4. 4
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Carpal Tunnel Syndrome (CTS)
• common condition in which the median nerve
in the wrist becomes compressed, causing
pain and numbness
• most common repetitive strain injury (RSI) –the
fastest growing type of occupational injury
6. 6
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
carpal tunnel
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
9. 9
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
• 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
11. 11
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Etiology
o Causes of Acute CTS – rare
excessive hand exercise
edema or hemorrhage into carpal tunnel
thrombosis of median artery
12. 12
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Etiology
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
13. 13
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Etiology
o repetitive strain injury
job requiring repetitive hand actitivites involving
pinch or grasp during wrist flexion (factory
workers, computer 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)
14. 14
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Incidence/prevalence
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
15. 15
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Prevention
o if use computer regularly
use appropriate ergonomically designed work
stations
take regular breaks
if beginning symptoms – tell medical attention
16. 16
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Assessment
o numbness and pain on hand
o pain
worse at night as result of flexion or direct
pressure 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
19. 19
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Assessment
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
20. 20
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Phalen’s test
21. 21
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Assessment
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
22. 22
Maria Carmela 9/4/2011
L. Domocmat,
RN, MSN
Tinel’s sign
23. 23
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Assessment
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)
24. 24
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Assessment
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
25. 25
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Dx tests
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
26. 26
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Management
o nonsurgical mgmt
drug therapy
• NSAIDs
• inject corticosteroid directly into carpal
tunnel – weekly or monthly
immobilization
• splint to immobilize wrist – during day or
during night, or both
27. 27
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Management
o surgical mgmt
to relieve pressure on median artery by
providing nerve decompression
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
28. 28
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Management
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
29. 29
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Management
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
30. 30
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Management
postop care
• offer pain meds
• multiple operations and other treatments –
common
• may need assistance with routine daily
tasks or even self-care activities
32. 32
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Dupuytren’s contracture or
deformity
• slowly progressive contracture of the palmar
fascia, resulting in flexion of 4th or 5th digit of
hand
33. 33
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Dupuytren’s contracture or
deformity
• common problem
• can be bilateral
• cause:
• unknown
• incidence:
• older men, tend to occur in families
35. 35
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Dupuytren’s contracture or
deformity
• 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
37. 37
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Ganglion
• a round, cystlike lesions
• often overlying wrist joint or tendon
• synovium surrounding the tendon
degenerates, allow tendon sheath tissue to
become weak and distended
38. 38
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Ganglion
39. 39
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Ganglion
• painless on palpation, but can cause joint
discomfort after prolonged joint use or minor
trauma (ex: strain)
• can disappear and then recur
• common: 15 to 50 yrs old
40. 40
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Ganglion
• treatment:
• although fluid within lesion can be aspirated,
total excision is preferred
44. 44
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Tarsal tunnel syndrome
• the ankle version of carpal tunnel syndrome
(CTS)
• posterior tibial nerve in the ankle becomes
compressed, resulting in loss of sensation and
pain in a portion of the foot
46. 46
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Tarsal tunnel syndrome
• median and lateral plantar branches, which
supply the sole of the and distal phalanges, are
affected by nerve compression
• dx and treatment: same with CTS
48. 48
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Plantar fasciitis
• an inflammation of the plantar fascia, which is
located in the area of the arch of the foot
• common: middle-aged and older adults,
athletes esp runners
49. 49
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Plantar fasciitis
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19568.jpg
50. 50
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Plantar fascia
• A very thick band of tissue that covers the bones on
the bottom of the foot.
• extends from the heel to the bones of the ball of the
foot and acts like a rubber band to create tension
which maintains the arch of the foot.
• If the band is long it allows the arch of the foot to be
low, which is most commonly known as having a flat
foot.
• A short band of tissue causes a high arch.
• This fascia can become inflamed and painful in
some people, making walking more difficult.
51. 51
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Plantar fascia
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19567.jpg
52. 52
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Risk factors
o Foot arch problems (both flat feet and high
arches)
o Obesity or sudden weight gain
o Long-distance running, especially running
downhill or on uneven surfaces
o Sudden weight gain
o Tight Achilles tendon (the tendon connecting
the calf muscles to the heel)
o Shoes with poor arch support or soft soles
53. 53
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
s/s:
• The most common complaint is pain and
stiffness in the bottom of the heel. The heel
pain may be dull or sharp. The bottom of the
foot may also ache or burn.
54. 54
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
s/s
o The pain is usually worse:
In the morning when you take r first steps
After standing or sitting for a while
When climbing stairs
After intense activity
o The pain may develop slowly over time, or
suddenly after intense activity.
55. 55
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Treatment
o conservative treatment:
rest
ice - at least twice a day for 10 - 15 minutes,
more often in the first couple of days.
stretching exercises
strapping of foot to maintain arch
orthotics
56. 56
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Treatment
o conservative treatment:
heel stretching exercises
resting as much as possible for at least a week
shoes with good support and cushions
wear heel cup, felt pads in the heel area, or
shoe inserts
use night splints to stretch the injured fascia
and allow it to heal.
57. 57
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Treatment
o If these treatments do not work, doctor may
recommend:
Wearing a boot cast, which looks like a ski boot,
for 3-6 weeks. It can be removed for bathing.
Custom-made shoe inserts (orthotics)
Steroid shots or injections into the heel
NSAIDs or steroids
endoscopic surgery – to remove inflamed tissue
may be required
58. 58
Maria Carmela 9/4/2011
L. Domocmat,
RN, MSN
Boot cast
59. 59
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Orthotics
60. 60
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Expectations (prognosis)
o Nonsurgical treatments almost always
improve the pain.
• Treatment can last from several months to 2
years before symptoms get better. Most
patients feel better in 9 months. Some people
need surgery to relieve the pain.
61. 61
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Complications
o Pain may continue despite treatment.
o Some may need surgery.
63. 63
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Corn
• induration and thickening of skin
caused by friction and pressure,
painful conical mass
• appear as a horny thickening of the
skin on the toes.
• this thickening appears as a cone
shaped mass pointing down into
the skin.
65. 65
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Types of Corn
o Hard corns
most common
are concentrated areas of dry, hardened skin
about the size of a pea
usually located on the outer surface of the little
toe or on the upper surface of the other toes,
but can occur between the toes
may develop within a broader area of callused
skin
sometimes called digital corns
66. 66
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Types of Corn
o Soft corns
are white and rubbery
can be extremely painful and tend to develop
between toes
are like hard corns that have been softened by
continual exposure to moisture, usually because
you don’t dry between toes properly or from sweat.
may form opposite one another and are known as
‘kissing lesions’.
Sometimes, soft corns can become infected by
bacteria or fungi.
67. 67
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Other, rarer types of corn include:
• seed corns
▫ may appear as one corn or as clusters of small
corns on the bottom foot; they are usually
painless
• vascular corns
▫ occur in blood vessels and bleed if cut
• fibrous corns
▫ are corns that have been around for a long time
and have become attached to the deeper layers
of your skin, sometimes causing pain
68. 68
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Causes of corns
o Corns are caused by constant pressure on a
bony area of foot. This can happen for a
number of different reasons. These include:
poorly fitting footwear – for example, shoes that
are too small, cramp toes or have uneven soles;
this is the most common cause of corns
being very active – doing lots of exercise can put
pressure on feet
prominent bones – these can press against shoes
69. 69
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Causes of corns
o Corns are caused by constant pressure on a
bony area of foot. This can happen for a
number of different reasons. These include:
a misshapen foot because foot or toes have
developed unusually –may have a toe that is
overly curved or a particular bone that is too short
poorly healed fractures – if have broken a toe or
another bone in foot, it may have set out of place
causing foot to press against shoe
70. 70
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Corn
• Treatment:
• surgical removal by podiatrist
71. 71
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Prevention of corns
o wearing sensible, low-heeled footwear
(maximum 4cm heel) with a rounded toe
o not wearing slip-on shoes because these
cause feet to move forward and squash
toes
o not wearing court shoes because they
don’t support feet and can cramp toes
72. 72
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Corn pad
73. 73
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Prevention of corns
o drying properly between toes
o losing excess weight – this will help to
reduce pressure on feet
o If already have a corn, apply an antifungal
or antibacterial powder after washing foot
to help prevent it becoming infected.
76. 76
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Callus
• flat, poorly defined mass on the sole over a
bony prominence caused by pressure
• When skin is exposed to lots of pressure or
friction, the keratin layer thickens to protect it,
and develops into a callus.
• Although calluses can cover a wide area, they
aren't usually painful.
77. 77
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Callus
• Treatment:
o padding and lanolin creams
o overall good skin hygiene
78. 78
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
• Self treatment or management of corns and
callus includes:
▫ following the advice of a Podiatrist
▫ proper fitting of footwear
▫ proper foot hygiene and the use of emollients to
keep the skin in good condition
80. 80
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Ingrown Nail
• nail silver penetration of the skin, causing
inflammation
• occurs when the edge of the nail grows down
and into the skin of the toe. There may be pain,
redness, and swelling around the nail.
81. 81
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Anatomy of a toenail
82. 82
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Ingrown Nail
• AKA:
▫ Onychocryptosis
▫ Unguis incarnatus
▫ Nail avlusion
▫ Matrix excision
83. 83
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Causes, incidence, and risk factors
• An ingrown toenail can result from a number of
things,
• but poorly fitting shoes and toenails that are
not trimmed properly are the most common
causes.
• The skin along the edge of a toenail may
become red and infected.
• The great toe is usually affected, but any
toenail can become ingrown.
85. 85
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Causes, incidence, and risk factors
• Ingrown toenails may occur when extra
pressure is placed on toe.
• Most commonly, this pressure is caused by
shoes that are too tight or too loose.
• If walk often or participate in athletics, a shoe
that is even a little tight can cause this
problem.
• Some deformities of the foot or toes can also
place extra pressure on the toe.
86. 86
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Infected ingrown toenail
87. 87
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Causes, incidence, and risk factors
o Nails that are not trimmed properly can also
cause ingrown toenails.
When toenails are trimmed too short or the edges
are rounded rather than cut straight across, the
nail may curl downward and grow into the skin.
Poor eyesight and physical inability to reach the
toe easily, as well as having thick nails, can make
improper trimming of the nails more likely.
Picking or tearing at the corners of the nails can
also cause an ingrown toenail.
88. 88
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Causes, incidence, and risk factors
• Some people are born with nails that are
curved and tend to grow downward. Others
have toenails that are too large for their toes.
Stubbing your toe or other injuries can also
lead to an ingrown toenail.
89. 89
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Treatment
• If have diabetes, nerve damage in the leg or
foot, poor blood circulation to foot, or an
infection around the nail, go to the doctor right
away.
• Do NOT try to treat this problem at home
(Bathroom treatment)
90. 90
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Treatment
o To treat an ingrown nail at home:
Soak the foot in warm water 3 to 4 times a day
if possible. Keep the toe dry, otherwise.
Gently massage over the inflamed skin.
Place a small piece of cotton or dental floss
under the nail. Wet the cotton with water or
antiseptic.
91. 91
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Treatment
may trim the toenail one time, if needed. When
trimming toenails:
Consider briefly soaking your foot in warm water to
soften the nail.
Use a clean, sharp trimmer.
Trim toenails straight across the top. Do not taper or
round the corners or trim too short. Do not try to cut
out the ingrown portion of the nail. This will only make
the problem worse.
Consider wearing sandals until the problem has gone
away. Over-the-counter medications that are placed
over the ingrown toenail may help some with the pain
but do not treat the problem.
92. 92
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Proper and improper toenail trimming.
93. 93
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Treatment
If this does not work and the ingrown nail gets
worse, see family doctor, a foot specialist
(podiatrist) or a skin specialist (dermatologist).
removal of silver by podiatrist
94. 94
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
partial nail avulsion
o If ingrown nail does not heal or keeps coming
back, doctor may remove part of the nail.
o Numbing medicine is first injected into the toe.
o Using scissors, your doctor then cuts along the
edge of the nail where the skin is growing over.
This portion of the nail is then removed. This is
called a partial nail avulsion.
o It will take 2 to 4 months for the nail to regrow
95. 95
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Sometimes doctor will use a chemical,
electrical current, or another small surgical cut
to destroy or remove the area from which a new
nail may grow.
antibiotic ointment - If the toe is infected
96. 96
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Prevention
• Wear shoes that fit properly.
• Shoes worn every day should have plenty of
room around toes.
• Shoes that wear for walking briskly or for
running should have plenty of room also, but
not be too loose.
97. 97
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Prevention
o When trimming toenails:
Considering briefly soaking foot in warm
water to soften the nail.
Use a clean, sharp nail trimmer.
Trim toenails straight across the top. Do not
taper or round the corners or trim too short.
Do not pick or tear at the nails.
Keep the feet clean and dry. People with
diabetes should have routine foot exams and
nail care.
100. 100
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
Hypertrophic Ungual Labium
• chronic hypertrophy of nail lip
• caused by improper nail trimming
• results from untreated ingrown toenail
• treatment:
o surgical removal of necrotic nail and skin
o treatment of secondary infection
101. 101
Maria Carmela L. Domocmat, RN, MSN 9/4/2011
References
• 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/PMH
0004438/
• http://www.bupa.co.uk/individuals/health-
information/directory/c/corns
• http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH
0002217/
• http://orthoinfo.aaos.org/topic.cfm?topic=a00154