OT notes · Orthopaedics

Carpal tunnel / tarsal tunnel release (nerve decompression)

Usual anaesthesia
Carpal tunnel: local infiltration (WALANT), wrist or brachial plexus block, or IV regional. Tarsal tunnel: regional (spinal or popliteal / ankle block) or general
Position
Carpal tunnel: supine, arm on hand table. Tarsal tunnel: supine; mild Trendelenburg helps keep the field clear if no tourniquet is used
Setting
elective

Operative note template for open carpal tunnel release (mini-palm or extended open) and tarsal tunnel release, with a filled example for a mini-palm open carpal tunnel release under wide-awake local anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • symptoms may not be fully relieved, especially with long-standing or severe compression
  • numbness or painful neuroma from injury to a small cutaneous nerve
  • injury to the main nerve or its branches (median motor branch; medial or lateral plantar nerve)
  • scar tenderness and pain on pressing the palm or heel
  • wound infection or delayed healing
  • recurrence of symptoms
  • complex regional pain syndrome
  • tarsal tunnel: difficulty with footwear and swelling
  • a few symptoms may get worse after release

Pre-operative details for this operation

  1. Side and nerveRight carpal tunnelLeft carpal tunnelRight tarsal tunnelLeft tarsal tunnel
  2. Symptoms and durationnight symptoms, distribution of numbness, weakness, thenar or intrinsic wasting
  3. Clinical testsCTS: Phalen, Tinel, Durkan, two-point discrimination, thenar power (CTS-6 score if used). TTS: Tinel along tibial nerve and branches, hindfoot alignment
  4. Nerve conduction studydistal motor and sensory latency values; date
  5. ImagingCTS: usually none, ultrasound if unclear. TTS: X-ray foot and ankle; MRI if space-occupying lesion suspected
  6. Associated conditionsdiabetes, hypothyroidism, pregnancy, rheumatoid arthritis, previous fracture, ganglion, coalition
  7. Conservative treatment triedsplints, injection, orthosis, medicines, and for how long
  8. Anticoagulants / antiplateletscontinued or stopped, date

Anaesthesia and position

  1. AnaesthesiaWALANT (lidocaine with adrenaline, no tourniquet)Local with tourniquetWrist blockBrachial plexus blockIV regional (Bier block)SpinalPopliteal / ankle blockGeneraldrug, strength, volume
  2. PositionSupine, arm on hand tableSupine, operated foot (tarsal tunnel); mild Trendelenburg if no tourniquet
  3. TourniquetNot usedArm / thigh tourniquetpressure, time up and down
  4. Magnification and bipolar cauteryLoupesNone

Operative findings

  1. Ligament / retinaculumthickness; how tight
  2. Nerve appearancehourglass narrowing, flattening, colour, hyperaemia, adhesion to the ligament; pink-up after release
  3. TenosynoviumNormalThickened / inflamed
  4. Anatomical variationsmedian: motor branch through the ligament, anomalous muscles; tibial: early branching, accessory muscle, varicose veins
  5. Space-occupying lesionNoneGanglionLipomaNerve sheath tumourBony prominence / coalition

Procedure (steps)

  1. IncisionMini-palm: 2 to 3 cm longitudinal, from just distal to wrist crease in line with the third web spaceExtended open: palm incision carried to wrist crease, angled ulnar-wardsTarsal tunnel: curved incision from about 10 cm above the medial malleolus, 2 cm behind the tibia, to the talonavicular levellength in cm; incision kept ulnar to the thenar crease
  2. Superficial dissectionCTS: palmar fascia split, hypothenar fat retracted, palmar cutaneous branch protected. TTS: vessels cauterised, flexor retinaculum exposed
  3. Ligament / retinaculum dividedCTS: transverse carpal ligament divided on its ulnar side with No. 15 blade, 2 to 3 mm left on the hamate hook, deep palmar fat seen distally. TTS: retinaculum divided from proximal to distal over a curved clamp
  4. Proximal releaseCTS: distal 2 cm of antebrachial fascia divided with blunt scissors
  5. Nerve inspected and followedCTS: motor branch seen or protected. TTS: tibial nerve traced to medial plantar, lateral plantar and calcaneal branches; MPN released at abductor hallucis tunnel; deep fascia of abductor hallucis released for LPN and its first branch
  6. External neurolysisNot neededDone: nerve freed from ligament leafinternal neurolysis and epineurotomy are not routine
  7. Additional proceduresNoneFlexor tenosynovectomyExcision of ganglion / lipomaResection of coalition
  8. Superficial palmar arch protectedlies 5 to 8 mm beyond the distal edge of the ligament
  9. Tourniquet released (if used), nerve perfusion checked, haemostasis with bipolar

Closure, drains and dressing

  1. RetinaculumNot closed
  2. SkinCTS: skin only, interrupted nylon. TTS: layers
  3. DrainNoneDrain for oozing
  4. DressingLight compression dressingCompression dressing with volar splintCompression dressing with plaster splint (foot)

Specimens and implants

  1. Specimen for HPENoneTenosynoviumGanglion / lipoma / tumour

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Elevationhand above heart / foot on pillows; avoid a hanging hand
  2. Finger or toe movementCTS: active finger movement and hand use from the same day
  3. Weight bearing (tarsal tunnel)non-weight bearing on crutches for 2 to 3 weeks
  4. Analgesiadrug, dose, frequency
  5. DressingCTS: patient may remove bulky dressing at 2 to 3 days and wash gently
  6. Suturesremoved at 10 to 14 days (tarsal tunnel at about 10 days if healed)
  7. SplintCTS: only for comfort, up to 2 to 3 weeks
  8. Follow-upsymptoms at 2 weeks and 6 weeks; improvement continues up to 6 months; HPE report if a specimen was sent

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. P.D., 48 years, homemaker, right-handed, 14 months of night tingling in the right thumb, index and middle fingers, not relieved by night splint and one steroid injection. Mild thenar wasting.

Case details

Date: 05/08/2026. Elective, day-care. Minor OT.

In OT 10:10. Local injection 10:15. Skin incision 10:45. Dressing complete 11:05.

Surgeon: Dr A. (2nd-year resident, Orthopaedics). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist on standby: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Diagnosis: right carpal tunnel syndrome, moderate to severe. Phalen positive at 20 s, Tinel positive at wrist, Durkan positive. Two-point discrimination 7 mm over index pulp. Mild thenar wasting.

NCS 12/07/2026: right median distal motor latency 5.8 ms, sensory latency 4.4 ms. Ulnar normal.

Hypothyroid on levothyroxine, TSH normal. Not diabetic. Not on antiplatelets.

Antibiotic not given: clean hand procedure without implant.

Consent: procedure-specific consent taken in Hindi. Explained that numbness may improve slowly and thenar wasting may not recover, scar tenderness, palmar nerve neuroma, infection, recurrence.

WHO checklist sign in and time out done. Right side marked.

Anaesthesia and position

WALANT: 20 ml of 1% lidocaine with adrenaline 1:100,000 buffered with 8.4% sodium bicarbonate (10:1), 10 ml between median and ulnar nerves just proximal to the wrist crease and 10 ml under the planned incision. No tourniquet.

Supine, right arm on hand table. Parts painted with povidone-iodine and draped.

Findings

Thick transverse carpal ligament. Median nerve flattened with an hourglass narrowing under the ligament, pale at that level, adherent to the radial leaf.

Motor branch arising outside the ligament, not through it. Tenosynovium normal. No mass.

Procedure

Mini-palm incision 2.5 cm, starting just distal to the distal wrist crease, slightly ulnar to the midline, in line with the third web space.

Palmar fascia split in line with its fibres, hypothenar fat retracted ulnar-wards. Transverse carpal ligament exposed.

Ligament divided along its ulnar side with a No. 15 blade, leaving 2 to 3 mm on the hook of hamate. Deep palmar fat seen distally, confirming complete division. Superficial palmar arch seen and protected.

Contents freed from the undersurface with a mosquito forceps. Distal 2 cm of antebrachial fascia divided with blunt-tipped Metzenbaum scissors under direct vision.

Median nerve freed from the radial leaf of the ligament (external neurolysis). No internal neurolysis.

Patient asked to move the fingers and thumb: full movement, no tendon catching.

Haemostasis checked with bipolar cautery.

Closure

Ligament not repaired. Skin only, interrupted nylon (Ethilon) 4-0. No drain.

Light compression dressing. No splint.

End of procedure

Blood loss negligible. Mop, needle and instrument count correct.

No intra-operative complications. No specimen. No implant.

Patient comfortable, fingers pink. Shifted to day-care ward.

Post-op orders

Keep the right hand raised; do not let it hang down. Move the fingers fully and use the hand for light tasks from today.

Analgesia as per the unit day-care protocol.

Discharge today if comfortable. May remove the bulky dressing at 3 days and wash gently; keep a small dressing on the wound.

Suture removal at 12 days. Review in OPD at 2 weeks and 6 weeks.

Signature

Dr A., JR-2, Orthopaedics. Reg. no. ________. 05/08/2026, 11:15.

Must document for this operation

  • The pre-operative nerve findings (sensation, wasting) and the NCS values. Without a baseline, a later complaint of new numbness cannot be told apart from old disease.
  • That the ligament or retinaculum was divided completely, and how completeness was confirmed. Incomplete release is a common cause of persistent symptoms and the revising surgeon will look for it.
  • The motor branch and palmar cutaneous branch (or the plantar branches) seen and protected. Injury to these small nerves is a known complaint after release, and the note shows they were looked for.
  • The appearance of the nerve and any lesion found. Hourglass narrowing or a mass supports the diagnosis and explains the expected recovery.
  • Anaesthetic drug, strength and volume, and whether a tourniquet was used. Local anaesthetic has a maximum safe dose, and the record shows it was kept below it.
  • Whether neurolysis or any extra procedure was done. Extra procedures need a reason, and internal neurolysis is not routine.

Common mistakes in these notes

  • Writing 'CTR done' with no side, no incision type and no statement of complete release.
  • Not recording the NCS values or the thenar wasting before surgery.
  • Leaving out the local anaesthetic volume and adrenaline strength in WALANT cases.
  • Not writing whether the palmar cutaneous branch and motor branch were seen.
  • In tarsal tunnel release, not naming which branches (medial plantar, lateral plantar, calcaneal) were released.

Indian practice and paperwork

  • Consent must explain the procedure, risks, benefits, alternatives (splint, injection) and who will operate, in a language the patient understands. (NABH 5th ed. (2020), PRE.4(c))
  • Even for a day-care case, NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed. (2020), COP.14(e) and (f))
  • If a ganglion, tenosynovium or tumour is removed, write whether it went for HPE. Tissue not sent is human anatomical waste for the yellow bag; used formalin is yellow (f) chemical waste. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Azar FM, Beaty JH, eds. Campbell's Core Orthopaedic Procedures. 2nd ed. Elsevier; 2024, Technique 41, Mini-palm open and open carpal tunnel release (Weller WJ, Calandruccio JH), pp. 192-195.
  • Azar FM, Sawyer JR, et al., eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier, Ch 82, Compressive neuropathies: carpal tunnel syndrome (diagnosis, treatment, Techniques 82.1-82.2); Ch 69, Anaesthesia for hand surgery and WALANT, pp. 3542-3548; 3096-3102.
  • Coughlin MJ, Saltzman CL, Anderson RB, eds. Mann's Surgery of the Foot and Ankle. 9th ed. Elsevier Saunders; 2014, Ch 12, Disorders of the nerves: tarsal tunnel syndrome, pp. 641-649.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 2: clean procedures of the hand, knee or foot without implants: no prophylaxis recommended. academic.oup.com/ajhp/article/70/3/195/5112717
  • Campbell's Operative Orthopaedics 15e, Ch 69, WALANT, pp. 3101-3102 (pdf 3979-3980): 1% lidocaine with 1:100,000 adrenaline, buffered 10:1 with 8.4% bicarbonate, 20 ml for carpal tunnel; accepted maximum lidocaine with adrenaline 7 mg/kg.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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