Carpel tunnel syndrome presentation
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CARPEL TUNNEL SYNDROME
CAUSE AND EFFECT THE
CONFUSION
RICHARD RADECKI MDMEDICAL REHABILITATION CENTER OF NM
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1. EVIDENCE BASED MEDICINE = CONSCIENTIOUS, EXPLICIT, AND JUDICIOUS USE OF CURRENT BEST EVIDENCE IN MAKING DECISIONS ABOUT CARE OF INDIVIDUAL PATIENTS
2. EPIDEMIOLOGY = BIOMEDICAL DISCIPLINE FOCUSED ON THE DISTRIBUTION AND DETERMINANTS OF DISEASE IN GROUPS OF PEOPLE WHO HAPPEN TO HAVE SOME CHARACTERISTICS, EXPOSURE, OR DISEASE IN COMMON
DEFINITIONS
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3. CAUSE = AN EVENT, CONDITION OR CHARACTERISTIC THAT PLAYS AN ESSENTIAL ROLE IN PRODUCING AN OCCURRENCE OF THE DISEASE
4 RISK = THE PROBABLITY THAT AN EVENT WILL OCCUR
5. RISK FACTOR = ENVIROMENTAL, BEHAVIORAL, OR BIOLOGIC FACTOR CONFIRMED BY TEMPORAL SEQUENCE, THAT IF PRESENT, DIRECTLY INCREASES THE PROBABILITY A DISEASE WILL OR WILL NOT OCCUR
DEFINITIONS
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KEYBOARD ACTIVITIES COLD ENVIRONMENT LENGTH OF EMPLOYMENT DOMINANT HAND AWKWARD POSTURE BLUNT WRIST TRAUMA REPETITIVE WORK ALONE OR COMBINIATION
OF FACTORS SMOKING
INSUFFICIENT EVIDENCE
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AGE = AGING BMI (BODY MASS INDEX) SEX - FEMALE ETHNICITY FAMILIAL PERSONNEL FACTORS
STRONG EVIDENCE
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THE INDUSTRIAL COMMITTEE OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND
CONFIRMATION OF CARPEL TUNNEL SYNDROME PER ELECTRODIAGNOSTIC CRITERIA
“REPETITIVE” ACTIVITY – “AWKWARD POSTURE” DIAGNOSTIC TECHNIQUE FOR “ABNORMAL”
NO CAUSUAL RELATIONSHIP
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OBJECTIVE CONFIRMATION OF MEDIAN NERVE SLOWING WITH AT LEAST SOME NONSPECIFIC SYMPTOMS OF CTS
PATIENT MAY OR MAY NOT BE SYMPTOMATIC ONLY MEDIAN CONDUCTION STUDIES PROVIDE
OBJECTIVE DIAGNOSIS WITH LOCALIZATION AND QUANTIFICATION
IS “ABNORMAL” ABNORMAL COMPARISON BETWEEN OTHER NERVES STUDIED GIVES
STRONGER DIAGNOSTIC WIEGHT TO “ABNORMAL”
CARPEL TUNNEL DEFINITION
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MEN – MAYO CLINIC 22 % 1961-1980 CHINA – MEN = 16% SOUTH AFRICA – PRIMARY/TERTIARY CLINIC
DIAGNOSED 26 BLACK MEN WITH CTS OUT OF 6 MILLION NON-WHITE PATIENTS
0% WAS WORK RELATED OR IDIOPATHIC
2 FRACTURE, 2 INFECTIONS,1 GANGLION
GENDER AND ETHNICITY
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PHALEN STATED, “MANY PATIENT SAY THEIR PARENTS AND GRANDPARENTS HAD SIMILAR COMPLAINTS”
PROSPECTIVE STUDY FOUND◦ A 4 GENERATION FAMILY WITH CTS◦ IDENTICAL TWINS WITH CTS◦ 115/421 PATIENTS WITH MEDIAN NERVE SLOWING
TO HAVE ONE OR MORE FAMILY MEMBERS WITH CTS OR HISTORY OF MEDIAN NERVE DECOMPRESSION
◦ = 40% PREVALENCE OF CTS IN PATIENTS WITH PRIOR MEDIAN NERVE SURGERY
HEREDITY
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POTENTIAL HERITABLE PERSONAL CHARACTERISTICS
BASAL MASS INDEX (BMI) GREATER THEN AVERAGE WRIST DEPTH VS WIDTH
(INCREASE WRIST RATIO) THICKER THEN NORMAL CARPEL TUNNEL LIGAMENT CERTAIN FAMILIAL CASE REPORTS SHOW 100 %
INCIDENCE OF CTS IN THE FAMILY. FAMILY AGE GROUPS AFFECT 4 Y.O. TO MIDDLE AGES
HEREDITY
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LESS THEN 30 Y.O INCIDENCE = 3.9-12 % LESS THEN 40 Y.O. INCIDENCE = 12.5-22.7% 946 WOMEN AGE FACTOR MORE SPECIFIC
REGARDLESS OF WORK-RELATEDNESS OF PATIENTS COMPLAINTS
AGE MORE SIGNIFICANT THEN DURATION OF EMPLOYMENT
IE. POULTRY INDUSTRY
4462 ARMY PERSONNEL SENSORY MEDIAN .127M/SEC/YR MOTOR MEDIAN .108 M/SEC/YR
AGE = AGING PROCESS
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OBESITY, SHORTER STATURE, WEIGHT GAIN MALE PATIENTS OF NORMAL BMI (SLENDER)
=0% CTS NONPATIENT POPULATION (ASYMPTOMATIC)
FOUND HIGH CORRELATION IN 427 PATIENTS WITH MEDIAN NERVE SLOWING
MEDIAN – ULNAR SENSORY LATENCY HAS STRONG CORRELATION TO BMI
PATIENTS WITH HIGHEST BMI HAD 100% PRESENCE OF MEDIAN NERVE SLOWING (15 TO 60KG/m2)
BODY MASS INDEX (BMI)
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STRONG POSITIVE COORELATION BETWEEN MEDIAN MOTOR LATENCY AND THE WRIST RATIO( LONGER LATENCY WITH HIGHER RATIO) ADJUSTING FOR AGE AND SEX
1472 PATIENTS STRONG ASSOCIATION (P< .0001) WEATHER OR NOT WORK RELATED
WRIST DEPTH DIVIDED BY WIDTH (1983) SIGNIFICANT IN BOTH ASYMPTOMATIC AND PATIENTS
AUTO WORKERS WRIST RATIO X> OR = .7 OR GREATER HAD MEDIAN NERVE SLOWING (WITHIN 4-12 MONTHS OF EMPLOYMENT) 29/39 = 74 %, ADJUSTED FOR AGE AND SEX
JOHNSON WRIST RATIO
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0 % INCIDENCE WITH RECTANGULAR WRIST TO NEARLY 100% INCIDENCE WITH HIGH RATIOS REGARDLESS OF OCCUPATION
ANOTHER STUDY STUDENTS, WORKERS, AND PATIENTS FOUND WRIST RATIO ONE OF 3 PERSONAL FACTORS EXCEEDING ANY OCCUPATIONAL FACTORS FOR MEDIAN LATENCY VARIATION
JOHNSON WRIST RATIO
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DISTAL FOREARM, WRIST, HAND ? DID TRAUMA CAUSE AGRAVATION OF PRE-
EXISTING CTS / ASYMPTOMATIC (92 WITH COLLES’S FRACTURE;80 WOMEN)
1961 -1980 3/79 SAME DAY 56/79 DAY 2 AND 2 YEARS (59/79 = 74%) FOR BLUNT TRAUMA WITHOUT FRACTURE 8/1016 (.7%)
TRAUMA, WRIST FRACTURES AND FALLS
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FORMULA IS UNEFFECTED BY OCCUPATOIN UTILIZING GENDER, HANDEDNESS, LACK OF
MAJOR WRIST TRAUMA IE. FRACTURES THE “EXPECTED”LATENCY DIFFERENCE =
-4.463+5.644 X RIGHT WRIST RATIO+.O23 X BMI / .011 X AGE
PREDICTS THE EXPECTED PALMAR LATENCY DIFFERENCE BETWEEN THE MEDIAN AND ULNAR NERVE LATENCIES IN RIGHT – HAND – DOMINANT WOMAN
PREDICTED PALMAR LATENCY DIFFERENCE OF .2 MSEC OR LESS (N=24) LACKED ACTUAL MEDIAN NERVES SLOWNESS
PREDICTED MEDIAN PALMAR LATENCY DIFFERENCE >1 34/35 HAD PALMAR LATENCY DIFFERENCE .4MSEC
CTS EQUATION
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QUESTIONS
THANK –YOU HAVE A HAPPY THANKSGIVING