Wim WillemsCraiova, September 2011

Presenting a medical topic to colleagues

Program

• Who is everybody?

• What makes a medical presentation good / what makes it bad?

• A medical program: carpal tunnel syndrome

• Rules & take home messages

What makes a training good / bad?

• Tell your colleagues about a training / seminar that was really bad and didn’t teach you anything. Why was it bad?

• Tell your colleagues about a training / seminar that was really good and educational. Why was it good?

Rule 1 – avoid boredom

Rules to avoid boredom

• Keep it small

• Start with the needs of the group

• Use the knowledge that the group has already

• Be interactive (little groups, avoid monologue)

• Change methods (presentation, quiz, case history, discussion regarding statements, skills)

Rules to avoid boredom

• Keep it small

• Start with the needs of the group

• Use the knowledge that the group has already

• Be interactive (little groups, avoid monologue)

• Change methods (presentation, quiz, case history, discussion of statements, skills)

Keep it small

Carpal tunnel syndrome

Start with the needs of the group

• What do you want to know?

What do Dutch GP’s want to know?

• Is it necessary to perform an EMG to establish the diagnosis CTS ?

• Is it necessary to have positive tests like Tinel, Phalen etcetera ?

• Are injections with corticosteroids helpful ?• Can I give an injection with corticosteroids myself ?

What dosage should I give? How can I do this safely ? How often can I do this ?

Quiz 1

• Mrs A, 53 years old, complains of nightly tingling in her right hand which wakes her up. When you examine her you find nothing abnormal. The tests of Tinel and Phalen are negative.

Mrs A has no carpal tunnel syndrome

Correct / Incorrect

Quiz 2

• Mrs A, 53 years old, complains of nightly tingling in her right hand which wakes her up. You refer her for an EMG: this is negative (no nerve conduction abnormality).

Mrs A has no carpal tunnel syndrome

Correct / Incorrect

Quiz 3

Where is the carpal tunnel ?

“Painful nightly tingling”

• Female, 52 years• Wakes up in the early morning with painful tingling

in the hand (thumb / index) • Flapping of hand eases complaints

Carpal tunnel syndrome

• Female, 52 years• Wakes up in the early morning with painful tingling in the hand (thumb / index) • Flapping of hand eases complaints

What do you do in Romania?

Carpal tunnel syndrome

Epidemiology

Open population (history + nerve conduction examination):

– Female: 9 %– Male: 0,6%– Peak between 40-60 year

Risk factors

WeightPregnancyDiabetes mellitusHypo/hyperthyreoidyOvariectomyAnatomic deviation (traumatic / RA / congenital) Work related

Natural course

• ¼ - 1/3 significant improvement > 1 year

• After pregnancy 50% without complaints

Pathofysiology

• Narrow tunnel

• compression n. medianus in carpal tunnel

• 90% idiopatic

Diagnosis = history !

Dutch consensus (CBO 2006) / guideline NHG 2009:

• Nightly tingling• Median nerve area• Sleep disturbance• Other tingling / pains • Flapping (Flick sign)• Advanced stages: tingling during the day

Sensory innervation N. Medianus

Atypical localisations tingling sensations

• Often outside median nerve area

• Sometimes ulnar nerve area

Provocation tests:

CBO 2006 / NHG 2009:

Limited usefulness

Diagnostic tests CTS

test sensitivity specificity

Tinel 0.25-0.60 0.64-0.89

Phalen 0.10-0.91 0.33-0.86

Flick sign 0.93 0.96

Square wrist sign 0.47-0.69 0.73-0.83

Pressure provocation test

0.28-0.63 0.33-0.74

Tourniquet test 0.21-0.51 0.36-0.87

Tests

• Tinel: percussion median nerve

• Phalen: flexion during 60 seconds

• Further: -sensory loss median nerve area

-thenar dystrophy -dry skin (thumb / index /

middle finger)

sensitivity specificity

EMG 60-82 95-100%

Neurophysiological examination

• Verification of clinical diagnosis prior to operation

Limitation EMG:

• No golden standard

• 10-15% false negative • No relation between complaints and

results

• Results not predictive for therapy

• Value unclear for primary health care

Treatment

Splint

• Day and night

• Short term effective

• Minor complaints / recent onset

Surgery:

• Highly effective

• Major / recurrent complaints. Patient’s wish

• Open / endoscopic

• Success: 75-90%

• Complications: damage to nerve, pain, scar, complex regional pain syndrome)

Corticosteroid injection

• Short term effectiveness +

• 50% without complaints after one year

• Diagnostic use?

Referral

• Insufficient reaction to symptomatic treatment

(2 injectons)

• Common sense

• Diagnostic uncertainty

• Severe complaints

Corticosteroid injection

• Several techniques• Safe• Effective• Tradition / experience / authority determines

technique

Medicament / Dosage

• Most common: Triamcinolonacetonide 10 mg/ml (Kenacort® A10), or methylprednisolonacetaae (Depo-Medrol®) 40 mg/ml

• Volume: 1-2ml

• Interval between injections: 1-3 weeks

• Effectiveness: 1st injection 80%, after 2 injections 15%, after 3 injections 5%

Needle?

--orange/ light brown (0,45x23mm)

-light blue (0,5x25mm)

-green (0,8x40mm)

Localisation carpal tunnelOs pisiforme

Os scaphoideum

m. Palmaris longus

Tendon m. Palmaris longus

• Absent tendon: ulnar to median axis

Localisation insertion

• ulnar to tendon m. palmaris longus

3-4 cm before distal wrist line

3

Injection underneath retinaculum

• Angle 30 degrees

Hygiene

• Wash hands, wear gloves or disinfect fingers

• Once-only ampoules

• Change needles

• Disinfect skin

Side effects and complications

• Side effects-flushing: 1 day after injection-steroid-flare 24-48 hours-menstruation problems-hyperglycemia-locale effects: redness, atrophy fatty tissue, hypopigmentation

• Complications-very rare, case-reports-tendon ruptures, median neuritis (CTS), local infection

Take home messages

• Organize and prepare your own training for yourself and for your colleagues

• Keep it small

• Try to answer only questions that have immediate consequences for your everyday practice

• Do it yourself – specialists can tell you only what is important to them

Take home messages

• Organize and prepare your own training for yourself and for your colleagues

• Keep it small

• Try to answer only questions that have immediate consequences for your everyday practice

• Do it yourself – specialists can tell you only what is important to them

Take home messages

• Organize and prepare your own training for yourself and for your colleagues

• Keep it small

• Try to answer only questions that have immediate consequences for your everyday practice

• Do it yourself – specialists can tell you only what is important to them

Take home messages

• Organize and prepare your own training for yourself and for your colleagues

• Keep it small

• Try to answer only questions that have immediate consequences for your everyday practice

• Do it yourself – specialists can tell you only what is important to them

Take home messages

• Organize and prepare your own training for yourself and for your colleagues

• Keep it small

• Try to answer only questions that have immediate consequences for your everyday practice

• Do it yourself – specialists can tell you only what is important to them

Material

• www.hovumc.nl/gp

• www.nice.org.uk

• www.cks.nhs.uk/home

Did you see this? Did it work?

• Keep it small

• Start with the needs of the group

• Use the knowledge that the group has already

• Be interactive (little groups, avoid monologue)

• Change methods (presentation, quiz, case history, discussion regarding statements, skills)

Va Mulţumesc, la revedere