Disorders of Hands and FeetMaria Carmela L. Domocmat, RN, MSNInstructorNorthern Luzon Adventist College
2 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Disorders of Hands and FeetDisorders of the hand Additional Problems of foot• Carpal Tunnel Syndrome • Tarsal tunnel syndrome• Dupuytren’s Contracture • Plantar Fasciitis• Ganglion • Corn • Callus • Ingrown Nail • Hypertrophic Ungual Labium
4 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Carpal 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011carpal tunnelo a rigid canal lying between the carpal bones and a fibrous tissue sheet called the flexor retinaculumo a group of nine tendons enveloped by synovium share space with the median nerve in the carpal tunnelo when the synovium becomes swollen or thickened, the nerve is compressed
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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Etiologyo Causes of Acute CTS – rare excessive hand exercise edema or hemorrhage into carpal tunnel thrombosis of median artery
12 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Etiologyo 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Etiologyo 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, racquetballo familial or congenital, manifesting in adulthoodo space-occupying lesions (ganglia, tophi, lipomas)
14 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Incidence/prevalenceo peaks between 30 and 60 yrso but children are adolescents are getting common –due to use of computero women – 5 times more commono affects dominant hand, but can occur both hands simultaneously
15 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Preventiono if use computer regularly use appropriate ergonomically designed work stations take regular breaks if beginning symptoms – tell medical attention
16 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Assessmento numbness and pain on hando pain worse at night as result of flexion or direct pressure during sleep may radiate to arm, shoulder and neck, or chesto paresthesia (painful tingling)o sensory changes – usually precedes motor manifestations by weeks or months
19 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Assessmento (+) 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Phalen’s test
21 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Assessmento 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 Maria Carmela 9/4/2011 L. Domocmat, RN, MSNTinel’s sign
23 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Assessmento 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Assessmento strenuous hand activity worsens the subjective complaintso wrist swellingo autonomic changes skin discoloration nail changes (e.g., brittleness) increased or decreased palmar sweating
25 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Dx testso routine x-rays to visualize bone changes, space-occupying lesions, synovitiso for uncertain definitive dx: EMG – reveals nerve dysfunction b4 muscle atrophy MRI – enlarged median nerve within carpal tunnel UTZ – newest technique
26 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Managemento 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Managemento 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Management 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Management 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Management postop care • offer pain meds • multiple operations and other treatments – common • may need assistance with routine daily tasks or even self-care activities
35 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Dupuytren’s contracture ordeformity• 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Ganglion• 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Ganglion
39 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Ganglion• 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Ganglion• treatment: • although fluid within lesion can be aspirated, total excision is preferred
41Other problems of foot Maria Carmela 9/4/2011 L. Domocmat, RN, MSN
44 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Tarsal 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Tarsal 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Plantar 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Plantar fasciitis http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19568.jpg
50 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Plantar 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Plantar fascia http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19567.jpg
52 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Risk factorso Foot arch problems (both flat feet and high arches)o Obesity or sudden weight gaino Long-distance running, especially running downhill or on uneven surfaceso Sudden weight gaino Tight Achilles tendon (the tendon connecting the calf muscles to the heel)o Shoes with poor arch support or soft soles
53 Maria Carmela L. Domocmat, RN, MSN 9/4/2011s/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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011s/so 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 activityo The pain may develop slowly over time, or suddenly after intense activity.
55 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Treatmento 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Treatmento 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Treatmento 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 Maria Carmela 9/4/2011 L. Domocmat, RN, MSNBoot cast
59 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Orthotics
60 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Expectations (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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Complicationso Pain may continue despite treatment.o Some may need surgery.
63 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Corn• 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Types of Corno 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Types of Corno 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Other, 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Causes of cornso 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Causes of cornso 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Corn• Treatment: • surgical removal by podiatrist
71 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Prevention of cornso wearing sensible, low-heeled footwear (maximum 4cm heel) with a rounded toeo not wearing slip-on shoes because these cause feet to move forward and squash toeso not wearing court shoes because they don’t support feet and can cramp toes
72 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Corn pad
73 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Prevention of cornso drying properly between toeso losing excess weight – this will help to reduce pressure on feeto If already have a corn, apply an antifungal or antibacterial powder after washing foot to help prevent it becoming infected.
76 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Callus• 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 arent usually painful.
77 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Callus• Treatment: o padding and lanolin creams o overall good skin hygiene
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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Ingrown 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Anatomy of a toenail
82 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Ingrown Nail• AKA: ▫ Onychocryptosis ▫ Unguis incarnatus ▫ Nail avlusion ▫ Matrix excision
83 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Causes, 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Causes, 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Infected ingrown toenail
87 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Causes, incidence, and risk factorso 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Causes, 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Treatment• 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Treatmento 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Treatment 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Proper and improper toenail trimming.
93 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Treatment 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011partial 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Sometimes doctor will use a chemical,electrical current, or another small surgical cutto destroy or remove the area from which a newnail may grow.antibiotic ointment - If the toe is infected
96 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Prevention• 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Preventiono 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011Hypertrophic 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 Maria Carmela L. Domocmat, RN, MSN 9/4/2011References• 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