Musculoskeletal disorders Part 4 Disorders of the Hands: Carpal Tunnel Syndrome, Dupuytren's contracure, Ganglion

Maria Carmela L. Domocmat, RN, MSN

Instructor

Northern Luzon Adventist College

� Part 1: Degenerative & Metabolic bone disorders:

� Part 2: Bone infections� Part 3: Muscular disorders � Part 4: Disorders of the hand� Part 4: Disorders of the hand

� Carpal tunnel syndrome

� Dupuytren’s 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

� Carpal Tunnel Syndrome

� Dupuytren’s Contracture

� Ganglion



• common condition in which the median

nerve in the wrist becomes compressed,

causing pain and numbness causing pain and numbness

• most common repetitive strain injury

(RSI) –the fastest growing type of

occupational injury



o a rigid canal lying between the carpal

bones 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

o when the synovium becomes swollen or

thickened, the nerve is compressed




• median nerve

o supplies motor, sensory, and autonomic

function for the 1st three digits of the hand

and the palmar aspect of the 4th digit

o 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



o Causes of Acute CTS – rare

� excessive hand exercise

� edema or hemorrhage into carpal tunnel

� thrombosis of median artery


o common complication of certain metabolic

and 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


o repetitive strain injury � job requiring repetitive hand activities

involving pinch or grasp during wrist flexion (factory workers, computer operators, jackhammer operators)jackhammer operators)

o overuse in sports activities � golf, tennis, racquetball

o familial or congenital, manifesting in adulthood

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


o peaks between 30 and 60 yrs

o but children are adolescents are getting

common –due to use of computer

o women – 5 times more common

o affects dominant hand, but can occur both

hands simultaneously


o if use computer regularly

� use appropriate ergonomically designed

work stations

� take regular breaks

� if beginning symptoms – tell medical

attention


o numbness and pain on hand

o pain

� worse at night as result of flexion or direct

pressure during sleeppressure during sleep

� may radiate to arm, shoulder and neck, or

chest

o paresthesia (painful tingling)

o sensory changes – usually precedes motor

manifestations by weeks or months




o (+) Phalen’s wrist test or Phalen’s 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



o Tinel’s sign

� tap lightly over the area of median nerve in

wrist

� if test is unsuccessful – a BP cuff can be

placed on upper arm and inflated to

clients systolic pressure;

� result – pain and tingling



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)


o strenuous hand activity worsens the

subjective complaints

o wrist swelling

o autonomic changes

� skin discoloration

� nail changes (e.g., brittleness)

� increased or decreased palmar sweating


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


o nonsurgical mgmt

� drug therapy

• NSAIDs

• inject corticosteroid directly into carpal • inject corticosteroid directly into carpal

tunnel – weekly or monthly

� immobilization

• splint to immobilize wrist – during day or

during night, or both


o surgical mgmt

� to relieve pressure on median artery by

providing nerve decompression

� Open Carpal Tunnel Release (OCTR) � Open Carpal Tunnel Release (OCTR)

� 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


� 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


� postop care

• hand movements – including lifting heavy

objects – restricted for 4 to 6 wks postop

• encourage t o move all fingers of affected

hand frequently

• teach client to expect weakness and

discomfort for weeks or perhaps months


� postop care

• offer pain meds

• multiple operations and other treatments –

common

• may need assistance with routine daily

tasks or even self-care activities



• slowly progressive contracture of the

palmar fascia, resulting in flexion of 4th or

5th digit of hand5 digit of hand


• common problem

• can be bilateral

• cause: • cause:

• unknown

• incidence:

• older men, tend to occur in families



• Treatment

o when function becomes impaired, surgical

release is required

o partial or selective fasciectomy

o splint application - post removal of dressing

and drain

• nursing care

o same with carpal tunnel repair



• a round, cystlike lesions

• often overlying wrist joint or tendon

• synovium surrounding the tendon • synovium surrounding the tendon

degenerates, allow tendon sheath tissue

to become weak and distended



• painless on palpation, but can cause joint

discomfort after prolonged joint use or

minor trauma (ex: strain)minor trauma (ex: strain)

• can disappear and then recur

• common: 15 to 50 yrs old


• treatment:

• although fluid within lesion can be aspirated,

total excision is preferred


� 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

H0004438/H0004438/� 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=a0015

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Musculoskeletal disorders Part 4 Disorders of the Hands: Carpal Tunnel Syndrome, Dupuytren's contracure, Ganglion