CARPAL TUNNEL
SYNDROME
NI KADEK SULISTYANINGSIH
CONTENTS
01 INTRODUCTION
02 LITERATURE REVIEW
03 CASE REPORT
04 DISCUSSION
05 CONCLUSIONS
INTRODUCTION
INTRODUCTION
CTS is the most common compressive
neuropathy affecting the upper extremity
and is an important cause of lost India
workplace productivity. USA (557)
(346) Siena
Between 1997 and 2010 CTS was the (276)
Inggris
second most common cause of days (105)
lost from the workplace. Indonesia
(???)
The prevalence of CTS is estimated to
be 0.7/10,000 workers or 2.5 cases/1000
• American Academy of Orthopaedic Surgeons (AAOS). Appropriate Use Criteria For The Management Of Carpal
Tunnel Syndrome. 2016.
• LeBlanc KE, Cestia W. Carpal Tunnel Syndrome. American Family Physician Journal. 2011. Vol.83, No.8. Halam
an 292-298
• NHS Foundation Trust [Internet]. Carpal-Tunnel.net. East Kent Hospital University. 2012. Diakses pada 5 Mei 20
18. [https://www.carpal-tunnel.net/about-cts/epidemiology.]
LITERATURE
REVIEW
DEFINITION
CARPAL TUNNEL SYNDROME
“A symptomatic compression “This syndrome became the most
neuropathy of the median nerve common cause of disability found
at the level of the wrist (carpal in orthoapedic and neurologist
tunnel), characterized by practice.”
increased intracanal pressure
and decreased neural function at
that level.” NHS, 2012
AAOS,2007
American Academy of Orthophaedic Surgeons (AAOS). Clinical Practice Guideline on the Diagnosis of Carpal Tunnel Syndrome.May 2007.
NHS Foundation Trust [Internet]. Carpal-Tunnel.net. East Kent Hospital University. 2012. Diakses pada 5 Mei 2018. [https://www.carpal-tunnel.net/about-cts/epidemiology.]
ANATOMY
CARPAL TUNNEL
Flexor retinaculum ligament : thick con
nective tissue that bridge the wrist
arch, and make it a tunnel
A 90o Flexion and 40o extension will
decrease its volume,
increase its pressure to 90-110 mmHg
Drake RL, Vogl W, Mitchell AWM. Gray’s anatomy for Students. 2007. Elsevier Inc. diakes pada 23 Juli 2018. [http://www.studentconsult.com/content/defaul t.cfm?ISBN= 044 3066124&ID=C00766124]
ANATOMY
MEDIAN NERVES
Motoric function : all anterior Sensory : palmar digiti 1, 2, 3, and half of
compartmen, exc ulnaris flexor carpi and medi digiti 4, lateral part of hand part, and media
al part of digitorum profundus flexor. l part of wrist
Drake RL, Vogl W, Mitchell AWM. Gray’s anatomy for Students. 2007. Elsevier Inc. diakes pada 23 Juli 2018. [http://www.studentconsult.com/content/defaul t.cfm?ISBN= 044 3066124&ID=C00766124]
EPIDEMIOLOGY
Occupation
Pregnant, Oral
contraception
3-10
1
Menopasue
Obesity
More common in women at age 45-60 y.o.
But, the latest study showed the risk
increased in men by age.
Newington L, Harris EC, Walker-Bone K. Carpal Tunnel Syndrome and Work. 2015. Best Pract Res Clin Rheumatol. 2015 June ; 29(3): 440–453. doi:10.1016/j.berh. 2015.04.026
NHS Foundation Trust [Internet]. Carpal-Tunnel.net. East Kent Hospital University. 2012. Diakses pada 5 Mei 2018. [https://www.carpal-tunnel.net/about-cts/epidemiology.]
ETIOLOGY AND RISK FACTORS
ANATOMICAL FACTORS
Gender, age, genetic,
antrophometric
MECHANICAL FACTORS
Occupation, ergonomic,
work tools
PHYSIOLOGY FACTORS
Pregnancy, hypotiroidism, etc
LeBlanc KE, Cestia W. Carpal Tunnel Syndrome. American Family Physician Journal. 2011. Vol.83, No.8. Halaman 292-298
PATHOGENESIS
Increased carpal tunnel pressure
Median nerve compression and entrapment Increased carpal tunnel pressure
Changes of microvascular structure of the nerve
Median nerve connective
tissue alterations
Reduction in the endoneurial blood flow
Increased permeability of
endoneurial vessels Median nerve microcirculation
Edema injury
Increased diffusion
distance for oxygen
Hypoxia
Upregulation of angiogenic factors
(HIF-1 α and VEGF
Axonal degeneration of median nerve and neuritis Aboonq MS. Article Review : Pathophysiology of carpal tunnel syndrome. 2015. Neuro
sciences Journal. Vol.20(1).
DIAGNOSE
CLINICAL FINDINGS
Katz Hand Diagram
Classic pattern
At least two of digits 1,2,3. +/-
symptoms in digits 4,5, wirst pain,
radiation to proximal to the wrist. No
symptoms allowed in on the palm or
dorsum
Probable pattern
Classic pattern with palmar symptoms
are allowed unless confined solely to
ulnar aspect.
Possible pattern
Symptoms only in one digits 1,2, or 3
Unlikely pattern • LeBlanc KE, Cestia W. Carpal Tunnel Syndrome. American Family Physicia
n Journal. 2011. Vol.83, No.8. Halaman 292-298
No symptoms in digits 1,2,or 3 • Yunoki M, Kanda T, Suzuki K, Uneda A, Hirashita K, Yoshino K. Importanc
e of Recognizing Carpal Tunnel Syndrome for Neurosurgeons: A Review. 2
017. Neurol Med Chir (Tokyo) 57, 172-183.
CTS-6
DIAGNOSIS
SUPPORTING EXAMINATION
NERVE CONDUCTION STUDIES AND
ELECTROMYOGRAPHY
• Sensitivity 56-85%, specificity >94%.
• Gold standard for CTS
• Compare median and ulnar nerve will
increase this examination accuracy
• Ring difference : most
recommendate in CTS
evaluation. >0.4ms CTS
Rukmigarsari RRE, Andarini S, Sakti ISP, Santoso IE. Analysis of Electroneuromyography Component Result as the Supporting Diagnosis of Carpal Tunnel Syndrome. 2016. Int
ernational Journal of ChemTech Research. V ol.9, No.09 pp 270-273.
LeBlanc KE, Cestia W. Carpal Tunnel Syndrome. American Family Physician Journal. 2011. Vol.83, No.8. Halaman 292-298.
DIAGNOSE
SUPPORTING EXAMINATIONS
Plain photo or CT scan
Magnetic resonance imaging (MRI)
Ultrasonografi (USG)
Laboratory
DIFFERENTIAL DIAGNOSIS
LeBlanc KE, Cestia W. Carpal Tunnel Syndrome. American Family Physician Journal. 2011. Vol.83, No.8. Halaman 292-298
“Therapy for CTS should be decided by doctor and
patient. Skills and experiences that doctor has,
and also patient compliance and understanding
will determine the outcome of the therapy”
AAOS,2008
MANAGEMENT
CARPAL TUNNEL SYNDROME
PATIENT TREATMENTS
PATIENT INDICATIONS
American Academy of Orthopaedic Surgeons (AAOS). Appropriate Use Criteria For The Management Of Carpal Tunnel Syndrome. 2016.
MANAGEMENT
CARPAL TUNNEL SYNDROME
NON-SURGICAL UNDERLYING
APPROACH SURGICAL APPROACH DISEASES
Indicated when there is evidence of me There is no sufficient evide
• Oral steroid dian nerve denervation or patient elect nce to provide treatment
or NSAIDs to proceed directly surgical treatment. recommendation for CTS
• Splint in association with DM, rad
• Steroid Inj. Suggested when current treatment fails iculopathy, pregnacy, etc
to resolve within 2-7 weeks.
(Grade B,C (Inconclusive, No evidence found)
Level I and II) (Grade A,B. Level I and II)
American Academy of Orthopaedic Surgeons (AAOS). Appropriate Use Criteria For The Management Of Carpal Tunnel Syndrome. 2016.
MANAGEMENT ISSUE
American Academy of Orthopaedic Surgeons (AAOS). Appropriate Use Criteria For The Management Of Carpal Tunnel Syndrome. 2016.
PREVENTION
CARPAL TUNNEL SYNDROME
• Minimize repetitive movement with hands
• Try to put hands in neutral position
• Fix the way to grasp somethings. Always use the whole
fingers to grasp/hold things.
• Rest hands periodically
• Keep hands warm
• Try to maintain healthy weight
• Treat suspected underlying diseases
• Exercise and relax hands, wrist and lower arms regularly
PROGNOSIS
CARPAL TUNNEL SYNDROME
• Mild CTS with conservative treatment usually give good
prognosis.
• Chronic CTS will need longer time to recover.
• Recent study shows that 34% of idiopathic CTS that took
surgical approach recover in 6 months
• If its not.. Consider this :
The location of nerve injury may locate more proximal
The total nerve damage already happen
Another CTS as complication of surgery (oedema,
infection, adhesion, hematoma, scar tissue, etc.
CASE REPORT
IDENTITY
Name : Mrs. S
Age : 48 y.o
Sex : Female
Last education : SD
Nationality : Indonesia
Ethnic : Bali
Religion : Islam
Address : By Pass Ngurah Rai,Pesanggaran
Occupation : Housewife
Date of examination : 12 Desember 2017
AUTO-ANAMNESIS
Past
Present
Family
Chiefillness
complaint
History
illness cont’
•NoPatient
one
Other
Numb incomplaints
the
andpatient’s
feels tingling
the complaint
suchfamily
onas complains
thefever,
for
fingers
the andabout
headache,
first time the same
palmweakness
of the leftthing.
or
hand
tingling in other parts
of the body, pain or tenderness spread from the neck to the tip of the fingers
•Present
are
Patient
Social illness
denied.had history of right humerus fracture and done ORIF
History
•• surgery
Complaint
Patient inoccur
is a2015 atatleast
housewife since
Trijata
who 5 months ago.
Hospital.
spends most of her time at home doing house
•• History
Numbness and tingling
of swelling are felt
and trauma on the palm,
tocooking, thumb,
the hands, index finger
sleeping and middle
position finger. the
that presses
works, such as washing clothes, taking care
• Tingling sensation can be accompanied by pain that spreads to the left arm.
of her children, and
• cleaning
wrist,patient
The andthe history
has
house. a of
history
weaknessof hypertension
on the limbs and
is has
also regularly
denied. consumed
• Complaints diminish in the morning, stretches her hand or massages his wrist with balm.
•• Amlodipine
Patient
Complaint has 1two
worsenx 5children
mg since
when thewho 2016.
aredoes
patient quite independent,
some house works her husband
during works as a
the day.
• police officer,
The agility of hismiddle
left hand socio-economy class.
is slightly reduced, such as when buttoning a shirt or when
•• Patient
Historysomething
holding of diabetes
denies having
withmellitus,
habit
his hypothyroidism,
of
left handsmoking, heart
for a longdrinking
period disease,
ofalcohol,
time. kidney disease
or consuming and
illegal
other neurological
drugs. Patients aredisease not taking areany
denied.
contraception and are not pregnant at this
time.
PHYSICAL EXAMINATION
PRESENT STATUS
Weight : 57 kg
Height : 156 cm
BMI : 23,42 kg/m2
Consciousness : compos mentis ( GCS : E 4 V 5 M 6 )
Blood pressure : Right – left arm : 130/90mmHg-130/90mmHg
Heart rate : 80 x/minute, regular
Respiratory rate : 20 x/minute
PHYSICAL EXAMINATION
GENERAL STATUS
Head
Abdomen
Eye : an ( -/ -);: tenderness (-),reflex
ict ( -/ -); pupil bowel( sounds
+/ + ); Ø(+)( 3N,mm / 3mm)
ENT : Ear liver/spleen
: within normal not limit
palpable
Genitalia Nose : not evaluated
: secret (-/-), concha edema (-/-)
Skin Throat : cyanosis (-)
: T1/T1 hiperemia (-/-), Pharynx hiperemia (-)
Extremity : warm +/+ ; edema -/-
Neck +/+ -/-
Communis carotid artery : bruit ( - / - )
Lymph nodes : not palpable
Thorax
Cor : S1 S2 normal regular; murmur ( - )
Pulmo : Vesicular ( + / + ); ronchi ( - / - ) wheezing ( - / - )
PHYSICAL EXAMINATION
MUSKULOSKELETAL STATUS
Regio Manus Sinistra
Look : deformity (-), mass/tumor (-), erythema (-),
thenar atrophy (+)
Feel : Hiperemis (-) tenderness (-), crepitation (-), mass(-)
Move : ROM active and passive within normal limit.
PHYSICAL EXAMINATION
NEUROLOGY STATUS
• GCS E4V5M6 • Sensibility examination on left hand :
• Meningeal Sign (-)
• Brain stems reflex intact
• Cranial nerves within normal limits
• Pathological reflexes (-)
• Upper extremities
– Slight thenar atrophy (S) compare to right hand
– Strength (thumb abduction) = 5 / 4
• Tinel sign (+) on N.median at carpi S.
• Phalen’s test, tourniquet test, wrist
extension test (+) spread to Left side. ‒ Touch sensation
‒ Paresthesia spreads form wrist to tip of finger
I,II,III.
DIAGNOSIS AND PLANNING
DIAGNOSIS PLANNING
TOPICAL DIFFERENTIAL WORKING
DIAGNOSIS DIAGNOSIS DIAGNOSIS ENMG
Nervus Cervical Carpal Tunnel examination
medianus at Radiculopathy Syndrome
carpi level (S) (C6-C7) (CTS) Sinistra
MANAGEMENT PROGNOSIS
• Amlodipine 1x5 mg PO Ad Vitam : Dubius
• Metil prednisolon 3 x 4 mg PO Ad Functionam : Dubius
• Paracetamol 3 x 500 mg PO Ad Sanationam : Dubius
• Physiotherapy
DISCUSSION
DISCUSSION
CASE THEORY
Female, 48 y.o, housewife More common in women at
age 45-60 y.o. F:M = 3-10:1
The risk in productive
age grup (40-60 y.o).
Complaint : • Classic or Probable pattern
• Numb and tingling on left hand palm, finger I,II, Sensitivity 64% ; Specificity 73%
III since 5 m.o ago.
• Worsen at night time • Worsen at night time 70% ; 43%
• Shaking the hand or flicking the wrist in an attempt • The flick sign predicts electro diagnostic
to alleviate the discomfort abnormalities in 93% of cases and has a
• The agility of left hand slightly reduced false-positive rate of >5%.
• Thenar weakness suggestive CTS increase.
DISCUSSION
CASE THEORY
Physical examination:
• General status within normal limit Katz Hand Diagram
• Brain stems reflex intact
• Cranial nerves within normal limits
• Pathological reflexes (-)
• Upper extremities :
Slight thenar atrophy (S) compare to right hand
Strength (thumb abduction) = 5 / 4
• Tinel sign (+) on N.median at carpi S.
• Phalen’s test, tourniquet test, wrist
• extension test (+) spread to Left side.
• Touch sensation and paresthesia spreads form
wrist to tip of finger I,II,III
DISCUSSION
CASE THEORY
Anamnesis + Physical Examination NERVE CONDUCTION STUDIES AND
Carpal Tunnel Syndrome Sinistra, ELECTROMYOGRAPHY :
• Sensitivity 56-85%, specificity >94%.
with planning ENMG
• Gold standard for CTS
examination. • Compare median and ulnar nerve will increase this examination
accuracy
Management : • Non-Surgical Approach :
• Amlodipine 1x5 mg PO Oral steroid or NSAIDs, Splint, Steroid Inj.
• Surgical Approach if current therapy fails to resolve within 2-7wks
• Metil prednisolon 3 x 4 mg PO
• Treat underlying ds.
• Paracetamol 3 x 500 mg PO
• Physiotherapy
Prognosis : • Uncertain diagnosis ENMG confirmation
Dubia • Already found sign of muscle atrophy chronic CTS, after surgery will
need more time to recover.
• Reccurent in idiopatic >>
CONCLUSIONS
• CTS is the most common entrapment neuropathy in community
• CTS in most cases, are idiopathic
• Early recognise and treatment will give good
prognosis, even with non-surgical approach
• Even after surgery, still there’s a chance for recurrent CTS
THANK YOU
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