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

1. MEDICAL FACULTY
MUSLIM UNIVERSITY OF INDONESIA
2016

2. 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

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

4. 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

5. 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

6. What are the risk
factor that cause
the disease?

7. The incidence of carpal tunnel syndrome is 1-3 cases per 1000
subjects per year; prevalence is approximately 50 cases per 1000
subjects in the general population
The gender distribution of CTS was two-thirds to one-third female
to male. According to one study, it was found the male to female
ratio to be 1:1.4
The risk of CTS increased 8% for each unit of increase in BMI (about
6 lbs.)

8. It was noted 50% of CTS cases in pregnant women occurred in the third
trimester, but will usually resolve after pregnancy
In addition, increased sleeping in the lateral position which puts the wrist at
increased risk of flexion or extension, compressing the median nerve in the
carpal tunnel
Huldani. Carpal Tunnel Syndrome. 2013. Banjarmasin: Fakultas Kedokteran Universitas Lampung Mangkurat. Pg.8-10.

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

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

11. Why the pain occur
especially at night?

12. 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.

13. Why when the hand
on wiggle the pain
lessen?

14. "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.

15. What is the type of
pain experienced on
the scenario?

16. NOCICEPTIKVS NEUROPATHIC
Nociceptive pain is pain that is caused by the presence of stimuli
noksius (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

17. 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 pain
Pain 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

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

19. 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?

20. 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?

21. 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

22. Phalen's test Tinel's sign

23. • 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

24. What are the additional
examination needed?

25. Nerve Conduction Studies (NCS)/
electromyography
 To measure nerve conduction
velocity
 Measuring the impulse travel
time from the forearm to the
wrist
 NCS slowed when nerve is
compressed

26. Carpal tunnel view (A) and CT scan (B) shows that calcifying mass is located just above
the capitate.
Radiologic Imaging Methods
CTSCAN
Browning, Patrick D. Carpal Tunnel Syndrome Imaging. Oct.09, 2015.

27. (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.

28. 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

29. What is the differential
diagnose of the scenario?

30. ETIOLOGY
CTS
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.

31. CTS PTS TRIGGER FINGER

32. SYMPTOMS
CTS
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

33. TREATMENT
CTS
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

34. What is the management
of disease based from the
scenario?

35. A. Non farmacology
1. Resting the affected hand and wrist for at least 2
weeks.
2. Immobilizing the wrist in a splint
3. If there is inflammation, applying cool packs can help
reduce 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.

36. Surgical treatment
Surgery 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

37. 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.

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

39. 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.

40. Good Posture
The 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.

41. Reducing Force from HandTools
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.

42. 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

43. Hand and Wrist Exercises for the Prevention of Carpal
Tunnel Syndrome

46. What are the prognosis
and complication?

47. 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 more
proximal.
• There has been a total breakdown in the median nerve.
• The new CTS occurred as a result of complications due to the surgery such as
edema, adhesions, infection, hematoma or hypertrophic scarring.
If after surgery, there was also obtained
improvements then reconsidered the following
possibilities:
PROGNOSIS

48. 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

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

50. `Abdullah bin Mas'ud radi anhu narrated from the Prophet
sallallaahu 'alaihi wa sallam, he said:
‫المتنطعون‬ ‫هلك‬
"Woe to those who exaggerated!" He said it three times. "

51. ِ‫ن‬َ‫ع‬َ‫ل‬‫ا‬َ‫ق‬ ‫سلم‬ ‫و‬ ‫عليه‬ ‫هللا‬ ‫صلى‬ ِ‫هللا‬ َ‫ل‬ْ‫و‬ ُ‫س‬َ‫ر‬ َّ‫ن‬َ‫أ‬ ،‫ب‬ِ‫از‬َ‫ع‬ ِ‫بن‬ ‫اء‬َّ‫ر‬َ‫ب‬‫ال‬:((َ‫ت‬َ‫أ‬ ‫َا‬‫ذ‬ِ‫إ‬ْ‫أ‬َ‫ض‬َ‫و‬َ‫ت‬َ‫ف‬ ‫ك‬َ‫ع‬َ‫ج‬ْ‫ض‬َ‫م‬ َ‫ت‬ْ‫ي‬
ْ‫ُل‬‫ق‬ َّ‫م‬ُ‫ث‬ ،ِ‫ن‬َ‫م‬ْ‫ي‬َ‫أل‬‫ا‬ َ‫ك‬ِ‫ق‬ِ‫ش‬ ‫على‬ ْ‫ع‬ِ‫ج‬َّ‫ط‬ْ‫ض‬‫ا‬ َّ‫م‬ُ‫ث‬ ،ِ‫ة‬‫ال‬َ‫ص‬‫لل‬ َ‫ك‬َ‫ء‬‫و‬ُ‫ض‬ُ‫و‬:َّ‫م‬ُ‫ه‬‫الل‬،َ‫ك‬ْ‫ي‬َ‫ل‬ِ‫إ‬ ‫ي‬ِ‫س‬ْ‫ف‬َ‫ن‬ ‫ت‬ْ‫م‬َ‫ل‬ ْ‫س‬َ‫ا‬ ‫ي‬ِ‫ن‬ِ‫إ‬
َ‫ل‬ِ‫إ‬ ‫ي‬ِ‫ر‬ْ‫ه‬َ‫ظ‬ ُ‫ت‬ْ‫أ‬َ‫ج‬ْ‫ل‬َ‫أ‬ َ‫و‬ َ‫ك‬ْ‫ي‬َ‫ل‬ِ‫إ‬ ‫ي‬ِ‫ر‬ْ‫م‬َ‫أ‬ ُ‫ت‬ْ‫ض‬َ‫و‬َ‫ف‬ َ‫و‬ ،َ‫ك‬ْ‫ي‬َ‫ل‬ِ‫إ‬ ‫ي‬ِ‫ه‬ْ‫ج‬َ‫و‬ ُ‫ت‬ْ‫ه‬َ‫ج‬َ‫و‬َ‫و‬َ‫ج‬ْ‫ل‬َ‫م‬ َ‫ال‬ َ‫ك‬ْ‫ي‬َ‫ل‬ِ‫إ‬ ً‫ة‬َ‫ب‬ْ‫ه‬َ‫ر‬ ‫و‬ ً‫ة‬َ‫ب‬ْ‫غ‬َ‫ر‬ َ‫ك‬ْ‫ي‬َ‫ال‬ َ‫و‬ َ‫أ‬
َ‫ك‬ِ‫ي‬ِ‫ب‬َ‫ن‬ِ‫ب‬ َ‫و‬ َ‫ت‬ْ‫ل‬َ‫ز‬ْ‫ن‬َ‫أ‬ ‫ي‬ِ‫ذ‬َّ‫ل‬‫ا‬ َ‫ك‬ٍ‫ب‬‫ا‬َ‫ت‬ِ‫ك‬ِ‫ب‬ ُ‫ت‬ْ‫ن‬َ‫م‬َ‫أ‬ ، َََ‫ك‬ْ‫ي‬َ‫ل‬ِ‫إ‬ ‫ال‬َ‫إ‬ ‫منك‬ ‫ا‬َ‫ج‬ْ‫ن‬َ‫م‬ِ‫م‬َ‫ال‬َ‫ك‬ َ‫ر‬ِ‫خ‬‫آ‬ َّ‫ن‬ُ‫ه‬ْ‫ل‬َ‫ع‬ْ‫اج‬ َ‫و‬ َ‫ت‬ْ‫ل‬ َ‫س‬ْ‫ر‬َ‫أ‬ ‫الذ‬ْ‫ن‬ِ‫إ‬َ‫ف‬ َ‫ك‬
‫ة‬َ‫ر‬ْ‫ط‬ِ‫ف‬‫ال‬ ‫على‬ َّ‫ت‬ِ‫م‬ َ‫ك‬ِ‫ت‬َ‫ل‬ْ‫ي‬َ‫ل‬ ْ‫ن‬ِ‫م‬ َّ‫ت‬ِ‫م‬)
"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: "OAllah! I surrender my
soul just toThee, I confronted my face toThee : 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 "

52. CONCLUSION

53. CONT..

54. See you in the next panel