A Intermediate Evaluation and Management 1 Obtain focused history and performs focused orthopedic exam night pain, paresthesias Median nerve motor/ sensory evaluation MN numbness, thumb abduction provocative maneuvers: Tinel tap the median nerve over the volar carpal tunnel Phalen wrist flexed with elbow extended for ~60 sec produces symptoms less sensitive than Durkin compression test Durkins compression test is the most sensitive test to diagnose carpal tunnels syndrome press thumbs over the carpal tunnel and hold pressure for 30 seconds. onset of pain or paresthesia in the median nerve distribution within 30 seconds is a positive result. 2 Evaluate other sites of MN compression pronator syndrome cervical radiculopathy 3 Orders and interprets required diagnostic studies EMG and NCV often the only objective evidence of a compressive neuropathy (valuable in work comp patients with secondary gain issues) not needed to establish diagnosis (diagnosis is clinical) NCV increase latencies (slowing) of NCV distal sensory latency of > 3.2 ms motor latencies > 4.3 ms decreased conduction velocities less specific than latencies velocity of < 52 m/sec is abnormal EMG test the electrical activity of individual muscle fibers and motor units detail insertional and spontaneous activity potential pathologic findings increased insertional activity sharp waves fibrillations fasciculations complex repetitive discharges 4 Prescribes and manages nonoperative treatment night splints steroid injections attempts trial of physical therapy 5 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 6 Provides simple post operative management and rehabilitation postop: 2-3 Week postoperative visit wound check remove sutures start hand therapy diagnose and management of early complications<br /> B Advanced Evaluation and Management 1 Complex postop management worsening numbness worsening pain additional radiating symptoms C Preoperative H & P 1 Perform basic history and physical exam check neurovascular status identify medical co-morbidities that might impact surgical treatment screen medical studies to identify and contraindications for surgery 2 Perform operative consent describe complications of surgery including incomplete release median nerve damage or scarring ulnar nerve or ulnar artery damage palmer arterial arch damage RSD
E Preoperative Plan 1 Execute surgical walkthrough describe the steps verbally to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Loupes recommended 2 Room setup and equipment standard operative table with hand table 3 Patient positioning supine position G Superficial Dissection 1 Mark the incision mark the incision at the intersection of the Kaplan cardinal line and the radial border of the fourth ray ending at the wrist crease 2 Make incision make incision anywhere along this mark incision needs to be long enough that the proximal and distal aspects of the TCL can be visualized H Expose the TCL 1 Expose the TCL use a scalpel or scissors to dissect through the subcutaneous fat and palmar tissue the palmaris brevis muscle is often seen superficial to the TCL incise and feather the palmaris brevis muscle from the TCL to allow adequate visualization use a mosquito clamp or Carroll elevator into the carpal canal just deep to the TCL this space defines the undersurface of the TCL and the hamate hook 2 Visualize the superficial surface of the TCL place a right angle retractor this is placed to protect the critical structures that are located between the skin and the ligament I TCL Release 1 Release the most ulnar aspect of the TCL identify the most ulnar aspect of the TCL in the canal close to the hook of hamate release the TCL under direct visualization make sure to release proximally and distally use scissors, scalpel or mini meniscotome type beaver blade keep the radial leaflet of the TCL over the median nerve 2 Release the distal forearm fascia proximally this is a common secondary site of compression 3 Confirm release of the TCL proximally and distally J Explore Median Nerve to Ensure Decompressed 1 Check nerve check all areas for possible nerve compression before wound closure K Wound Closure 1 Superficial wound closure use 3-0 nylon to close skin 2 Dressings place in a soft dressing
O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds outpatient PT schedule follow up in 2 weeks wound care R Complex Patient Care 1 Able to identify and manage complex complications postoperatively