Maria Carmela L. Domocmat, RN, MSNInstructorNorthern Luzon Adventist College
Part 1: Degenerative & Metabolic bone     disorders:     Part 2: Bone infections     Part 3: Muscular disorders     Part 4...
Carpal Tunnel Syndrome     Dupuytren’s Contracture     Ganglion3/5/2012      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•   most co...
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 n...
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       ...
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        ...
o    common complication of certain metabolic      and connective tissue diseases           ex: synovitis in RA – hypertro...
o    repetitive strain injury           job requiring repetitive hand activities           involving pinch or grasp during...
o peaks between 30 and 60 yrs o but children are adolescents are getting   common –due to use of computer o women – 5 time...
o    if use computer regularly           use appropriate ergonomically designed           work stations           take reg...
o numbness and pain on hand o pain           worse at night as result of flexion or direct           pressure during sleep...
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 b...
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...
3/5/2012   Maria Carmela L. Domocmat, RN, MSN   23
o    motor changes           weak pinch, clumsiness, difficulty with fine           movements           progress to muscle...
o strenuous hand activity worsens the   subjective complaints o wrist swelling o autonomic changes           skin discolor...
o    routine x-rays           to visualize bone changes, space-occupying           lesions, synovitis o    for uncertain d...
o    nonsurgical mgmt           drug therapy            • NSAIDs            • inject corticosteroid directly into carpal  ...
o    surgical mgmt           to relieve pressure on median artery by           providing nerve decompression           Ope...
postop care            • ECTR – less invasive but pain and              numbness longer time postop            • monitor V...
postop care            • hand movements – including lifting heavy              objects – restricted for 4 to 6 wks postop ...
postop care            • offer pain meds            • multiple operations and other treatments –              common      ...
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 hand3/5/2012   ...
•   common problem•   can be bilateral•   cause:    • unknown•   incidence:    • older men, tend to occur in families3/5/2...
3/5/2012   Maria Carmela L. Domocmat, RN, MSN   35
•   Treatment      o when function becomes impaired, surgical        release is required      o partial or selective fasci...
3/5/2012   Maria Carmela L. Domocmat, RN, MSN   37
•   a round, cystlike lesions•   often overlying wrist joint or tendon•   synovium surrounding the tendon    degenerates, ...
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)•   ...
•   treatment:    • although fluid within lesion can be aspirated,           total excision is preferred3/5/2012          ...
Ignatavicius and Workman (2006). Medical     surgical nursing [5th ed]. Singapore: Elsevier.     http://www.epodiatry.com/...
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Musculoskeletal disorders Part 4 Disorders of the Hands: Carpal Tunnel Syndrome, Dupuytren's contracure, Ganglion

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Musculoskeletal disorders Part 4
Disorders of the Hands: Carpal Tunnel Syndrome, Dupuytren's contracure, Ganglion

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Musculoskeletal disorders Part 4 Disorders of the Hands: Carpal Tunnel Syndrome, Dupuytren's contracure, Ganglion

  1. 1. Maria Carmela L. Domocmat, RN, MSNInstructorNorthern Luzon Adventist College
  2. 2. Part 1: Degenerative & Metabolic bone disorders: Part 2: Bone infections Part 3: Muscular disorders 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 Injuries3/5/2012 Maria Carmela L. Domocmat, RN, MSN 2
  3. 3. Carpal Tunnel Syndrome Dupuytren’s Contracture Ganglion3/5/2012 Maria Carmela L. Domocmat, RN, MSN 3
  4. 4. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 4
  5. 5. • 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 injury3/5/2012 Maria Carmela L. Domocmat, RN, MSN 5
  6. 6. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 6
  7. 7. 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 compressed3/5/2012 Maria Carmela L. Domocmat, RN, MSN 7
  8. 8. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 8
  9. 9. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 9
  10. 10. • 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 tunnel3/5/2012 Maria Carmela L. Domocmat, RN, MSN 10
  11. 11. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 11
  12. 12. o Causes of Acute CTS – rare excessive hand exercise edema or hemorrhage into carpal tunnel thrombosis of median artery3/5/2012 Maria Carmela L. Domocmat, RN, MSN 12
  13. 13. 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 CTS3/5/2012 Maria Carmela L. Domocmat, RN, MSN 13
  14. 14. o repetitive strain injury job requiring repetitive hand activities 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)3/5/2012 Maria Carmela L. Domocmat, RN, MSN 14
  15. 15. 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 simultaneously3/5/2012 Maria Carmela L. Domocmat, RN, MSN 15
  16. 16. o if use computer regularly use appropriate ergonomically designed work stations take regular breaks if beginning symptoms – tell medical attention3/5/2012 Maria Carmela L. Domocmat, RN, MSN 16
  17. 17. 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 months3/5/2012 Maria Carmela L. Domocmat, RN, MSN 17
  18. 18. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 18
  19. 19. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 19
  20. 20. 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 secs3/5/2012 Maria Carmela L. Domocmat, RN, MSN 20
  21. 21. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 21
  22. 22. 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 tingling3/5/2012 Maria Carmela L. Domocmat, RN, MSN 22
  23. 23. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 23
  24. 24. 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
  25. 25. 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 sweating3/5/2012 Maria Carmela L. Domocmat, RN, MSN 25
  26. 26. 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 technique3/5/2012 Maria Carmela L. Domocmat, RN, MSN 26
  27. 27. 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 both3/5/2012 Maria Carmela L. Domocmat, RN, MSN 27
  28. 28. 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 lesions3/5/2012 Maria Carmela L. Domocmat, RN, MSN 28
  29. 29. 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 hr3/5/2012 Maria Carmela L. Domocmat, RN, MSN 29
  30. 30. 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 months3/5/2012 Maria Carmela L. Domocmat, RN, MSN 30
  31. 31. postop care • offer pain meds • multiple operations and other treatments – common • may need assistance with routine daily tasks or even self-care activities3/5/2012 Maria Carmela L. Domocmat, RN, MSN 31
  32. 32. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 32
  33. 33. • slowly progressive contracture of the palmar fascia, resulting in flexion of 4th or 5th digit of hand3/5/2012 Maria Carmela L. Domocmat, RN, MSN 33
  34. 34. • common problem• can be bilateral• cause: • unknown• incidence: • older men, tend to occur in families3/5/2012 Maria Carmela L. Domocmat, RN, MSN 34
  35. 35. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 35
  36. 36. • 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 repair3/5/2012 Maria Carmela L. Domocmat, RN, MSN 36
  37. 37. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 37
  38. 38. • a round, cystlike lesions• often overlying wrist joint or tendon• synovium surrounding the tendon degenerates, allow tendon sheath tissue to become weak and distended3/5/2012 Maria Carmela L. Domocmat, RN, MSN 38
  39. 39. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 39
  40. 40. • 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 old3/5/2012 Maria Carmela L. Domocmat, RN, MSN 40
  41. 41. • treatment: • although fluid within lesion can be aspirated, total excision is preferred3/5/2012 Maria Carmela L. Domocmat, RN, MSN 41
  42. 42. 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/ 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 43/5/2012 Maria Carmela L. Domocmat, RN, MSN 42

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