1. Common Health Problem/Condition: MSK Carpal Tunnel Syndrome (CTS)

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Clifford Lee
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1 Midwifery Management Process for Common Health Problems 1. Common Health Problem/Condition: MSK Carpal Tunnel Syndrome (CTS) Definition: Carpal Tunnel Syndrome (CTS) is an upper extremity disability. It is most often identified as a work-related musculoskeletal disorder but exact causes of carpal tunnel syndrome are unknown. Repetitive use, forceful wrist extension, flexion, using tools that cause vibration and repetitive gripping can increase the risk of CTS. Signs and symptoms are brought on by compression of the median nerve as it travels through the carpal tunnel (Kothari, 2012 and Star, Lommel & Shannon, 2004). Etiology/Pathophysiology: The carpal tunnel is made up of the transverse carpal ligament and the carpal bones. The carpal tunnel is formed by the transverse carpal ligament on the superior side and bones on the inferior side. The formation of Carpal Tunnel Syndrome is multi-factorial but affects the median nerve, which innervates the palm, the first three digits and the radial half of the fourth digit to provide sensation and movement. The median nerve emerges from the brachial plexus in the upper arm and passes through the carpal tunnel along with nine flexor tendons of the forearm musculature (Kothari, 2011). When swelling occurs in this narrow area, compression on the median nerve can cause a mechanical disruption, which leads to pain, paresthesia and weakness (ncbi.nlm.nih.gov and Kothari, 2012) Incidence: Carpal tunnel syndrome is a common disorder likely occurring between the ages of Carpal tunnel syndrome occurs more frequently in women than in men. A Swedish study published in 2011 estimated that physician-diagnosed CTS was likely to occur annual in 428 per 100,000 women and 182 per 100,000 men (Atroshi et al., 2011). Other research shows that the estimated occurrence of CTS in the general population is 1 to 5 percent and is more likely to occur in obese women (Kothari, 2011). 2. Collection of essential history: Subjective information to gather: Have you had a recent injury, if so can you describe how it occurred? Is the pain in your dominant limb? Did you overuse a joint? What is the severity of pain? When does the pain occur (with activity or at rest)? Can you describe your usual daily activity at home, work and with hobbies? How does the pain affect your activities? What activities make the pain worse?

2 What movement makes the pain worse? Do you have any other illness 3. Findings of directed physical assessment: Thumb abduction weakness when thumbs are positioned at right angles to palms Diminished sensation over the median nerve determined by light touch applied with a stroking motion over the tip of the index finger compared with that of the small finger. Swelling over volvar aspects of the wrist Paresthesias of the hand when wrists are held in the 90-degree flexion for up to 60 seconds (Phalen s test). Weakened grip strength Tingling sensation in pointer fingers and wrist pain with Tinel sign test. 4. Differential diagnoses: Carpal Tunnel Syndrome: positive Phalen test and Tinel sign, weakness of hand; dry skin over distribution of median nerve. Diagnostic test includes an electrodiagnostic nerve conduction study. No lab tests. Rheumatoid arthritis: rheumatoid nodules, ulnar deviation of wrists. Diagnositic tests would show Increased ESR, positive rheumatoid factor and anemia on CBC Wrist fracture: increased pain with palpation of snuffbox, joint deformity. Diagnostic test would include a three-view radiograph to determine scaphoid or Colles fracture. Ganglion: gelatinous filled nodule that is soft and transilluminates. No diagnostic test 5. Diagnosis/Assessment:: Carpal Tunnel Syndrome 6. Treatment/ Management plan: treatment is based on severity and duration of symptoms. Non-pharmacological treatments include wrist splints worn at bedtime to maintain the wrist in a neutral position and inhibit the degree of nerve compression. It is also recommended that the patient stop or reduce the aggravating factor whether it is work or hobby related. Pharmacological treatments: There is limited evidence that NSAIDS are effective for CTS. Steroid injections should be recommended for mild to moderate relief of CTS. This injection requires a referral to an orthopedist or other qualified clinician.

3 Complementary and alternative therapies: Topical arnica cream: used for its anti-inflammatory properties. Prevention strategies may include occupational or hand therapy. 7. Consultation, collaboration or referral: A patient with symptoms that are job related should be referred to occupational medicine. If conservative management does not resolve CTS, a patient should be referred to an orthopedist for surgical consultation. 8. Patient education: Explain the disease process and associated symptoms of CTS Educate the patient about proper use of wrist splints o Wear at night to maintain the wrist in a neutral position o Do not over-immobilize as this could lead to weakness. 9. Evaluation & follow-up: Patient should seek follow up if: o No resolution of symptoms after adequate trial of conservative treatment o Numbness and tingling in fingers has become persistent and unremitting. o Decreased sensation in fingertips or weakness in the thumb. Return to clinic in 6 weeks. 10. Documentation in chart:

4 SOAP CHART NOTE 2/29/12 ID/CC: 47-year old presents to clinic with right wrist pain. SUBJECTIVE: HPI: Reports pain in right wrist and tingling and numbness in first two fingers. Has experienced a dull, aching discomfort in the forearms at the end of the day. Symptoms started about one week ago and have gotten progressively worse. Numbness is making working as an art teacher in an elementary school more challenging because she reports she doesn t feel like she has good fine motor skills with her hands and her grip strength has decreased. ROS: Denies headache, fever, loss of consciousness, SOB, palpitations, difficulty voiding. PMH: Chichenpox in childhood PSH: Wisdom teeth removed at 18 Related FH: Mother- obesity Medications: None Allergies: KNDA No environmental or food allergies Social: Married. Lives at home with husband. Has worked for 20 years as an elementary school art teacher. SH: non-contributory. OBJECTIVE:. VS: Height: 67, Weight: 170 lbs. BMI: 26.6 BP sitting: 116/70 General Appearance: Patient is well developed, well nourished. In no acute distress Alert and cooperative. Skin: Intact without rashes or lesions. HEENT: Head: normocephalic, atraumatic. Neck: no masses,

5 LUNGS: clear bilaterally to A&P HEART: RRR, S1 and S2 present without murmurs, rubs, gallops or clicks. Upper extremities: minimal swelling in right wrist, positive Phalen s test on right side ASSESSMENT: Carpal Tunnel Syndrome PLAN: Lab and or diagnostic tests: Electodiagnostic nerve conduction study. Referral/Consultation: Accupuncture referral provided Referral to orthopedist for surgical consult if conservative treatment fails, pain is intolerable or there is ongoing numbness. Education: Use wrist splints at night to maintain the wrist in the neutral position. Informed patient there is limited and low quality evidence that supports therapeutic exercise. Do not wear splints continuously as continued immobilization can lead to weakness of surrounding muscles and tendons. Follow-up: Call if symptoms worsen Return to clinic in 6 weeks. 11. References: A.D.A.M Medical Encyclopedia. Carpal Tunnel Syndrome: Median nerve dysfunction; median nerve entrapment. Last reviewed June 29, Retrieved from on October 26, 2012 Atroshi, I., Englund, M., Turkiewicz, A., Tägil, M., & Petersson, I. (2011). Incidence of physician-diagnosed carpal tunnel syndrome in the general population. Archives Of Internal Medicine, 171(10), doi: /archinternmed Kothari, M.J. (2012). Clinical manifestations and diagnosis of carpal tunnel syndrome. UpToDate. Retrieved on 10/26/12. Kothari, M.J. (2011). Etiology of carpal tunnel syndrome. UpToDate. Retrieved on 10/26/2012 Page, M., O'Connor, D., Pitt, V., & Massy-Westropp, N. (2012). Exercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database Of Systematic Reviews, (6)

6 Star, W.L., Lommel, L.L., Shannon, M.T. (2004). Women s Primary Health Care: Protocols for Practice (2 nd Edition). San Franscico, CA: UCSF Nursing Press.

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