Surg 58(3):158-166, 1992.)