Musculoskeletal disorders Part 4 Disorders of the Hands: Carpal Tunnel Syndrome, Dupuytren's...
-
date post
19-Oct-2014 -
Category
Health & Medicine
-
view
1.885 -
download
2
description
Transcript of Musculoskeletal disorders Part 4 Disorders of the Hands: Carpal Tunnel Syndrome, Dupuytren's...
Maria Carmela L. Domocmat, RN, MSN
Instructor
Northern Luzon Adventist College
� Part 1: Degenerative & Metabolic bone disorders:
� Part 2: Bone infections� Part 3: Muscular disorders � Part 4: Disorders of the hand� Part 4: Disorders of the hand
� Carpal tunnel syndrome
� Dupuytren’s contracture
� Ganglion � Part 5: Spinal column deformities� Part 6 : Disorders of foot � Part 7: Sports Injuries
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 2
� Carpal Tunnel Syndrome
� Dupuytren’s Contracture
� Ganglion
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 3
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 4
• common condition in which the median
nerve in the wrist becomes compressed,
causing pain and numbness causing pain and numbness
• most common repetitive strain injury
(RSI) –the fastest growing type of
occupational injury
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 5
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 6
o a rigid canal lying between the carpal
bones and a fibrous tissue sheet called the
flexor retinaculum
o a group of nine tendons enveloped by
synovium share space with the median
nerve in the carpal tunnel
o when the synovium becomes swollen or
thickened, the nerve is compressed
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 7
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 8
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 9
• median nerve
o supplies motor, sensory, and autonomic
function for the 1st three digits of the hand
and the palmar aspect of the 4th digit
o bcoz of its proximity to other structures
� wrist flexion causes nerve impingement against
the flexor retinaculum
� extension causes increased pressure in distal
portion of carpal tunnel
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 10
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 11
o Causes of Acute CTS – rare
� excessive hand exercise
� edema or hemorrhage into carpal tunnel
� thrombosis of median artery
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 12
o common complication of certain metabolic
and connective tissue diseases
� ex: synovitis in RA – hypertrophied
synovium compresses median nerve
� DM – inadequate blood supply can cause
median nerve neuropathy, or dysfunction,
resulting in CTS
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 13
o repetitive strain injury � job requiring repetitive hand activities
involving pinch or grasp during wrist flexion (factory workers, computer operators, jackhammer operators)jackhammer operators)
o overuse in sports activities � golf, tennis, racquetball
o familial or congenital, manifesting in adulthood
o space-occupying lesions (ganglia, tophi, lipomas)
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 14
o peaks between 30 and 60 yrs
o but children are adolescents are getting
common –due to use of computer
o women – 5 times more common
o affects dominant hand, but can occur both
hands simultaneously
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 15
o if use computer regularly
� use appropriate ergonomically designed
work stations
� take regular breaks
� if beginning symptoms – tell medical
attention
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 16
o numbness and pain on hand
o pain
� worse at night as result of flexion or direct
pressure during sleeppressure during sleep
� may radiate to arm, shoulder and neck, or
chest
o paresthesia (painful tingling)
o sensory changes – usually precedes motor
manifestations by weeks or months
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 17
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 18
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 19
o (+) Phalen’s wrist test or Phalen’s maneuver
� ask client to relax wrist into flexion
� or place he back of hands together and flex
both wrists simultaneously
� (+) paresthesia in median nerve
distribution (palmar side of thumb, index,
and middle finger, radial half of ring finger)
within 60 secs
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 20
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 21
o Tinel’s sign
� tap lightly over the area of median nerve in
wrist
� if test is unsuccessful – a BP cuff can be
placed on upper arm and inflated to
clients systolic pressure;
� result – pain and tingling
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 22
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 23
o motor changes
� weak pinch, clumsiness, difficulty with fine
movements
� progress to muscle weakness and wasting
(muscle atrophy)
� assess task performance
• assess pinching ability by asking client to
perform a fine-movement task (ex:
threading a needle)
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 24
o strenuous hand activity worsens the
subjective complaints
o wrist swelling
o autonomic changes
� skin discoloration
� nail changes (e.g., brittleness)
� increased or decreased palmar sweating
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 25
o routine x-rays
� to visualize bone changes, space-occupying
lesions, synovitis
o for uncertain definitive dx:
� EMG – reveals nerve dysfunction b4 muscle
atrophy
� MRI – enlarged median nerve within carpal
tunnel
� UTZ – newest technique
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 26
o nonsurgical mgmt
� drug therapy
• NSAIDs
• inject corticosteroid directly into carpal • inject corticosteroid directly into carpal
tunnel – weekly or monthly
� immobilization
• splint to immobilize wrist – during day or
during night, or both
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 27
o surgical mgmt
� to relieve pressure on median artery by
providing nerve decompression
� Open Carpal Tunnel Release (OCTR) � Open Carpal Tunnel Release (OCTR)
� Endoscopic Carpal Tunnel Release (ECTR)
� synovectomy when synovitis is caused by
RA
• removal of excess synovium thru a small
inner-wrist incision
� removal of space-occupying lesions
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 28
� postop care
• ECTR – less invasive but pain and
numbness longer time postop
• monitor VS
• check dressing carefully for drainage and
tightness
• elevate above the heart for several days
postop – reduce swelling from surgery
• check neurovascular status of digits q hr
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 29
� postop care
• hand movements – including lifting heavy
objects – restricted for 4 to 6 wks postop
• encourage t o move all fingers of affected
hand frequently
• teach client to expect weakness and
discomfort for weeks or perhaps months
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 30
� postop care
• offer pain meds
• multiple operations and other treatments –
common
• may need assistance with routine daily
tasks or even self-care activities
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 31
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 32
• slowly progressive contracture of the
palmar fascia, resulting in flexion of 4th or
5th digit of hand5 digit of hand
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 33
• common problem
• can be bilateral
• cause: • cause:
• unknown
• incidence:
• older men, tend to occur in families
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 34
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 35
• Treatment
o when function becomes impaired, surgical
release is required
o partial or selective fasciectomy
o splint application - post removal of dressing
and drain
• nursing care
o same with carpal tunnel repair
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 36
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 37
• a round, cystlike lesions
• often overlying wrist joint or tendon
• synovium surrounding the tendon • synovium surrounding the tendon
degenerates, allow tendon sheath tissue
to become weak and distended
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 38
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 39
• painless on palpation, but can cause joint
discomfort after prolonged joint use or
minor trauma (ex: strain)minor trauma (ex: strain)
• can disappear and then recur
• common: 15 to 50 yrs old
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 40
• treatment:
• although fluid within lesion can be aspirated,
total excision is preferred
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 41
� Ignatavicius and Workman (2006). Medical surgical nursing [5th ed]. Singapore: Elsevier.
� http://www.epodiatry.com/corns-callus.htm� http://www.ncbi.nlm.nih.gov/pubmedhealth/PM
H0004438/H0004438/� http://www.bupa.co.uk/individuals/health-
information/directory/c/corns� http://www.ncbi.nlm.nih.gov/pubmedhealth/PM
H0002217/� http://orthoinfo.aaos.org/topic.cfm?topic=a0015
4
3/5/2012 Maria Carmela L. Domocmat, RN, MSN 42