Carpal tunnel syndrome @

carpal tunnel syndrome neurological condition

1. Name of the bones of wrist…

2. C. T. S.

3. C. T. S. ( carpal tunnel syndrome) PRESENTED TO: PRESENTED BY: Ms. VINAY KUMARI AMANDEEP KAUR ASSOCIATET PROFESSOR Msc . Nsg . 2 nd Year (MED.-SURG. NURSING) Roll No. 1915703

4. oBJECTIVES Anatomy and physiology of median nerve Introduction of carpal tunnel syndrome Definition Etiology Pathophysiology Clinical manifestations Diagnostic Evaluations Management

5. ANATOMY AND PHYSIOLOGY OF BRACHIAL PLEXUS The brachial plexus (plexus brachialis ) is a somatic nerve plexus formed by intercommunications among the ventral rami (roots) of the lower 4 cervical nerves (C5-C8) and the first thoracic nerve (T1). The plexus, depicted in the images below, is responsible for the motor innervation of all of the muscles of the upper extremity, with the exception of the trapezius and levator scapula

6. BRACHIAL PLEXUS

7. BRACHIAL PLEXUS

8. Brachial nerve

9. Radial nerve

10. Median nerve

11. Carpal tunnel

12. MEDIAN NERVE MOTOR INNERVATION: 1 st and the 2 nd lumbricals Muscles of thenar eminence: Opponens pollicis brevis Flexor pollicis brevis SENSORY INNERVATION: Skin of the palmar side of the thumb, index and middle finger. Half the ring finger and nail bed of these fingers.

13. introduction Carpal tunnel syndrome/ median nerve entrapments is a nerve compression syndrome where the median nerve gets compressed at the wrists. The median nerve is most frequently entrapped at the wrist because of its vulnerable anatomic position .

14. DEFINITION “Carpal tunnel syndrome is pressure on the median nerve -the nerve in the wrist that supplies feeling and movement to parts of the hand. It can lead to numbness, tingling, weakness, or muscle damage in the hand and fingers. ”

15. RISK FACTOR Sewing Driving Painting Writing Use of tools (especially hand tools or tools that vibrate) Sports such as handball Playing some musical instruments

16. CAUSES The most common cause of carpal tunnel syndrome is idiopathic (which means that the exact etiology is unknown). In general, anything that crowds, irritates or compresses the median nerve in the carpal tunnel space can lead to carpal tunnel syndrome.

17. CAUSES con… Bone fractures and arthritis of the wrist Acromegaly Diabetes Alcoholism Hypothyroidism Kidney failure and dialysis Menopause, premenstrual syndrome (PMS), and pregnancy

18. CAUSES con.. Infections Obesity Rheumatoid arthritis, systemic lupus erythematosus (SLE). Synovitis Excessive hand exercise Edema or haemorrhage of the carpal tunnel Thrombosis of the median artery.

19. INCEDENCE Prevalence :- approximately 50 cases per 1000 population. Race :- Whites are probably at highest risk . Gende r:- The female-to-male ratio for carpal tunnel syndrome is 3-10:1 . Age :- The peak age range for development of carpal tunnel syndrome (CTS) is 45-60 years . Only 10% of patients with CTS are younger than 31 years.

20. PATHOPHYSIOLOGY Due to the etiological factors   Synovium swollen   Pressure on the median nerve Temporary blockage of mylineated nerve fibers

21. PATHOPHYSIOLOGY Numbness on the fingers and hands   Continued pressure causes Ischemia, axonal death, muscular dystrophy, pain.

22. Signs and symptoms Tingling Numbness or discomfort in the lateral 3 1/2 fingers. Intermittent pain in the distribution of the median nerve. Symptoms gets aggravated at night. To relieve the symptoms, patients often “flick” their wrist as if shaking down a thermometer (flick sign).

23. MOTOR CHANGES: Apelike thumb deformity Loss of opposition of thumb Index and middle finger lag behind when making the fist.

24. SENSORY CHANGES: Loss of sensation of lateral 3 1/2 digits including the nail bed and distal phalanges on dorsum of hand. (An important point to remember for Carpal tunnel syndrome is that there is no sensory loss over the thenar eminence in Carpal tunnel syndrome because the branch of median nerve that innervates it ( palmar cutaneous branch) passes superficial to Carpal tunnel and not through it).

25. VASOMOTOR CHANGES: Skin area with sensory loss is warmer Dry skin TROPHIC CHANGES: Long standing cases leads to dry and scaly skin Nail crack easily Atrophy of the pulp of the fingers( thenar muscle).

26. MANAGEMENT Physical Assessment Tests: Less sensitivity to pain where the median nerve runs to the fingers. Thumb weakness. Inability to tell the difference between one and two sharp points on the fingertips. Flick Signal   The patient is asked, "What do you do when your symptoms are worse?

27. PHALEN’S TEST: The patient rests the elbows on a table The wrists dangle( flexion) with fingers pointing down and the backs of the hands pressed together. POSITIVE: If symptoms develop within a minute, CTS is indicated.

28. TINEL’S SIGN TEST: In the Tinel's sign test, the doctor taps over the median nerve to produce a tingling or mild shock sensation.

29. DURKAN TEST/ Carpal compression test Pressure over the carpal tunnel for 30 seconds produce tingling or shock in the median nerve. Wrist should be in neutral position and forearm supinated .

30. HAND ELEVATION TEST: The patient raises his or her hand overhead for 2 minutes to produce symptoms of CTS.

31. TORNIQUET TEST: Torniquet inflated above systolic for one minute intensifies the symptoms

32. DIAGNOSTIC EVALUATION History Physical examination Nerve Conduction Study

33. A nerve conduction study (NCS), also called a nerve conduction velocity (NCV) test --is a measurement of the speed of conduction of an electrical impulse through a nerve . NCS can determine nerve damage and destruction. During the test , the nerve is stimulated, usually with surface electrode patches attached to the skin

34. management

35. CONSERVATIVE TREATMENTS GENERAL MEASURES WRIST SPLINTS ORAL MEDICATIONS LOCAL INJECTION ULTRASOUND THERAPY

36. GENERAL MEASURES :- Avoid repetitive wrist and hand motions that may exacerbate symptoms or make symptom relief difficult to achieve. Not use vibratory tools. Ergonomic measures to relieve symptoms depending on the motion that needs to be minimized.

37. WRIST SPLINTS:- Probably most effective when it is applied within three months of the onset of symptoms. The following orthoses help manage the carpal tunnel syndrome pain: Wrist hand orthosis

38. Cock-up wrist splint Thumb spica splint

39. ORAL MEDICATIONS:- Diuretics Nonsteroidal anti-inflammatory drugs (NSAIDs) pyridoxine (vitamin B6) Orally administered corticosteroids . Prednisolone :- :- 20 mg per day for two weeks :-followed by 10 mg per day for two weeks.

40. LOCAL INJECTION :- local corticosteroid injection may be administered.

41. ULTRASOUND THERAPY Predicting the Outcome of Conservative Treatment

42. SURGERY Surgery should be considered if a patient needs more than two injections . Should be considered in patients with symptoms that do not respond to conservative measures. patients with severe nerve entrapment as evidenced by nerve conduction studies, thenar atrophy, or motor weakness.

43. OPEN RELEASE Cut The Ligament (Flexor Retinaculum ) Surgery is one treatment option for carpel tunnel syndrome. The surgeon makes an incision (cut) less than 5 cm long in the palm, and perhaps into the wrist as well, to expose the transverse carpal ligament. The surgeon then cuts the ligament to reduce pressure on the underlying median nerve. The incision in the palm is sutured (sewn) closed.

44. Endoscopic release :- Endoscopic surgery uses a thin tube with a camera attached ( endoscope ). The endoscope is guided through a small incision in the wrist (single-portal technique) or at the wrist and palm (two-portal technique). The endoscope lets the doctor see structures in the wrist, such as the transverse carpal ligament without opening the entire area with a large incision.

45. RESEARCH INPUT TITLE : - “PROSPECTIVE EVALUATION OF OPIOID CONSUMPTION FOLLOWING CARPAL TUNNEL RELEASE SURGERY.”

46. Aim:- To understand factors affecting opioid consumption, a prospective study was undertaken with the hypothesis that CTR performed under local anesthesia (wide awake local anesthesia with no tourniquet [WALANT]) would result in increased opioid consumption postoperatively compared with cases performed under sedation.

47. Method: All patients undergoing open CTR surgery were consecutively enrolled over a 6-month period. Information collected included patient demographics, surgical technique, amount and type of narcotic prescribed, number of pills taken, and type of anesthesia.

48. Results:- Opioid consumption following CTR is more influenced by age and gender, and less influenced by anesthesia type, insurance type, or the type of opioid prescribed. Many more opioids were prescribed than needed, on an average of 5:1. Many patients, particularly older patients, do not require any opioid analgesia after CTR .

49. prognosis Surgery is usually successful. In some cases it does not completely relieve the numbness and pain in the fingers or hand. This may be the case if there has been permanent nerve damage caused by long-standing carpal tunnel syndrome or by other health problems such as diabetes.

50. COMPLICATIONS FROM SURGERY The most common complications of carpal tunnel release surgery include: Nerve damage with tingling and numbness (usually temporary) Infection Scarring Pain Stiffness Loss of some wrist strength is a complication that affects 10% to a third of patients

51. NURSING MANAGEMENT Nursing diagnosis Acute pain related to nerve compression. Self-care deficit: bathing/hygiene, dressing/grooming, feeding, and/or toileting related to bandaged hands. Risk for peripheral neurovascular dysfunction related to disease process. Risk for infection related to surgical procedure.

52. Intervention Advise the patient hands should not be kept under the head. Examine the patients hand and wrists for any nail atrophy Note patients range of motion of fingers, wrists and hand strength. Teach the patient how to remove the splint in order to exercise, how to perform daily, gentle range of motion exercise

53. Intervention Teach the patient how apply splint. Advice the patient to do occasional exercise in warm water is therapeutic. Encourage the patient to use the hands as much as possible Encourage the patient to verbalize about disease. If the patient hand is impaired, assist in daily activities.

54. PREVENTION Avoid or reduce the number of repetitive wrist movements whenever possible. Use tools and equipment that are properly designed to reduce the risk of wrist injury. Ergonomic aids, such as split keyboards, keyboard trays, typing pads, and wrist braces, may be used to improve wrist posture during typing. Take frequent breaks when typing and always stop if there is tingling or pain.

55. Research input Title:- “Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial.”

56. Aim: - Randomized clinical trial investigated the effectiveness of surgery compared with physical therapy consisting of manual therapies including desensitization maneuvers in carpal tunnel syndrome (CTS).

57. Setting:- a public hospital and 2 physical therapy practices in Madrid, Spain. One hundred twenty women with CTS were enrolled between February 2013 and January 2014, with 1-year follow-up completed in January 2015. Interventions consisted of 3 sessions of manual therapies including desensitization maneuvers of the central nervous system (physical therapy group, n = 60) or decompression/release of the carpal tunnel (surgical group, n = 60).

58. PERSPECTIVE: This study found that surgery and physical manual therapies including desensitization maneuvers of the central nervous system were similarly effective at medium-term and long-term follow-ups for improving pain and function

59. SUMMARY:-

60. CONCLUSION:- Carpal tunnel syndrome is a disease of median nerve affects more to white, females after the age of 30yrs. Affects neuro sensory function of the hand and if left untreated can cause permanent loss of functioning of affected area.

61. REFERENCES Books- 1. Hickey J. The clinical practice of neurological and neurosurgical nursing. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014. 2. CLEMENT I. text book of neurological and neurosurgical nursing. 1st ed. 4838/24, Ansari Road, Daryaganj , New Delhi: Jaypee brothers medical publishers(p) Ltd.; 2015. Internet- http://www.carpal-tunnel-symptoms.com/anatomy-of-the-carpal-tunnel.html https://www.ncbi.nlm.nih.gov/labs/articles/23798040/ https://www.ncbi.nlm.nih.gov/pubmed/28082841 https://www.ncbi.nlm.nih.gov/pubmed/26281946

62. 1. which nerve is affected in carpal tunnel syndrome?

63. Ans :- Median Nerve

64. 2. Another name of carpal tunnel syndrome?

65. Ans :- median nerve entrapments

66. 3. Types of surgeries performed for CTS?

67. Ans :- OPEN RELEASE Cut The Ligament (Flexor Retinaculum ) Endoscopic release