Musculoskeletal Disorders Part 4 Disorders of the Hands

8/2/2019 Musculoskeletal Disorders Part 4 Disorders of the Hands

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Maria Carmela L. Domocmat, RN, MSN

InstructorNorthern Luzon Adventist College


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Part 1: Degenerative & Metabolic bonedisorders:

Part 2: Bone infections Part 3: Muscular disorders

a : so e s o e a Carpal tunnel syndrome

Dupuytrens contracture

Ganglion Part 5: Spinal column deformities Part 6 : Disorders of foot Part 7: Sports Injuries

3/5/2012 Maria Carmela L. Domocmat, RN, MSN 2


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Carpal Tunnel Syndrome Dupuytrens Contracture

Ganglion



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common condition in which the mediannerve in the wrist becomes compressed,

causin ain and numbness

most common repetitive strain injury

(RSI) the fastest growing type of

occupational injury



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o

a rigid canal lying between the carpalbones 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

owhen the synovium becomes swollen or

thickened, the nerve is compressed



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median nerveo supplies motor, sensory, and autonomic

function for the 1st three digits of the hand

and the palmar aspect of the 4th digito 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



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o

Causes of Acute CTS rare excessive hand exercise

edema or hemorrhage into carpal tunnel

thrombosis of median artery



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o

common complication of certain metabolicand 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



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o repetitive strain injuryjob 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 inadulthood

o space-occupying lesions (ganglia, tophi,lipomas)



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o peaks between 30 and 60 yrs

o but children are adolescents are getting

common due to use of computer

owomen 5 times more commono affects dominant hand, but can occur both

hands simultaneously



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o if use computer regularly

use appropriate ergonomically designed

work stations

take regular breaks

if beginning symptoms tell medical

attention



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o numbness and pain on hand

o pain

worse at night as result of flexion or direct

pressure ur ng s eep may radiate to arm, shoulder and neck, or

chest

o

paresthesia (painful tingling)o sensory changes usually precedes motor

manifestations by weeks or months



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o (+) Phalens wrist test or Phalens 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



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o Tinels sign

tap lightly over the area of median nerve in

wrist

if test is unsuccessful a BP cuff can beplaced on upper arm and inflated to

clients systolic pressure;

result pain and tingling



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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)



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o strenuous hand activity worsens the

subjective complaints

owrist swelling

o autonomic changes skin discoloration

nail changes (e.g., brittleness)

increased or decreased palmar sweating



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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 technique



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o nonsurgical mgmt

drug therapy

NSAIDs

inject corticosteroid directly into carpaltunnel weekly or monthly

immobilization

splint to immobilize wrist during day orduring night, or both



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o surgical mgmt

to relieve pressure on median artery by

providing nerve decompression

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



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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



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postop care

hand movements including lifting heavy

objects restricted for 4 to 6 wks postop

encourage t o move all fingers of affectedhand frequently

teach client to expect weakness and

discomfort for weeks or perhaps months



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postop care

offer pain meds

multiple operations and other treatments

common may need assistance with routine daily

tasks or even self-care activities



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slowly progressive contracture of the

palmar fascia, resulting in flexion of 4th or

5th di it of hand



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common problem

can be bilateral

cause:

unknown

incidence:

older men, tend to occur in families



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Treatment

owhen function becomes impaired, surgical

release is required

o partial or selective fasciectomyo splint application - post removal of dressing

and drain

nursing careo same with carpal tunnel repair



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a round, cystlike lesions

often overlying wrist joint or tendon

s novium surroundin the tendon

degenerates, allow tendon sheath tissue

to become weak and distended



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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



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treatment:

although fluid within lesion can be aspirated,

total excision is preferred



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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

00044 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=a00154


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Musculoskeletal Disorders Part 4 Disorders of the Hands