-CTS-

BOY - CTS
1. Definisi:
- entrapment neuropathy of the median nerve in the carpal tunnel
2. Etiologi dan patofisiologi
Etiologi:
Idiopathic process
increased canal volume from thyroid disease, congestive heart failure (CHF), renal failure, mass (tumor,
hematoma) and pregnancy (usually occurs at 6 months and resolves postpartum)
Decreased canal volume from a fracture, arthritis, and Rheumatoid tenosynovitis
Double crush syndrome from DM and cervical radiculopathy and TOS

3. Anatomi tulang metacarpal, struktur yg lewat di dalamnya

**greater multang : trapezium, lesser multang: trapezoid

Radial side dibatasi sama schapoid, trapezoid. Ulnar : capitatum,
hamatum

4. Bagaimana mendiagnosis CTS

 Database (Age, Occupation)
 Chief complaint: nyeri di tangan/kesemutan/mati rasa
 History of present illness:
Symptoms usually begin gradually, and are often experienced at night. The thumb, index, and middle fingers are
most frequently affected. The most common symptoms of CTS include night pain or aching; numbness, tingling,
 and pain in the hand; pain in the forearm that may travel toward the shoulder; a feeling of electric shock in the
finger or hand.
Sensation is abnormal to the lateral 3–1/2 fingers of the hand except at the base of the thumb. Muscle weakness
can be noted in “LOAF” muscles (Lumbricals 1 and 2, Opponens pollicis, Abductor pollicis brevis, and Flexor pollicus
brevis)

 Mild CTS
–– The patient may complain of numbness, paresthesias, or dysesthesias radiating to the first, second, third, and lateral
fourth digits. Symptoms may be exacerbated during sleep and relieved with wrist shaking.
• Moderate CTS
–– The patient may complain of continuous sensory deficits in the median nerve distribution, involving the entire palm and
radiating proximally. The ability to handle fine objects is impaired.
• Severe CTS
–– The patient may complain of severe sensory loss and muscular atrophy of the thenar eminence.

 History of past Illness:

Thyroid disease, HT, congestive heart failure (CHF), renal failure, mass (tumor, hematoma), and pregnancy, fracture,
DM, Cervical pain (radiculopathy), TOS
 History of medicine
 Socioeconomic
Pemeriksaan Fisik
Physical Examination:
• General status
- consciousness, ambulation, hand domination
- VS (BP, HR, RR, term)
- BW, BH, BMI
**BMI untuk tau obese apa gak, kalo semakin obese, entrapment >>
• Musculoskeletal status
- ROM, MMT, MMT LOAF muscle
• Neurological status
- cranial nerve
- DTR
- pathological reflex
- sensory deficit
• Local status
Inspection: deformity, atrophy, inflammation sign (swelling, redness)
Palpation: warmth, tender point
• Hand function
Grip, grasp, pinch, lateral tip, spherical, cylindrical, Hook
**muscles yang berkerja ~ nerves:
Grasp: median ulnar
Pinch: median
Lateral tip: ulnar
Palmar tip : median
Spherical: median ulnar
 Cylindrical: terutama intrinsic muscle, terutama ulnaris
Hook: median dominant, ulnar jg tp dominan median
• Special test: to provoke median nerve
5. Pemeriksaan penunjang CTS
- Xray  mengecek ada bone problems, ada Riwayat trauma, arthritis just to rule out
- USG  melihat kondisi nerve *honey comb appearance di nerve nya* , melihat entrapment
- EMG  melihat kerusakan saraf sejauh mana, prognosis
6. Klo pada CTS, trus di emg, nampak apa.
- Fibrilasi polyfasic gelombang positif, berkurangnya motor unit pada otot2 thenar
- kecepatan hantar saraf bisa normal tapi bisa turun, distal latency memanjang  ada ggn konduksi saraf
- EMG : inserational activity (saat di masukin needlenya, ada reaksi apa? Fibrilasi, sm PSW curiga ke denervasi
otot). Aktivasi spontan (px suruh kontraksi minimal  kita lihat trifasik, polifasik. Normalnya trifasik.) terus px di
berikan tahanan (lihat interference current nya, untuk lihat motor unit nya bnyk yg kerja ato mati  nunjukin lesi
axonal. Kalo masih rapet2  kerusakan axonal gak tll berat, gk tll tinggi ato udah ada sprouting dll. Kalo udah
renggang2  mungkin udah denervasi).
NCS ini untuk lihat kabel. Otot nya yg di ‘pos’ mana, cek ke otot2nya masing2 lihat ototnya ini. Nilai distal latency,
amplitude dan kecepatan hantar saraf (NCV)
Ingat ada EMG ada NCV
NCV  SNAP CMAP distal latensi.. Bila SNAP distal latensi memanjang, yang lain normal  neuropraxia (mild CTS)
SNAP amplitude menurun, distal latensi memanjang  axonomesis (moderate CTS)
CMAP amplitude turun  axonotemesis / neurotemesis severe CTS
Kalau EMG  lihat fungsi otot

7. Emg fungsinya apa, jenisnya apa aja.

Pemeriksaan EMG + NCS. Jenisnya surface dan EMG
Fungsi : menentukan aktivitas fisik otot, menentukan letak lesi (needle), severitas, prognosis
Jenis : surface dan needle
Surface fungsinya mengetahui aktivitas fisik otot, menentukan kontraksi otot sesuai gerakannya, severitas
Needle fungsinya menentukan letak lesi, severitas, prognosis

8. Manajemen CTS termasuk sampai wrist splint nya (resting wrist spint)
Rehabilitation
• Indications: Mild symptoms (no weakness or atrophy, no denervation on EMG)
• Orthotics: Hand splint 0 to 30° neutral to extension
• Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) or a steroid injection, diuretics, vitamin B6.
• Ergonomic modifications
• Treat underlying medical disorders
Surgical indications
• Muscle atrophy, severe pain, and failure of conservative treatment, limited symptomatic relief and return of
muscle strength with severe median nerve damage and profound muscle atrophy. In some cases, CTS
symptoms continue even after surgery. They may require an additional surgery, which is called a revision
surgery.
(Cucurulo, 3rd edition, 2015)
Management of CTS:
Pain Relief
 Splinting (see above for more information)
  RICE to decrease pain & edema3
 Modalities such as ice, heat, ultrasound, or electrical stimulation to decrease pain and inflammation. 3 
Decreasing Swelling
 Active/passive ROM, RICE to decrease pain & edema, modalities such as ice, heat, ultrasound, or electrical
stimulation to decrease pain and inflammation.4
Increasing Strength
 Progressive resisted exercises within pain free ROM with wrist in neutral position. 1, 3

Improving ROM
 Nerve gliding exercises to restore mobility of the median nerve through the carpal tunnel. 3
Functional Activities
 Gripping exercises using a hand grip dynamometer, putty, or balls may be beneficial at restoring mobility and
strength in functional activities. The PT should tailor the rehab program specifically to the patient’s
occupational needs.1
 Pinching activities are also practiced with keys or picking up small pegs to improve finger dexterity. 3
 Eccentric wrist strengthening exercises by adding occupation specific tasks such as lifting or carrying objects up
to 40lbs. is commonly added to the rehab program to progress the patient and set them up for success. 3
 Patient Education regarding ergonomics is imperative especially since majority of CTS patients develop the
nerve entrapment due to overuse, repetitive activities such as typing or manipulating small tools such as
dental work.5
Home Exercise/Modality Use1
 Providers should offer instruction in a HEP of therapeutic exercises to improve flexibility, mobility, strength,
and proper work techniques.
 To improve flexibility & mobility- Stretches:
 Stretch flexors and extensors to improve ROM and prevent recurrence of nerve compression: hold
stretch for 15-30 seconds, 2 sets, 3x/day everyday
 To stretch the flexors: Straighten your arm and pull your hand back with your other hand so your
fingers are pointing up & hold.
 To stretch the extensors: same as above with hand pointing downward.
 To improve strength- Progressive resisted isometrics within pain free ROM with wrist in neutral position.
*Ortosis:
- cock up splint
- resting wrist splint

9. Edukasi ke pasien CTS, termasuk ke pasien yg mau ga mau kerja dengan gerakan wrist
- hindari repetitive movement
- pake splint
- proper positioning + handling
- icing bila nyeri (?)
10. Pemeriksaan hand function pada CTS, dan fungsi apa yg terganggu.
Medianus fungsinya precision  pinch, palmar tip, sylindrica
- Palmar tip
- pinch
11. Jempol tangan fungsinya apa?
Precision, power
Bila fungsi jempol hilang maka 40% hand function terganggu
 - precision, memegang
‘Oposisi’
12. Modalitas pada CTS dan exercise nya
Intensity 1MHz (celc) 3MHz (celc) - LASER : pain + inflammation reduction at joint, pada tenderpoint nya
(W/cm2) *dosis: Trigger point: 1-3 J/cm2. Edema : 0,1-0,5 J/cm2. Wound healing superficial: 0,5-1 J/cm2 (acute), 4 J/cm2 (chronic).
0,5 0,04 0,3 Wound healing deep: 0,05 – 0,1 J/cm2 (acute), 0,5-1 J/cm2 (chronic)
1,0 0,2 0,6 - USD : untuk mengurangi pain. pada flex. retinaculum
1,5 0,3 0,9 *dosis: Peningkatan 1 derajat: healing, 2 derajat: pain + spasm, 4 derajat:
2,0 0,4 1,4
meningkatkan extensibilitas jaringan
- Tendon and nerve gliding exercise

Nerve gliding exc

Tendon gliding:
1.Straight, 2.full fist, 3.straight fist, 4.table
top, 5.hook

13. DDx CTS

- other entrapment of median nerve.
• Origin
–– Nerve fibers from the C5–T1 nerve roots contribute to the upper, middle, and lower trunks → medial and lateral cords →
median nerve.
Arm
• The nerve runs medial to the axillary artery. It continues down the humerus and runs under the ligament of Struthers
(LOS) at the medial epicondyle of the humerus.
Forearm
• Innervations and cutaneous branches:
 Pronator teres (PT)
 FCR
 Palmaris longus
 Flexor digitorum superficialis (FDS)
 Palmar cutaneous branch
 The AIN branches from the median nerve to innervate (four Ps):
 Flexor pollicis longus (FPL)
 Flexor digitorum profundus (FDP 1 and 2)
 Pronator quadratus (PQ)
Hand
• Through the carpal tunnel, the median nerve innervates
the “LOAF” muscles:
–– Lumbricals (1, 2)
–– Opponens pollicis
–– Abductor pollicis brevis
–– Flexor pollicis brevis (superficial)
–– (Digital cutaneous branches)
DD:
1. Injury in LOS (Ligament of Struthers)
- Weakness grip strength (FDS, FDP)
- Weakness wrist flexion (FCR)
- Weaknes FDP
- Dull, ache sensation
- Brachial pulse menurun
- LOAF gak masalah
2. Bicipital Aponeurosis
- Thickening antebrachial fascia (attaching
the bicep to the ulna)  gejala mirip LOS
3. Pronator teres syndrome
- N. medianus melewati 2 head dari pronator
teres
- Dull acneh of the proximal fore arm
- Exacerbated by forcefull pronation (PT) / Finger flexion (FDP)
- Muscle become easily fatigue
- All median inntervated muscle kena, kecuali PT
4. AIN Syndrome
- Injury to MOTOR nerve branch, jadi PURE MOTOR
- OK sign
- 4 Ps! FPL, FDP 1-2, PQ
- Sensory masih bagus

14. Aktivitas apa yang harus di modifikasi utk kasus CTS pada ibu rumah tangga
- NGULEK!
- meres baju  di injak2 ato gmn lah
- Handle sutil, cara motong

15. Otot thenar apa aja

- Opponens pollicis
 - Abductor Pollicis brevis - longus
- Adductor Pollicis
- Flexor pollicis brevis dan longus

16. Kenapa pada CTS, di posisikan 20-30 derajat fleksi

- *EKSTENSI
- neutral position  ekstensor dan flexor paling seimbang di sudut
- tunnel paling besar di sudut itu

17. Edukasi pemakaian resting wrist splint

- dipake saat tidur dan saat aktifitas
Sebagai reminder

18. Precaution modalitas laser pada pasien CTS

Jangan kena mata,
- kontraindikasi: tumor, kehamilan
- pake kacamata pelindung….

VNA: Penguji dr HLP, dr MY, dr YU -- CTS

Definisi?
Struktur apa saja dlm carpal tunnel?
Gejala? Etiology?

Body structure, impairment?

Fungsi hand apa saja yg terganggu?
Jelaskan n. Medianus berasal dr mana?
Dimana saja bisa terjadi entrapment dr n.
Medianus?
DD CTS?
Bedakan dengan CRS?
- Dari Identitas  pekerjaannya
- Ax: keluhan CRS menjalar dari leher ke tangan. Risk factor. Gerakan repetitive di hand kalo CTS.
- Pem.Fisik: deficit sensoris CRS sesuai dermatome. MMT di CRS bisa ad kelemahan, sesuai dgn myotome tgntg root
nya. Kalo CTS deficit nya perifer, di wrist aja.. Ada atropi thenar.
- Tinnel sign, phallen, prayer di CTS. Kalo CRS ya spurling, compression, distraction

**dari RI mbak NIN

• When distal paraesthesiae are the result of a cervical disc lesion: The most common causes of nerve root compression
are spondylosis of the facet joint and herniation of the intervertebral disc.
 The symptoms usually come and go in an erratic fashion during the day as well as at night.
 They are transient and not particularly activity related.
 The distribution within the fingers is related to a dermatome, but the patient cannot localize the paraesthesia
exactly.
 They are preceded and accompanied by severe root pain and often followed by segmental motor and/ or
sensory deficit.
 On examination of the cervical spine, a partial articular pattern is found.
  The symptoms disappear spontaneously in the course of a few weeks to a few months

DD lain yg manifes dihand?

- Canal Guyon
- OA manus-wrist
Canal guyon dmn? Batas2nya apa saja?

https://www.youtube.com/watch?v=3yfj9ecNGC8

Klasifikasi kerusakan saraf? Jelaskan masing2? Prognosis

masing2?
- Prognosis kalo neuropraxia masih bagus

Apakah menegakkan diagnosa cukup dr klinis?

- sebenernya bisa dari klinis, cm untuk melihat
prognosis dll mgkn butuh penunjang.
Pemeriksaan penunjang?
Kenapa di emg ncv?
Neuroplasticity? sprouting? **di soal stroke paling terakhirrr

Otot apa dl yg atrophy?  thenar

Bagaimana edukasi ke pasien?
Edukasi ke pasien tua dan muda sama atau beda? Gimana?
- Muda lebih aktif, jadi mgkn untuk gerakan repetitive modifikasi dll bisa
- Kalo tua biasa e dibilangi ngeyel... HAHAHA
- Muda kemampuan untuk recovery lebih bagus.
Rehabilitasi pada yg mild dan severe beda/sama? Bedanya apa?
 Beda
Perbedaan rehabilitasi persiapan pre op, yang lain kurang lebih sama
Kalau severe  operasi (mau di rehab juga sulit)
- Kalo severe kan udah ada atropi tenar, mungkin sudah ada kelemahan… bisa di stimulasi dengan ES kalo
MMT <2
- Kalo ada hand function disturbance (moderate ke atas) ya bisa di lakukan Latihan hand function di OT
- Kalo Mild, mostly bisa di hindari gerakan repetitive, resensitisasi sensori
Penggunaan orthosis?
Fungsi diberikan orthosis?
Beda ga dikasi saat baru datang dg yg sdh kronis? Bedanya apa? Prognosisnya gimana bedanya?
Beda.
Fungsi orthosis  positioning, mengurangi nyeri
Fase akut : neuropraxia aja diharapkan dengan positioning diharapkan penyembuhan lebih cepat
Fase kronis : mencegah perburukan lebih lanjut
Prognosis : akut lebih baik, kronis jelek terutama bila sudah ada atrofi
- Beda, kalo baru dateng, dan fasenya masih mild kan lebih bagus..
- Kalo kronis, udah entrapment luama, kan kondisi nerve nya jg kurang bagus.. jadi ya mau di kasi orthosis
paling cm buat reminder.
Bagaimana menentukan goal pasien CTS?
Menyesuaikan dgn kondisi px. Usia, pekerjaan, aktifitas sehari2 jelas berpengaruh. Bagaimana dia nanti mau
Kembali bekerja, modifikasi dll.
Komorbiditas pasien CTS?
- DM - Renal failure
- Obese - Arthritis2an
- Repetitive movement - Trauma
- Kehamilan - Infeksi
- CHF - Herediter *nek gak kepekso jok ngmg
- Thyroid disease  hypothyroid iki jare mbak wul

CTS - RIF
1. Definisi
2. Anatomi carpal tunnel
3. Ax px : CC, data dan karakteristik px(faktor risiko
Cts),RPD,Riw.sosek
4. Pemx fisik
- Bmi (faktor predisposisi : obesitas)
- st.musculosk : LOAF muscle,cara nguji MMT
- N.Medianus mensarafi ap,pada level wrist kena otot ap
5. Cts dd CRS Level brp?C6-C7
6. Cara membedakannya gmn?bentuk nyeri dan otot yg terlibat
Nyeri CRS menjalar dari leher ke sesuai dermatome,
seandainya C6-7 ya wes.. mengikuti..
Kalo CTS dia dari carpal tunnel ke arah distal 3 ½.
Otot yang terlibat C6-7 ya bicep, wrist extensor, triceps,
wrist flexor, finger extensors..
Kalo CTS ya otot2 LOAF.