MEDICAL FACULTY MUSLIM UNIVERSITY OF INDONESIA

2016

Muh. Asy Shidiq 110 2015 0003

A. Muh. Yasser Mukti 110 2015 0022

Andira Ratu Nurrasyid 110 2015 0030

Andi Aisya Zealand 110 2015 0051

Nur Zamzam Azizah 110 2015 0059

Amaliah Hakim 110 2015 0070

Rifqy Aditya 110 2015 0078

Rindang Cahyani Abas 110 2015 0101

Elsa Shafira Prasetyati 110 2015 0117

Cindy Purnamasari 110 2015 0136

Atika Rahmah Mustapa 110 2015 0147

A woman aged 55 years of diligent work and cooking. Hecomplained fingers of the right hand 1-3 (thumb, forefinger,and middle finger) tingling, especially at night., but when thehand on wiggle will improve. When you tap the middle of themovement of the right hand, there is a pain radiating to thefinger 13.

Tingling : a pricky sensation in the skin

or a body part, accompanied by

diminished sensitivity to

stimulation of the sensory nerves

Image source: https://edc2.healthtap.com/ht-staging/user_answer/avatars/1185971/large/open-

uri20130615-19205-189kqvm.jpeg?1386655000

A woman 55 years

Diligent work and cooking

Complained right hand finger 1-3 tingling

Especially at night

Improve by wiggle

Pain radiating to fingers 1-3

when tapped

What are the risk factor that cause the disease?

The incidence of carpal tunnel syndrome is 1-3 cases per 1000subjects per year; prevalence is approximately 50 cases per 1000subjects in the general population

The gender distribution of CTS was two-thirds to one-third femaleto male. According to one study, it was found the male to femaleratio to be 1:1.4

The risk of CTS increased 8% for each unit of increase in BMI (about6 lbs.)

It was noted 50% of CTS cases in pregnant women occurred in the thirdtrimester, but will usually resolve after pregnancy

In addition, increased sleeping in the lateral position which puts the wrist atincreased risk of flexion or extension, compressing the median nerve in thecarpal tunnel

Huldani. Carpal Tunnel Syndrome. 2013. Banjarmasin: Fakultas Kedokteran Universitas Lampung Mangkurat. Pg.8-10.

Why there is pain radiating when the wrist tapped and the fingers feel tingling?

Huldani. Carpal Tunnel Syndrome. 2013. Banjarmasin: Fakultas Kedokteran Universitas Lampung Mangkurat. Pg 7

Why the pain occur especially at night?

The initial stage of CTS is characterized by paresthesia at night, and this is based on intraneural

microvascular insufficiency night due to the increasing pressure on the carpal tunnel at night.

A gradual increase in pressure of tissue fluid reflects the redistribution of body fluids in the

horizontal position, and palmar flexion of the wrist. Should not be forgotten that in addition

there is a vascular pressure drop at night, which is associated with circadian rhythm, there is

also a decrease in perfusion pressure in the carpal tunnel.

Symptoms arise due to local metabolic disorganization on the nerves, resulting in oxygen

deficiency secondary to involvement intraneural microcirculation. The symptoms are reversible

when the position of the wrist, muscles, and posture becomes normal or if surgery on carpal

ligament.

Why when the hand on wiggle the pain lessen?

"Flicking“ (as also rubbing or beating the hand or repeatedly flexing the wrist and fingers):

increases thick fiber proprioceptive input,

increases venous pressure and volume, might briefly increase arteriolar pressure

and moves the nerve underneath the free distal edge of the flexor retinaculum.

Wem Pryse-Phillips. Journal Validation of a diagnostic sign in carpal tunnel syndrome. Division of Neurology, Faculty of Medicine, Memorial University of Newfoundland, Canada.

What is the type of pain experienced on the scenario?

NOCICEPTIK VS NEUROPATHIC

Nociceptive pain is pain that is caused by the presence of stimulinoksius (trauma, disease or inflammation).

• Come from the stimulation to the visceral organs, or somatic pain, when derived from tissues such as skin, muscles, bones or joints.

VISCERAL PAIN

• The superficial (skin) and the inside (of the others).SOMATIC

PAIN

Neuropathic pain is pain with impulses coming from damage or dysfunction of either

the peripheral nervous system or central.

The cause is trauma, inflammation, metabolic disease (diabetes mellitus, DM), infection

(herpes zoster), tumors, toxins, and primary neurological disease.

Central neuropathic painPain caused by a lession or disease of the central somatosensory nervous system

Peripheral neuropathic pain

Pain caused by a lession or disease of the peripheral somatosensory nervous system

What are the general examination to the suspected disease of the scenario?

Anamnesis

• Name of the patient?• Age of the patient?• Occupation of the patient?• What is the patient complain

about?• If pain, which part?• When the pain begins?

Anamnesis

• Where the source of the pain? • What time usually the pain felt the

most?• How long the patient feels the pain?• Patient’s history of the disease?• Family history of the disease?• The drugs have been consumed?

PHYSICAL EXAMINATION

• Phalen's test• Torniquet test• Tinel's sign• Flick'ssign• Thenar wasting.• Assessing the strengths and skills

and muscle strength either manually or by means of a dynamometer

Phalen's test Tinel's sign

• Wrist extension test• Pressure test• Luthy's sign (bottle's sign)• Examination of sensibility• Examination of autonomic

function

PHYSICAL EXAMINATION

Jen Sayles. 2007. Standard of Care: Carpal Tunnel Syndrome . Brigham & Women’s Hospital Department of Rehabilitation Services Occupational Therapy

What are the additional examination needed?

Nerve Conduction Studies (NCS)/ electromyography

To measure nerve conductionvelocity

Measuring the impulse traveltime from the forearm to thewrist

NCS slowed when nerve iscompressed

Carpal tunnel view (A) and CT scan (B) shows that calcifying mass is located just above the capitate.

Radiologic Imaging MethodsCTSCAN

Browning, Patrick D. Carpal Tunnel Syndrome Imaging. Oct.09, 2015.

(A) MRI shows hypertrophied palmaris longus is compressing median nerve in carpal tunnel (white arrow: hypertrophied palmaris longus

muscle). (B) Open transverse carpal ligament release and hypertrophied palmaris longus excision was performed

MRI

Saidoff and Apfel. The Healthy Body Handbook. NY:Demos Medical Publishing. Pg 207-208.

Ultrasound shows the CSA of median nerve and bowing of the flexor retinaculum were

significantly increased (CSA larger than about 10.5 mm)

USG

Aroori and Spence. Carpal Tunnel Syndrome. The Ulster Medical Society.2008

What is the differential diagnose of the scenario?

ETIOLOGYCTS

Hereditary, Trauma, Work, Infection, Metabolic, Endocrine, Neoplasms, Collagen vascular diseases

PTS

Entrapment of the median nerve between the two caput pronator teres muscle.

TRIGGER FINGER

Local trauma to the palm/base of the finger may be a factor on occasion, but in most cases there is not a clear cause.

CTS PTS TRIGGER FINGER

SYMPTOMSCTS

Usually paresthesias, less feeling (numbness) or taste like electric shock (tingling) in the fingers 1-3 and half the radial side of the finger 4

PTS

Heaviness, stiffness or cramping of the hands.

Tingling sensation in the muscles of the thenar thumb and three fingers on his side.

Pain in the area pronator teres muscle in the elbow or forearm when muscles contract.

TRIGGER FINGER

Discomfort felt at the base of the finger or thumb, where they join the palm

A nodule may sometimes be found in this area

TREATMENTCTS

Rest your wrist. The non-steroidal anti-inflammatory drugs.Installation splint at a neutral wrist position. Injection of steroids. Vitamin B6 (pyridoxine).Physiotherapy.

PTS

Management of the types of jobs and hobbies:Drugs and dosing neurorehabilitasi exercises to loosen the tension fibromuscular and to reduce pain.Exercise actively and dynamically in the upper limb

TRIGGER FINGER

To eliminate the catching or locking and allow full movement of the finger or thumb without discomfort

What is the management of disease based from the scenario?

A. Non farmacology

1. Resting the affected hand and wrist for at least 2weeks.

2. Immobilizing the wrist in a splint

3. If there is inflammation, applying cool packs can helpreduce swelling.

4. Exercise

5. Physical therapy

Non-surgical treatment

B. Farmacology

1. NSAIDs

2. Corticosteroid

3. vitamin B6 (pyridoxine) supplements

Department of Health and Human Services. Carpal tunnel syndrome. Public Health Service National Institutes of Health.

Surgical treatmentSurgery is recommended if symptoms last for 6 months or if there is evidence of muscle

damage in severe cases. The following are types of carpal tunnel release surgery:

Open release surgery

Endoscopic surgery

https://i.ytimg.com/vi/UMcPJhGYISQ/maxresdefault.jpg http://i1.ytimg.com/vi/uyEVwBXHAL0/hqdefault.jpg

Jen Sayles. 2007. Standard of Care: Carpal Tunnel Syndrome . Brigham & Women’s Hospital Department of Rehabilitation Services Occupational Therapy

Contraindication :

• Pronounced thenar muscle atrophy

• Loss of finger dexterity

• Loss of two-point discrimination (Please refer to Sensory SOC for description of Two-point

discrimination test)

• Severe pain (> 8/10 on the patient pain analog scale)

• Patients who cannot tolerate NSAIDs

• Consider a patient’s ability to provide an accurate history of symptoms, and the ability to carry over

education, written programs and directions to the home and occupational environments.

• The referring physician should be contacted if the patient’s neurological symptoms continue to

worsen or not respond to conservative treatment despite compliance with the treatment plan.

What are the prevention, promotion and rehabilitation for this scenario?

Rest Periods and Avoiding Repetition.

Anyfrequent

avoid overexertion of the hand and finger muscles whenever possible.

one who does repetitive tasks should begin with a short warm-up period, take

Employers should be urged to vary their employees' tasks and work.

Good PostureThe worker should sit with the spine against the back of the chair

with the shoulders relaxed.

The elbows should rest along the sides of the body, with wrists straight.

The feet should be firmly on the floor or on a footrest.

Typing materials should be at eye level so that the neck does not bend over the work.

Keeping the neck flexible and the head upright maintains circulation and nerve function to the arms and hands.

Reducing Force from Hand Tools

No task should require the wrist to deviate from side to side or to remain flexed or highly extended for long periods of time.

People who need to hold tools (including pencils and steering wheels) for long periods of time should grip them as loosely as possible.

In order to apply force appropriately, the ability to feel an object is extremely important. Tools with textured handles are helpful.

If possible, people should avoid working at low temperatures, which reduces sensation in the hands and fingers.

Power tools and machines should be designed to minimize vibrations.

Wearing thick gloves, when possible, may lessen the shock transmitted to the hands and wrists.

Jen Sayles. 2007. Standard of Care: Carpal Tunnel Syndrome . Brigham & Women’s Hospital Department of Rehabilitation Services Occupational Therapy

Hand and Wrist Exercises for the Prevention of Carpal Tunnel Syndrome

What are the prognosis and complication?

In mild cases of CTS, with conservative therapy generally good prognosis.

In general, surgery prognosis is also good.

• Faulty diagnosis, may trap / pressure on the median nerve is located in a moreproximal.

• There has been a total breakdown in the median nerve.

• The new CTS occurred as a result of complications due to the surgery such asedema, adhesions, infection, hematoma or hypertrophic scarring.

If after surgery, there was also obtained improvements then reconsidered the following possibilities:

PROGNOSIS

The most severe complication is reflex sympathetic dystrophy that is characterized

by severe pain, hyperalgesia, disestesia and trophic disorders.

Although the prognosis CTS with conservative or operative therapy is quite good, but

the risk for recurrence remains. In case of recurrence, the procedure either

conservative or operative treatment can be repeated.

COMPLICATION

What are the perspective islam we can learn from the scenario?

`Abdullah bin Mas'ud radi anhu narrated from the Prophet sallallaahu 'alaihi wa sallam, he said:

هلك المتنطعون

"Woe to those who exaggerated!" He said it three times. "

يت مضجعك فتوضأ إذا أت )) :البراء بن عازب، أن رسول هللا صلى هللا عليه و سلم قال عن

ك األيمن، ثم قل إن ي اسلمت نفسي إليك، اللهم : وضوءك للصالة، ثم اضطجع على شق

أ و ال يك رغبة و رهبة إليك ال ملج ووجهت وجهي إليك، و فوضت أمري إليك و ألجأت ظهري إل

، أمنت بكتابك الذي أنزلت و بنبي ك ك فإن الذ أرسلت و اجعلهن آخر كالم منجا منك إال إليك

(مت من ليلتك مت على الفطرة

"From al-Barra bin Azib, that the Prophet said," If you were heading pembaringanmu, then berwudhulah as you

perform ablutions for prayers, then lie down on your ribs right side and then recite the prayer: "O Allah! I surrender my

soul just to Thee, I confronted my face to Thee : I put all my business only to you, I rested my back to thee alone, with

hope and fear thee, I believe that you sent down the book and to the prophet that thou hast sent "and you shall make

a prayer earlier as the cover of your conversation that evening. So if you have undoubtedly died during the night you

died on nature "

CONCLUSION

CONT..

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