Overview
Open carpal tunnel release decompresses the median nerve by dividing the constricting flexor retinaculum while preserving the nerve, its branches, flexor tendons and palmar vessels. A small incision is useful only when the necessary structures remain visible and the release can be completed safely. This guide follows Campbell's mini-palm method with the option of extending exposure (Chapter 82, Techniques 82.1–82.2).
Assessment and Indications
Confirm a compatible history and examination, including sensory symptoms, nocturnal pain, thenar function and competing proximal or peripheral neurologic causes.
Use ancillary studies when the presentation is unclear or the assessment requires them; the source emphasizes clinical diagnosis rather than routine reliance on MRI.
Mild symptoms without thenar atrophy may respond to night splinting or injection. Intermediate or advanced chronic disease is more appropriately considered for release.
Acute carpal tunnel symptoms after injury require cause-specific assessment, including constrictive dressings and wrist position. Persistent compression may require urgent decompression.
Discuss that advanced nerve dysfunction may recover incompletely and thenar atrophy may resolve slowly or not at all.
(Campbell, Chapter 82.)
Planning and Anatomy
Structure | Technical relevance |
|---|---|
Palmar cutaneous median nerve branch | Vulnerable in a radial or thenar-crease incision; a painful neuroma can compromise the result. |
Recurrent motor branch | May follow an atypical or transligamentous course; identify what is being divided. |
Median nerve and flexor tendons | Can lie adherent to the deep ligament surface and must be protected during release. |
Superficial palmar arch | Lies close to the distal retinaculum; avoid blind distal extension. |
Plan exposure appropriate to primary disease, revision scarring, a mass or anticipated tenosynovectomy. The source describes limited and extended open methods; the incision should permit safe identification of the structures requiring release (Campbell, Chapter 82).
Surgical Technique
Incision and Exposure
Mark a longitudinal palmar incision beginning just distal to the distal wrist crease and extending approximately 2–3 cm along the source's ulnar palmar/ring-finger reference.
Keep the incision away from the variable thenar crease to reduce risk to the palmar cutaneous branch.
Open the skin and expose the palmar fascia with controlled dissection.
Split the fascia and retract the hypothenar fat to identify the transverse carpal ligament.
If muscle obscures the ligament, carefully mobilize it sufficiently to visualize the underlying structure.
(Campbell, Chapter 82, Technique 82.1.)
Retinacular Release
Open the ligament under direct vision, protecting the median nerve beneath it.
Divide the constricting fibers distally while identifying the transition to the deep palmar fat and avoiding the nearby arterial arch.
Confirm that the tunnel contents are not adherent to the remaining proximal or distal fibers before advancing scissors.
Complete the proximal decompression, including the necessary distal antebrachial fascia. Technique 82.1 describes division of approximately the distal 2 cm under protected visualization.
Assess completeness of the entire release rather than equating one divided segment with successful decompression.
(Campbell, Chapter 82.)
Inspection and Selective Additional Work
Inspect the median nerve and released ligament margins for residual constriction or adherence.
Use external neurolysis only when needed to free an adherent nerve in the described setting.
Inspect the tenosynovium and consider targeted tenosynovectomy when the underlying condition warrants it, such as inflammatory disease or suspected amyloid.
Recognize anomalous muscles, tendons and nerve connections before dividing unfamiliar tissue.
Enlarge the exposure if visualization is inadequate. Do not continue a blind limited release for the sake of incision length.
(Campbell, Chapter 82, Techniques 82.1–82.2.)
Final Checks and Closure
The distal and proximal constricting fibers have been released completely.
The median nerve and recurrent branch are intact and free of a residual compressing band.
The palmar arch and flexor tendons have been protected.
No unnecessary internal neurolysis or epineurotomy has been performed; the source reports no routine benefit from these additions.
Close the skin and apply a light compressive dressing, with a volar splint when indicated by the chosen pathway.
(Campbell, Chapter 82.)
Postoperative Care
Encourage early finger and hand use as comfort allows while avoiding a dependent swollen position. In the source's open-release aftercare, the dressing is often removed after 2–3 days, gentle washing is permitted, and sutures are removed at 10–14 days. Progress ordinary hand use gradually according to the wound, discomfort and functional recovery (Campbell, Chapter 82).
Persistent or Recurrent Symptoms
Distinguish incomplete initial relief from later recurrence. Possible causes include incomplete release, scarring, recurrent tenosynovitis, a painful cutaneous neuroma or an alternative diagnosis. Revision requires reassessment rather than automatic repetition of the initial incision. Advanced preoperative nerve dysfunction can also explain incomplete recovery despite an adequate release (Campbell, Chapter 82).
Complications and Pearls
Incomplete release: verify distal and proximal extents under vision.
Nerve injury: respect the variable palmar cutaneous and recurrent motor branches.
Vascular or tendon injury: avoid blind distal cutting and inspect the deep surface before advancing instruments.
Scar or pillar pain: discuss recovery expectations and monitor hand function.
Recurrent symptoms: investigate residual constriction, scarring and other causes before revision.
(Campbell, Chapter 82.)
Outcomes and Technique Choice
Both open and endoscopic decompression can provide substantial benefit. Campbell notes earlier short-term recovery in some endoscopic series but similar outcomes by approximately 6 months and a concern for nerve injury. The technique should match the pathology, visibility and surgeon's expertise rather than an assumption that the smallest exposure is always preferable (Chapter 82).
References
Weller WJ. Compressive neuropathies of the hand, forearm, and elbow. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2026. Chapter 82, assessment and indications, pp. 3542–3546; open release and aftercare, pp. 3546–3549, Techniques 82.1–82.2; recurrent symptoms, pp. 3552–3553.