Carpal Tunnel Syndrome - Demo

8/6/2019 Carpal Tunnel Syndrome - Demo

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Carpal Tunnel Syndrome

Presented by:

Kim P. Suan


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Facts

According to the National Institute of Neurological

Disorders and Stroke (NINDS):

Carpal tunnel syndrome accounts for the highest

average number of days lost at work, when

compared to all other major work-related injuries or

illnesses in the US. About 260,000 carpal tunnelrelease operations are performed each year, and

about 47 percent are work related.


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Incidence Globally An estimated 4-10million peopleInternationally suffer

from carpal tunnel

syndrome, with a

prevalence of

approximately 50

cases per 1000subjects in the general

population. Up to half

of cases are bilateral.

There is a roughly 4 to

1 predominance forfemales, with a peak

incidence at 50 years

of age.


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Incidence In the PhilippinesA study on 298 women workers in selected manufacturing

industries in an export processing zone

94

6

The study consisted of

questionnaires and physical

assessment tests using Phalen's

and Tinels. The study also showed

that Phalen's and Tinel's Tests,

which may be indicative of Carpal

Tunnel Syndrome(CTS), are

present in 2% - 6% of the subjects.

(National Institute of Health,University of the Philippines

Manila, P. Gil St., Ermita, Manila,

Philippines)


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Wrist Anatomy

The wrist anatomy

includes the

bones, muscles, tendons

and other structures

around the wrist joint.The wrist or the carpus is

a part of the hand. It joins

the forearm bones with

the metacarpal bones of

the hand. It is made of 8

small bones called thecarpal bones.

HCAPITATE

HAMATE

PISIFORM

TRIQUETRAL

TRAPEZIUM

TRAPEZOID

LUNATE

SCAPHOID


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Wrist Anatomy

Towards the palm the

bones of the wrist form

a concave cavity. This

cavity is completed

into a tunnel by theflexor retinaculum.

This tunnel is called

the carpal tunnel. It

provides passage to

the flexor tendons of

the fingers and the

median nerve. At the

back of the wrist these

bones are convex.

Ulnar NerveFlexor

Retinaculum

Median Nerve


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Nerve Distribution of the Hand

The median n. is formed byspinal roots

C6, C7, C8, T1. It

innervates Pronator

teres, Palmaris

longus, Flexor carpiradialis, Flexor digitorum

superficialis, Flexor

digitorum profundus

(lateral half), Pronator

quadratus, Flexor pollicislongus, Abductor pollicis

brevis, Opponens

pollicis, Flexor pollicis

brevis, and Lumbricals 1 &

2.


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Nerve Distribution of the Hand

The ulnar n. is formedfrom spinal roots C8 and

T1. It innervates the

following muscles: Flexor

carpi ulnaris, Flexor

digitorum profundus,Palmaris brevis, Adductor

pollicis, Flexor pollicis

longus, Interossei,

Abductor digiti minimi,

Opponens digiti minimi,Flexor digiti minimi,

Lumbricales 3 & 4, and

the Interossei.


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Pathophysiology

Age (50 yo)

Sex (female)

Race (white)

Structure of the

wrist

Precipitating Factors:Predisposing Factors:

Repetitive Hand Movements

Joint or Bone Disease

Osteoarthritis

Rheumatoid Arthritis

Hormonal/Metabolic

Changes

Pregnancy

Hypothyroidism

Tumor

Infection

Hemodialysis

Trauma

Inflammation

WaterRetention

Amyloid

Deposits


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Increases pressure

inside the carpal

tunnel

60-80 mmHg

30 mmHg

Sensory

dysfunction

40 mmHg

Signs and Symptoms:

Pain Numbness

Tingling

Burning

In the wrist and palm side of

the hand (the thumb, index,middle, and part of the fourth

fingers)


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Signs and Symptoms


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Increases pressure

inside the carpal

tunnel

60-80 mmHg

30 mmHg

Sensory

dysfunction

40 mmHg

Signs and Symptoms:

Pain Numbness

Tingling

Burning

In the wrist and palm side of

the hand (the thumb, index,middle, and part of the fourth

fingers)

Diagnostic Tests:

Hoffman-Tinel Sign Phalen sign

The carpal compression test

Palpatory diagnosis

The square wrist sign


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Diagnostic Tests

Gentle tapping over themedian nerve in the carpal

tunnel region

Abnormal = tingling in median

nerve

Tingling in the median nervedistribution is induced by full

flexion of the wrists

Abnormal = reproduce Sx in 30-

60 sec

Hoffman-tinel test Phalen test


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Diagnostic Tests

The carpal compression test

This test involves applying firm pressure directly over

the carpal tunnel, usually with the thumbs, for up to

30 seconds to reproduce symptoms.

Palpatory diagnosis

This test involves examining the soft tissues directly

overlying the median nerve at the wrist for mechanical

restriction.

The square wrist signThe ratio of the wrist thickness to the wrist width is

greater than 0.7.


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Diagnostic Tests

Gentle pressure directly over

carpal tunnelp paresthesias in

30 seconds or less

Better for wrists with limited

motion

Highest sensitivity/specificity of

all physical exam tests


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Summary of Tests

Test Sensitivity Specificity

Phalens 75% 62%

Tinels 64% 71%

Compression 87% 90%


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Increases pressure

inside the carpal

tunnel

60-80 mmHg

30 mmHg

Sensory

dysfunction

sensory and

motor

dysfunction

40 mmHg

Signs and Symptoms:

The Whole Hand:

may become numb

lose the ability to feel heatand cold

sense of weakness and a

tendency to drop things

Diagnostic Tests:

Electromyography

Nerve conduction test


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Diagnostic Tests

Physicians insert a

tiny, sterile, disposable needle

beneath the surface of the

skin, into the muscle

Electromyography

Nerves are stimulated by

electric impulses passing overthe nerve while recording the

nerves response at a different

location

Nerve conduction test

Abnormal = across the wrist:

distal motor latency > 4.5ms

sensory latency > 3.5ms


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Pressure increases

inside the carpal

tunnel

60-80 mmHg

30 mmHg

Sensory

dysfunction

Decrease or

absence of sensory

and motor response

sensory and

motor

dysfunction

40 mmHg

Signs and Symptoms:

Wasting away of the muscle

under the thumb

May feel that hands are

swollen even though there is

no visible swelling


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Signs and Symptoms


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Pressure increases

inside the carpal

tunnel

60-80 mmHg

30 mmHg

Sensory

dysfunction

Decrease or

absence of sensory

and motor response

sensory and

motor

dysfunction

40 mmHg

Signs and Symptoms:

Wasting away of the muscle

under the thumb

May feel that hands are

swollen even though there is

no visible swelling

Diagnostic Tests:

Magnetic resonance imaging

Ultrasonography


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Diagnostic Tests

Magnetic Resonance Imaging Ultrasonography


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Nerve Pathology

Mild Moderate Severe


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Pathophysiology

Age (50 yo)Sex (female)Race (white)Structure of the wrist

Precipitating Factors:Predisposing Factors:

Repetitive Hand Movements

Joint or Bone DiseaseOsteoarthritisRheumatoid Arthritis

Hormonal/Metabolic ChangesPregnancyHypothyroidism

Tumor

Infection

Hemodialysis

Trauma

Inflammation

WaterRetention

Amyloid Deposits

Pressure increases inside thecarpal tunnel

Sensory dysfunction

Decrease or absence of sensory

and motor response

sensory and motordysfunction


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Medical Management

Mild Cases: Splint (usually worn at

night) to prevent the wristfrom bending. Relieves

swelling through rest.

Medications: Oral anti-inflammatories. The

swollen membranes arereduced


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Medical Management

Cortisone injection:

Medication surrounds the

swollen membranes &tendons shrinking

them.With 80% relief short-term,

~10-20% @ 1.5 years

Moderate and Severe Cases:


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Surgical Management

Indicated when non-operative treatment hasfailed or thenar motor denervation

Open Release Surgery

Under local anesthetic.

Relieves pressure on themedian nerve.

Usually considered day

surgery.


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Endoscopic Carpal Tunnel release

Patients benefit from a procedurewhich requires only a minimal incision

at the wrist, resulting in less

morbidity, with patients benefiting from:

Early return to activities of daily

living Early return to work for non-worker's

compensation patients-almost 50%

faster than those who undergo

conventional open carpal tunnel

surgery

Improved cosmetic results Faster recovery of grip and pinch

strength

Less morbidity and scar tenderness

Surgical Management


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Post Surgery

Range of motion of the fingers is important

after surgery and encouraged. It helps the

nerve to glide so adhesions dont form.

However, simultaneous wrist and finger

flexion should be avoided for at least 3

weeks after surgery

Day 0 - 5

The sutures are removed approximately 7

to 14 days after surgery. Your Physician

may allow you to remove your dressing in

2 to 3 days after surgery and apply Band-Aids and sometimes a removable splint.

Week 1- 6

Start progressive strengthening exercises.

Week 6-12


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Post Surgery Exercises

Physical activities can

be resumed only after

a few weeks & for

some a few months

Exercises will be given

in order to build

muscle

strength, joint flexibilityof hand and wrist


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Journal ReadingCarpal tunnel syndrome (CTS) and exposure to vibration, repetitivewrist movements, and heavy manual work: a case-referent study.

by: G Wieslander, D Norbck, C J Gthe, and L Juhlin

Abstract

Possible connections between carpal tunnel syndrome (CTS) and exposure to vibrating

handheld tools, repetitive wrist movements, and heavy manual work were examined in a

case-referent study. The cases were 38 men operated on for CTS between 1974 and

1980. For each case, two referents were drawn from among other surgical cases (hospital

referents) and two further referents from the population register and telephone

directory, respectively (population referents). Thirty four of 38 cases (89%) and 143 of 152

referents (94%) were interviewed by telephone. An increased prevalence of

obesity, rheumatoid disease, diabetes, or thyroid disease was observed among the cases

but most did not suffer from any of these disorders. CTS was significantly correlated with

exposure to vibration from handheld tools and to repetitive wrist movements but showed aweaker correlation with work producing a heavy load on the wrist. A cause-effect relation

between CTS and exposures to handheld vibrating tools and to work causing repetitive

movements of the wrist seems probable. Some differences between hospital and

population referents indicate that a case-referent study of this type could be biased by

inappropriate selection of referents.


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Curriculum Vitae

KIM PADRO SUAN, RN EMT(D)0204-A Quezon Ave. Ext. Pala-o

Iligan City, Philippines 09200

Telephone Number: (063) 223-3456

Mobile Number: 09166770074

Email Address: [email protected]

EDUCATIONAL BACKGROUND

Tertiary

20042008

June 1-2, 20081996 2004

BACHELOR OF SCIENCE IN NURSING

Graduated

Pala-o,

Passed the Philippine Nursing Licensure Examination

19th

PlacerBACHELOR OF SCIENCE IN COMPUTER SCIENCE

MichaelsCollege

Secondary

1992 1996 - INTEGRATED DEVELOPMENTAL SCHOOL

Tibanga,

Elementary

1986 1992 SAN MIGUEL VILLAGE SCHOOL

Pala-o,


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POST-GRADUATE COURSE

January 8 February 23, 2007 EMERGENCY MEDICAL TECHNICIAN-BASIC

Pre-Hospital Emergency CareLife Support Training International, PSEMT

Cubao,

Passed the Philippine Society of EmergencyMedicalTechnician Licensure

Examination

1stPlacer

June 22 June 26, 2009 EMERGENCY MEDICAL TECHNICIAN

DEFIBRILLATORLife Support Training International, PSEMT

Cubao,

Date post:	08-Apr-2018
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Carpal Tunnel Syndrome - Demo

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