Ricafrente Rochelle - Carpal Tunnel Syndrome

8/3/2019 Ricafrente Rochelle - Carpal Tunnel Syndrome

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CARPAL TUNNEL SYNDROME

Prepared by:

Rochelle Ricafrente L. S.N.

BSN III-2

Batch 2012


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CARPAL TUNNEL SYNDROME

It is also known Median nerve dysfunction orMedian nerve entrapment. It is entrapmentneuropathy that occurs when the median nerve atthe wrist is compressed by a thickened flexor

tendon sheath, skeletal encroachment, edema or asoft tissue mass.

It is usually occurs in women between 30-60 yrs ofage.

It is cause by repetitive hand and wrist movementand it is associated with arthritis, diabetes, tumor ortrauma. It is also cause repeatedly exposed to coldtemperature, vibration or extreme direct pressure.


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The median nerve travels under the transverse carpalligament. The nerve is pinched in carpal tunnelsyndrome.


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CLINICAL MANIFESTATIONS:

Pins and needles'. This is tingling or burning in part, orall, of the shaded area shown above. The index andmiddle fingers are usually first to be affected.

Pain in the same fingers may then develop. The pain

may travel up the forearm. Numbness of the same finger(s), or in part of the palm,

may develop if the condition becomes worse.

Dryness of the skin may develop in the same fingers.

Weakness of some muscles in the fingers and/or thumb

occurs in severe cases. This may cause poor grip andeventually lead to muscle wasting at the base of thethumb.


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PATHOPHYSIOOGY

The basic pathophysiology of nervecompression common to all the specificcauses has been well described. The initial

insult is a reduction in epineural blood flow,which occurs with 20 to 30 mm Hgcompression. Intracarpal canal pressures inpatients with CTS routinely measure at least

33 mm Hg and often up to 110 mm Hg withwrist extension. Continued or increasedpressure eventually causes edema in theepineurium and endoneurium


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If applied for 2 hours, pressure of 50 mm Hg willcause epineural edema, and if applied for 8 hours,

it will increase endoneural fluid pressure fourfoldand block axonal transport. As further injury occursto the capillary endothelium, more protein leaks outinto the tissues, which become more edematous,and a vicious cycle ensues. The effects are mostpronounced within the endoneurium, since moreexudate and edema accumulate there, unable todiffuse across the perineurium. The perineuriumresists pressure changes because of its higher

tensile strength and acts as a diffusion barriercreating in effect a "compartment syndrome" withinthe nerve.


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Carpal tunnel syndrome occurs morecommonly in women than men[14,15] and is most

common between the ages of 30 and 60 years.Anything that compromises the space available forthe median nerve in the carpal tunnel can causeCTS. Local structural changes and masses at thewrist are known causes, including distal radius

fractures, blunt trauma with associated hemorrhageand swelling, and tumors such as lipomas andganglion cysts. A wide variety of systemic illnesses,metabolic diseases, overuse syndromes, and

aberrant anatomic structures also have beendescribed as causes of CTS (Table).


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Whether occupation and job-related hand or wristoveruse are risk factors for developing CTS is highlycontroversial. Several authors have listed occupation

and heavy manual labor as causal factors for thedisorder.[16-19] The opposite view has been argued for aslong, and Phalen himself stated that CTS was not anoccupational disease.[5,7,8,20] Nathan et al[21] reported

that results of nerve conduction studies of largenumbers of industrial employees showed no consistentassociation between the prevalence of CTS (detectedby decreased sensory nerve conduction) and the typeand level of occupational hand activity, length of

employment, or bilateral versus unilateral activity. It hasbeen shown that patients covered by workers'compensation respond differently to standard treatmentof CTS.[22]


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DIAGNOSTIC TESTS:

NON-INVASIVE DIAGNOSTIC TEST

TINEL SIGN

- Is a way to detect irritated nerves. It is performed by

lightly tapping (percussing) over the nerve to elicit asensation of tingling or "pins and needles". Forexample, in carpal tunnel syndrome wherethe median nerve is compressed at the wrist, Tinel'ssign is often "positive" causing tingling in

the thumb, index, and middle finger. Tinel's sign issometimes referred to as "distal tingling onpercussion" or DTP.
http://en.wikipedia.org/wiki/Nervehttp://en.wikipedia.org/wiki/Pins_and_needleshttp://en.wikipedia.org/wiki/Carpal_tunnel_syndromehttp://en.wikipedia.org/wiki/Median_nervehttp://en.wikipedia.org/wiki/Wristhttp://en.wikipedia.org/wiki/Thumbhttp://en.wikipedia.org/wiki/Index_fingerhttp://en.wikipedia.org/wiki/Middle_fingerhttp://en.wikipedia.org/wiki/Middle_fingerhttp://en.wikipedia.org/wiki/Index_fingerhttp://en.wikipedia.org/wiki/Thumbhttp://en.wikipedia.org/wiki/Wristhttp://en.wikipedia.org/wiki/Median_nervehttp://en.wikipedia.org/wiki/Carpal_tunnel_syndromehttp://en.wikipedia.org/wiki/Pins_and_needleshttp://en.wikipedia.org/wiki/Nerve


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PHALENS TESTThis test is performed by having the patient maintain full wrist and finger

extension for two minutes. The reverse Phalen's test significantlyincreases pressure in the carpal tunnel within 10 seconds of thechange in wrist posture and the carpal tunnel pressure has thetendency to increase throughout the test's duration. In contrast, thechange in carpal tunnel pressure noted in the standard Phalen's testis modest and plateaus after 20 to 30 seconds.

The average pressure change for Phalen's test at one and two minuteswas only 4 mm Hg. The average pressure changes in the carpaltunnel for the reverse Phalen's test were 34 mm Hg at one minuteinto the test and 42 mm Hg at the two minute point.

The extended wrist posture significantly changes the pressure withinthe carpal tunnel and may be more useful as a provocative

examination maneuver. Reverse Phalen's maneuver results in asignificantly higher intracarpal canal hydrostatic pressure ascompared to a traditional Phalen's. This is thought to add to thesensitivity of conventional screening methods.


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PHALENS TEST


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ELECTROMYOGRAM (EMG)

is a test that is used to record the electrical

activity of muscles. When muscles are active,they produce an electrical current. This current

is usually proportional to the level of the muscleactivity. An EMG is also referred to as a

myogram.EMGs can be used to detect abnormal electrical

activity of muscle that can occur in manydiseases and conditions, including muscular

dystrophy, inflammation of muscles, pinchednerves, peripheral nerve damage (damage tonerves in the arms and legs).


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INVASIVE DIAGNOSTIC TEST

OPEN CARPAL TUNNEL RELEASE SURGERY

During open carpal tunnel release surgery, the transversecarpal ligament is cut, which releases pressure onthe median nerve and relieves the symptoms of carpaltunnel syndrome.

An incision is made at the base of the palm of the hand.This allows the doctor to see the transverse carpalligament. After the ligament is cut, the skin is closed withstitches. The gap where the ligament was cut is leftalone and eventually fills up with scar tissue.

The goal of this procedure is to increase the space in thecarpal tunnel in order to remove pressure on the mediannerve, which is compressed in the tunnel at the wrist.This operation is relatively simple and is usually done onan outpatient basis.
http://www.webmd.com/hw-popup/transverse-carpal-ligamenthttp://www.webmd.com/hw-popup/transverse-carpal-ligamenthttp://www.webmd.com/hw-popup/median-nervehttp://www.webmd.com/hw-popup/median-nervehttp://www.webmd.com/hw-popup/transverse-carpal-ligamenthttp://www.webmd.com/hw-popup/transverse-carpal-ligament


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It may be performed with either:

local anesthetic, with injection of anumbing substance directly into thehand where the incision is to be made

regional anesthetic, with injection ofa numbing substance into the upperarm to numb the entire arm

general anesthesia, with the patientasleep


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PROCEDURE A tourniquet may be placed over the upper arm to

limit bleeding. This will allow a clear, unobstructedAn incision, about one and a half to two incheslong, is made in the palm, usually in the skincrease, extending up to the wrist.

view of the nerve. The ligament is exposed and then carefully divided

- that is, it is opened along its length, making themedian nerve entirely visible in the tunnel.

The nerve is carefully inspected to be sure it is freealong its length in the tunnel and not obstructed.

The wound is then closed.


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AFTER OPERATIONAFTER OPERATION

The hand may be dressed with bandages and a splint or plaster cast,usually for up to a week or two. The arm should be elevated to reduceswelling, and a sling may be worn for comfort. Avoid leaving the handhanging down, since this position encourages swelling to remain in thehand.

It is best to remove the arm from the sling every few hours to move the

elbow and shoulder so they don't get stiff. Move the fingers regularly.

Be careful not to wet the dressing. Cover the dressing with a plastic bagwhen washing.

Sutures are usually removed after a week to 10 days. Some surgeonsprefer to use absorbable sutures or adhesive tape.

Once the dressings are removed, you will be encouraged to move thehand and fingers. You'll begin with gentle gripping exercises, first with thepalm empty and then with a soft sponge in the palm. Some physicianswill arrange a supervised hand therapy program.

Many physicians recommend massaging the scar with oil or cream.


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ENDOSCOPIC KEYHOLE SURGERYA newer procedure using a very small incision at the wrist

allows the surgeon to pass fiber-optic tools through anendoscope (a device consisting of a pencil-thin tube andan optical system) into the tunnel. Then, usingspecialized tiny instruments, the surgeon divides theligament. The surgeon views the carpal tunnel area andthe median nerve on a video monitor.

The advantages of endoscopic surgery are that recoverytime is quicker and the scar is smaller. However, sincethis is a newer procedure, not all surgeons areexperienced with it. Therefore, the success rate may bea little lower than the conventional technique and the

complication rate higher.Keyhole surgery for carpal tunnel syndrome has its

opponents as well as proponents. It is important toselect a surgeon with expertise in this procedure.


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DRUGS:

NSAIDS

Pain relief and reduction of inflammation. It reducinginflammation in the structure passing through in thecarpal tunnel to decrease pressure.

IBUFROPEN/NAPROXEN

CORTICOSTEROIDS injection given on the carpal tunnel area

DIURETICS

Reducing the edema HYDROCHLORO THIAZIDE (Esidrix, hydrodiuril, microzide)

Inhibits reabsorption of sodium in distal tubules, causingincrease excretion of sodium and water as well aspotassium and hydrogen ions.

VITAMIN B6 Pyrodoxine


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COMPLICATION

If the condition is treated properly, there usually no complication.If untreated the nerve can be damage it will causingpermanent weakness.

NURSING RESPONSIBILITIES

Instructed the patient reduce number of repetitive wristmovement.

Instructed the patient use tool and equipment that are properlydesigned to reduced the risk of wrist injury.

If the patient is to wear the splint teach proper techniques to

applying the slint it is not to tight. Advised the patient the occasional exercise in warm water is

therapeutic.

If the patient whose hand impaired, assist in bathing andeating task.


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CARPALTUNNELSYNDROMELEFTUNTREATED:


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NURSINGDIAGNOSIS

Trauma r/t loss skeletal integrity

Acute pain r/t wrist compression

Impaired physical mobility r/t pain andmusculoskeletal impairment

Peripheral dysfunction r/t reduction ofblood flow

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Ricafrente Rochelle - Carpal Tunnel Syndrome