Carpal Tunnel/Trigger Finger Release Operative Report

Date of Surgery: [Date of surgery]

Facility/Location: [Facility or surgical suite]

Laterality: [Right / Left]

Digit(s): [Digit name(s), e.g., thumb, index, middle, ring, small] (Only include if trigger finger release was performed.)

Preoperative Diagnosis

• [Diagnosis with laterality and digit when applicable]
• [Additional diagnosis] (Include additional lines only if applicable.)

Postoperative Diagnosis

[Same as preoperative diagnosis] (If different from preoperative diagnosis, list each updated diagnosis below instead.)

• [Updated diagnosis with laterality and digit]

Procedure(s) Performed

• Open release of [Right / Left] transverse carpal ligament (carpal tunnel release) (Include only if performed.)
• Open release of [Right / Left] [thumb / index / middle / ring / small] finger A1 pulley (trigger finger release) (Include only if performed; list each digit separately.)

Surgeon and Assistants

Primary Surgeon: [Surgeon name and credentials]

Assistant(s): [Assistant name(s) and role(s)] (Omit line if no assistants present.)

Anesthesia

Type: [Local / MAC / Regional block / General]

[Local anesthetic agent, concentration, volume, and injection site if local infiltration performed by surgeon] (For WALANT, document local anesthetic with epinephrine.)

Tourniquet

Tourniquet: [Not used / Used as described below / Not documented]

• Type: [Pneumatic / Non-pneumatic / Finger tourniquet]
• Location: [Upper arm / Forearm / Digit]
• Side: [Right / Left]
• Pressure: [Pressure in mmHg]
• Total time: [Duration in minutes]

(If tourniquet not used, omit the detail list above. Do not leave this section blank.)

Indications

[Brief summary of presenting symptoms and functional limitations], present for [duration]. [Failed conservative treatments]. [Relevant examination or electrodiagnostic findings]. Informed consent was obtained after discussion of risks, benefits, and alternatives.

Time-Out

A time-out was performed confirming correct patient, procedure(s), laterality, and digit(s).

Findings

• Carpal tunnel: [Appearance of transverse carpal ligament and median nerve] (Include only if carpal tunnel release performed.)
• Trigger finger: [A1 pulley and flexor tendon appearance] (Include only if trigger finger release performed.)
• [No unexpected findings / Unexpected finding: description]

Procedure in Detail

The patient was positioned [supine / seated] with the [Right / Left] upper extremity on a hand table. The extremity was prepped and draped in standard sterile fashion. Correct side and procedure(s) were confirmed.

Carpal Tunnel Release – Open – [Right / Left]

(Include this subsection only if carpal tunnel release was performed.)

A [length] incision was made [incision location relative to anatomic landmarks]. Dissection proceeded through skin and subcutaneous tissue to the palmar fascia, which was divided to expose the transverse carpal ligament. The transverse carpal ligament was released under direct visualization from [distal extent] to [proximal extent], with the median nerve protected throughout. Complete release was confirmed by [method of confirmation, e.g., direct visualization and palpation of released edges].

[Additional procedures such as synovectomy or neurolysis] (Include only if performed.)

Trigger Finger Release – [Digit] – [Right / Left]

(Include this subsection only if trigger finger release was performed. Duplicate for each digit released.)

A [length] incision was made over the A1 pulley at [incision location]. Dissection proceeded through subcutaneous tissue with the digital neurovascular bundles protected throughout. The A1 pulley was released longitudinally with the A2 pulley preserved. [Flexor tendon and tenosynovium condition] (Include only if notable or if intervention performed.) Smooth tendon glide without triggering was confirmed with [active / passive / active and passive] finger motion.

Hemostasis was achieved with [method]. The wound(s) were irrigated with [solution]. The skin was closed with [suture type and technique]. A sterile dressing was applied.

Operative Summary

Estimated Blood Loss: [Volume, e.g., minimal, <5 mL]

Specimens: [None / Specimen type and destination]

Implants: [None / Implant description]

Drains: [None / Drain type and location]

Complications: [None / Description of event, management, and outcome]

Disposition and Postoperative Plan

• Condition: [Stable / other]
• Destination: [PACU / Recovery / Home]
• Dressing care: [Instructions for wound care and dressing changes]
• Activity: [Activity restrictions and guidance on early finger range of motion]
• Pain management: [Analgesic plan]
• Follow-up: [Timeframe for follow-up appointment]
• Return precautions: [Warning signs: increasing pain, fever, redness, drainage, numbness, color or temperature changes]