Combined.pptx

8/15/2019 Combined.pptx

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CARPAL TUNNEL

SYNDROME(CTS)


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INTRODUCTION

MUHAMMAD HAIKAL BIN MOHD

HARIS012011100096


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WHAT IS CARPAL TUNNELSYNDROME?

1. Carpal tunnel syndrome is a set of symptoms cby compression of the median nerve in the cartunnel.

The symptoms :

I. Pain

II. Numbness

III. Weakness

IV. Pins and needles sensation


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CARPAL TUNNEL

I. narro! passa"e!ay on the palmar side of thmade of bones and li"aments


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CONTENT OF CARPAL TUNNE

I. # $e%or tendon

•.&le%or pollicis lon"us '&P()•.&le%or di"itorum profundus '&*P)

•.&le%or di"itorum super+cialis '&*,)FPL

FDP


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Con!""II. 1 median nerve


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PALMAR CUTANEOUS BRANCOF MEDIAN NER#E

I. The palmar cutaneous branch of median nervefrom the radiopalmar part of the nerve -cm prto volar !rist crease

P$%&$'$n*o+

,'$n- o.&*/$n n*'*


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B'$n-*+ o. &*/$n n*'*

ecurrent motor brannerve innerv

1. bductor pollic/. &le%or pollicis

0. pponens pollic


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PATHOPHYSIOLO4YAND ETIOLO4Y OFCARPAL TUNNEL

SYNDROME

Vaishini 2P Thanabalam


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PATHOPHYSIOLO4Y

• Co&'*++* +3n/'o&* o&,n*+ -*

-*no&*non o. o&'*++on $n/ *n+on.

• P'*++'* .'o& +5*%%n n nn*% $n/o&'*++ on &*/$n n*'*"

• N*'* o&'*++on 7 '$on '*$*'o,%*& '*%$n o n'$n*'$% ,%oo/&'o'%$on8 %*+on $ &3*%n +-*$%-8$ $on$% %**% 7 -$n*+ o -* +o'nonn** ++*"


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Tendons are!rapped by

synovium $uid forlubrication

With repetitivemovement3 the

lubrication systemmay malfunction

Causin"in$ammation and

s!ellin"surroundin" the

tendon 'synoviumsheath)


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I/o$

-

S*on/

$'3

D3n$&

Eo+'* o,'$on('$'*)

Eo%o3


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IDIOPATHIC

• &emale '5- 6 78 9)

• "e 'bet!een 8 and 58 years);-8;589 bil

• 4ereditary

• ,mokin"

• besity

SECONDARY


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SECONDARY A,no'&$%*+ n

on$n*'A,no'&$%*+ n on

S-$* : o+on o. $'$%,on*;*islocation or sublu%ation ofcarpal

Tenosynovial hypertrophy

S-$* o. -* /+$%*'*&*+ o. '$/+;&racture 'translation


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DYNAMIC

• ccupational patholo"ical condition.

• epetitive e%tension > $e%ion of !rist3 alon$e%ion of +n"er and supination of forearm


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REFERENCE

• ?lsevier rthopedia


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4istory Takin"(a! @oon (um

81/811188177


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0. Weakness

• Erippin" fails ' spendin" money !ithout noticin" it )

• Precision loss

• Aoney on the $oor also donFt !ant to take. ' more $e%ion an

compression over !rist)

. utonomic• 4and feel hot 2 cold all the time

• ,!eatin"


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isk factor

1. Bilateral : ' Aedical disease )• mneumonics G A?*IN TP G

• Commonly dominant hand aected +rst

• 8 to -8 years menopausal !omen

• Women < Aen


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/. Hnilateral 2 Bilateral : ' Aechanical )

• Hsin" !alkin" stick3 Wheelchair *rivin"

• Improper !ay 2 hei"ht

• Wrist fracture ' Colles )

• In Cotton;(oder position immobilisation

• Palmer $e%ion and Hlnar deviation

• Cyclist 'handlebar pressure)

• (unate dislocation 'football player fall do!n)

• @eyboard !arriors 'lon" hours)


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• eference:1. pley nd ,olomonFs Concise ,ystem f rtho

nd Trauma3 &ourth ?dition

/. http:22emedicine.medscape.com2article20/D008

http://emedicine.medscape.com/article/327330-clinicalhttp://emedicine.medscape.com/article/327330-clinical


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Physical ?%aminatio

Aaisaratul &ir=anah bt @hid=ir


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,ensory ?%amination

• sensory de+cits usually occur late• Involve median innervated area3

but spare the thenar eminence

Aotor ?%amination

• trophy and !eakness ofthenar muscle

• !eakness of thumb abductionand thumb opposition


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Provocative Aaneuvers

• PhalenFs Test

08;58 secs

Pain3Paraesthesia

,ensitivity 579,peci+city D09


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• TinnelFs Test

,ensitivity -89,peci+city DD9

Pain2Pas


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•Aanual Carpal Compression aka *urkan Test

pply pressure on transverse carpalli"ament

Paraesthesia,ensitivity 59

,peci+city 709


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•4and ?levation Test

1 m

Pain3paraesth

a

,ensitivity D-9,peci+city #79


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eferences:

•pleyKs ,ystem of rthopaedics and &ractures3 N?dition

• Hp to datehttp:22elibrary.ptpl.edu.my:/85/2contents2carpal;syndrome;clinical;manifestations;and;dia"nosisLsourceMsearchresult>searchMcarpalOtunnelOse>selectedTitleM/10/


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1" B%oo/ *+

•.*iabetes

•.hemathoid arthritis

•.hypothyroidism


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2">'$3

• Hsually only to aid in the dia"nosis of fractures aother disorder such as rheumatoid arthritis

@ U%'$+on/ +$n


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@"U%'$+on/ +$n

;;;fully developed cases3 a triad of:

• palmar bo!in" of the $e%or retinaculum '


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"N*'* on/on +/3

• nerve conduction study is a test that measurefast si"nals are transmitted throu"h your nerves

• *urin" the test3 electrodes are placed on your h!rist and a small electrical current is used to stimthe nerves in the +n"er3 !rist and3 sometimes3 e

• The results from the test indicate ho! much damthere is to your nerves.


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" E%*'o&3o'$-3

• Provides useful information about ho! !ell are tmuscles are able to respond !hen a nerve is stim

indicatin" any nerve dama"e.• *urin" the test3 +ne needles are inserted into yomuscles. The needles detect any natural electricactivity "iven o by your muscles.


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R*.*'*n*+• http:22!!!.nhs.uk2Conditions2Carpal;tunnel;synd

a"es2*ia"nosis.asp%

• http:22radiopaedia.or"2articles2carpal;tunnel;synd

http://www.nhs.uk/Conditions/Carpal-tunnel-syndrome/Pages/Diagnosis.aspxhttp://www.nhs.uk/Conditions/Carpal-tunnel-syndrome/Pages/Diagnosis.aspxhttp://radiopaedia.org/articles/carpal-tunnel-syndrome-1http://radiopaedia.org/articles/carpal-tunnel-syndrome-1http://www.nhs.uk/Conditions/Carpal-tunnel-syndrome/Pages/Diagnosis.aspxhttp://www.nhs.uk/Conditions/Carpal-tunnel-syndrome/Pages/Diagnosis.aspx


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T?TA?NT, > PEN,I, CP( THNN?( ,RN*A?

,ITI NH(IN BINTI SH(@?&(I

TREATMENTS


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MILDMODERATESE#ERE

NON SUR4ICAL1. Wrist splint2 braces/. N,I*, diuretics0. Elucocorticoid inUection :

a. Triamcinolone cetonide 18;/8m"b. Aethylprednisolone cetate 18;/8m"

. ral "lucocorticoid : prednisone /8 m" daily for 18 to 1 d-. Aodify hand activities

FAILURE• (on" duration of symptoms '

months)• "e "reater than -8 years• Constant paresthesia• Impaired t!o;point discrimina

'


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SUR4ICAL1. open carpal tunnel release

/. endoscopic carpal tunnel release

MILDMODERATESE#ERE

(ess pain > fast recoNeed e%perience sur


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P,T;P

the !rist is splinted in neutral or sli"ht e%tension this avodisplacement of median nerve

?arly motion '!ithin days after sur"ery) may promote

hypersensitivity

keepin" the !rist in a ni"ht splint may prevent the median

adherin" to the anterior scar

encoura"e di"it motion to prevent adhesions3 but do not allo! s

!rist and +n"er $e%ion


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CAP(ICTIN, P,T;

1. Nerve laceration : InUuries palmar cutaneous or recurrent motor bramedian nerve

/. rterial inUury

0. Tendon laceration

. Tendon adhesion

-. 4ypertrophic scarrin"5. Postoperative infection

D. 4ematoma

7. ,tiness of Uoint

#. Incomplete release 'endoscopic carpal tunnel release)


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PE

• Pro"ressive over time permanent median nerve dama

• Can recurs

• Patients !ith CT, secondary to underlyin" pathodiabetes3 !rist fracture) tend to have a less favorable than do those !ith no apparent underlyin" cause


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TIEE? &INE?',T?N,INE T?N,RNVITI

(VNNR 2P NE, PN

81/8111881/#


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*i"ital +brous sheath


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*i"ital +brous sheath

• stron" +brous sheath !hich covers the a

surface of the +n"ers and attached to the sthe phalan"es

• The sheath !ith the anterior surfaces of thphalan"es and interphalan"eal Uoints form

osteo+brous blind tunnel• &or the lon" $e%or tendons of the +n"ers

,ynovial $uid


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,ynovial $uid

• ,ecreted by synovial sheath

• ct as lubricant• educes friction !hen tendons move unde

retinaculum


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• There are t!o pulley system in the +n"ers

a) nnular pulley ')b) Cruciate pulley ' C)

•) &unction is to keep tendon from e%cursion

$e%ion of +n"ers.


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• Pulley system of the thumb

a) T!o annular pulleyb) ne obliQue pulley


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PATHOPHYSIO


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LO4Y

DAL#INDER SIN4H

01201110016

Normally3 the tendons of the +n"er$e%ors "lide back and forth under a Causin" painful snap as


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$e%ors "lide back and forth under arestrainin" pulley

Thickenin" of the $e%or tendonsheath restricts the normal "lidin"

mechanism.

esult from enlar"ement of thetendon itself or narro!in" of the +rst'1) pulley.

no lon"er able to "lide freely and may

s!ell formin" a nodular thickenin" atthe point !here it tries to pass intothe tunnel.

*urin" forceful bendin" of the +n"eror thumb3 the enlar"ed portion of thetendon is dra""edthrou"h the constricted openin".

This motion is oftenaccompanied by a paclick.

The +n"er or thumb m

become locked in a benposition.

,trai"htenin" the +n"erthumb may reQuire usinother hand to pull the +out strai"ht

Causin" painful snap ass!ollen part of the tendpasses back throu"h thsheath.


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CH,?,


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CH,?,• Hsually repetitive inUury to the tendon or the +brous sh

T-*'* $'* .$o'+ -$ *o%* $ '*$*' '+/**%on ;

1. Aore common in !omen than men.

/. People !ho are bet!een the a"es of 8 and 58 years

0. Aore common in people !ith certain medical problemas diabetes and rheumatoid arthritis. ther condition"out3 carpal turner syndrome3 *upuytrenFs contractu

. Aay occur after repetitive activities that strain the hausin" the keyboard or usin" the hp to key in !ords.

Presentation >Cl i+ i


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Classi+cation...

P'*+*n$on


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S3&o&+

1. ,tiness of the di"its in the mornin"/. Pain at distal palm near 1 pulley

'ACPX)0. ,!ellin" and redness. &in"er clickin"

-. &in"er becomin" catchin"2lockin" in$e%ed position P-3+$% *$&

1. Tenderness to palpation over 1pulley

/. Palpable bump

P'*+*n$on

E??N C(,,I&ICTIN


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4'$/* I 42o catchin" O tenderness at ;pulley

4'$/* IICatching but can actively extenthe digits

4'$/* IIILocked and need to

passively

extent the digits

4'$/* I# Locked fexion contracture


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INVESTIGATION

ANDCONSERVATIVE MANAGEMEN

PAVEETRAN BATHMANATHAN012011100174

INVESTIGATION


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• Trigger finger is CLINICAL DIAGNOSIS• On examination :

- Nodule in tendon

- Audible click

• Radiogra!" are rare#" indi$ated in trigger

finger

• Hand radiogra!s are erformed on#" if a%norma#


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at!o#og" are s&se$ted :

' abnormal sesamoids

- loose bodies in te metacar!o!alan"eal #oint

- osteoartritic s!urs on te metacar!al ead

- a$ulsion in#uries o% collateral li"aments

• He#f to ex$#&de :

- osteoartritis

- %racture malunion- %orei"n bod&

- lar"e sesamoid bone tat is a%%ectin" inter!alan"eal 'I()

#oint motion"

MANAGEMENT


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Prin$i#e of management' Reduce s*ellin"

- Reduce !ain

- Allo* smoot "lidin" o% te tendon

tus allo*in" normal e+tension o%

te %in"ers 'MC(,)

T"es of management

- Conser$ati$e 'non sur"ical)

- Sur"ical

Conser$ati$e mana"ement

Resting


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g

(#inting

A$ti)it" modifi$ation

P!"siot!era"

'maintain mo$ement o% te #oints

-startin" *it "entle mo$ement

(oa*ing in +arm +ater

' to ./ minutes in te mornin"-can el! reduce se$erit& o% catcin" sensation

trou"out te da&

N(A,-(

'reduce s*ellin" and in%lammation


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perative treatment


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Indications :;a) &ail conservative mana"ement

b) Aultiple di"it involvement

c) Infantile tri""er +n"er

d) Irreducibly locked tri""er +n"er

Percutaneous release of 1


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pulley

,ynovial tendon sheath

Tendonsof &*Pand &*,

Pulleys


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Post;perative Care


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a) ?ncoura"e active movement on the day ofsur"ery.

b) nti;in$ammatory dru"s and elevation areadvised for a period of /;0 days follo!in" sur"e

c) ,utures are removed on day 18 to 1 3 follo!inthe procedure.

d) s pain tolerable3 start !ith slo! and "entlemovement and increase the intensity of themovement "radually until patient can do normactivities.

Pro"nosis


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Very "ood pro"nosis.

Aost patients respond to corticosteroidinUection !ith or !ithout associatedsplintin".

Patients !ho need sur"ical release

"enerally have a very "ood outcome. Poor pro"nosis usually associated !ith

other medical condition.

eferences


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Apley’s

System o Orthopaedics and Fractures t !dition by Solomon "ar#ick $ayagam

http%&&emedicine'medscape'com&article&()**+,-treatment

http%&&orthoino'aaos'org&topic'cm.topic/a000)*

http://emedicine.medscape.com/article/1244693-treatmenthttp://emedicine.medscape.com/article/1244693-treatmenthttp://emedicine.medscape.com/article/1244693-treatmenthttp://emedicine.medscape.com/article/1244693-treatmenthttp://emedicine.medscape.com/article/1244693-treatmenthttp://emedicine.medscape.com/article/1244693-treatmenthttp://orthoinfo.aaos.org/topic.cfm?topic=a00024http://orthoinfo.aaos.org/topic.cfm?topic=a00024http://orthoinfo.aaos.org/topic.cfm?topic=a00024http://orthoinfo.aaos.org/topic.cfm?topic=a00024http://emedicine.medscape.com/article/1244693-treatmenthttp://emedicine.medscape.com/article/1244693-treatmenthttp://emedicine.medscape.com/article/1244693-treatmenthttp://emedicine.medscape.com/article/1244693-treatmenthttp://emedicine.medscape.com/article/1244693-treatmenthttp://emedicine.medscape.com/article/1244693-treatmenthttp://emedicine.medscape.com/article/1244693-treatment


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T0AN1 2O3

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