26 giai phong gan than kinh yd bs nhan

GIẢI PHÓNG GÂN - THẦN KINH BS NGUYỄN THÀNH NHÂN BỘ MÔN CTCH - PHCN ĐHYD TPHCM Carpal tunnel syndrome, described by Paget in 1854, is the most common upper extremity compression neuropathy and results from median nerve compression within the carpal tunnel The carpal tunnel is bound by The carpal bones arching dorsally; The hook of the hamate and the pisiform medially; And the scaphoid tubercle and trapezial ridge laterally The palmar aspect, or “roof,” of the carpal tunnel is formed by the flexor retinaculum, consisting of the deep forearm fascia proximally, the transverse carpal ligament over the wrist, and the aponeurosis between the thenar and hypothenar muscles distally The most palmar structure in the carpal tunnel is the median nerve Lying dorsal (deep) to the median nerve in the carpal tunnel are the nine long finger and thumb flexor tendons - Carpal tunnel syndrome is primarily a clinical diagnosis, with symptoms of tingling and numbness in the typical median nerve distribution (thumb, index, long, and radial side of ring) - Pain, described as deep, aching, or throbbing, occurs diffusely in the hand and may radiate up the forearm - Thenar muscle atrophy usually is seen in late-stage nerve compression - It occurs most often in patients 30 to 60 years old and is two to three times more common in women than in men - Carpal tunnel syndrome may affect 1% to 10% of the U.S population Older, overweight, and physically inactive individuals are more likely to develop CTS, and female sex, obesity, cigarette smoking, and vibrations associated with job tasks have been identified as carpal tunnel risk factors in industrial workers - Paresthesia in the median nerve sensory distribution is the most frequent symptom, often awakening patients with burning and numbness of the hand that is relieved by exercise - The Tinel sign also may be shown in most patients by percussing the median nerve at the wrist - Atrophy to some degree of the median-innervated thenar muscles has been reported in about half of patients treated by operation - Acute flexion of the wrist for 60 seconds (Phalen test) in some, but not all, patients or strenuous use of the hand increases the paresthesia - Application of a blood pressure cuff on the upper arm sufficient to produce venous distention may initiate the symptoms - …………… -Trigger thumb in adults is a distinctly separate entity from “congenital” trigger thumb (see Chapter 79) - Stenosing tenosynovitis, leading to inability to extend the flexed digit (“triggering”), usually is seen in individuals older than 45 years of age When associated with a collagen disease, several fingers may be involved (most often the long and ring fingers) - Patients may note a lump or knot in the palm The lump may be the thickened area in the first annular part of the flexor sheath or a nodule or fusiform swelling of the flexor tendon just distal to it - The nodule can be palpated by the examiner’s fingertip and moves with the tendon The tendon nodule usually is just proximal to the anulus at the metacarpophalangeal joint level; - however, in a rheumatoid patient, a nodule distal to this point may cause triggering - Occasionally, a partially lacerated flexor tendon at this level heals with a nodule sufficiently large to cause triggering Local tenderness may be present but is not a prominent complaint - Pressure accentuates the apparent snapping or triggering of the more distal joints Patients frequently state that the problem is in the proximal interphalangeal joint with trigger finger or in the interphalangeal joint with trigger thumb - Other conditions, such as intraarticular disorders (e.g., loose bodies, degenerative joint disease, and fractures) and common extensor tendon subluxation, can cause similar symptoms and must be considered to determine effective treatment for idiopathic trigger finger - Treatment of trigger digits usually is nonoperative, especially in uncomplicated conditions in patients with a short duration of symptoms - Nonoperative methods include stretching, night splinting, and combinations of heat and ice - Corticosteroid injection is effective, with 60% achieving success after one injection according to one study - Patients with diabetes mellitus may be more refractory to nonoperative management; however, corticosteroid injections may elevate serum glucose levels for days or more, and patients with unstable diabetes may be better treated without injection - Surgical release reliably relieves the problem for most patients: approximately 97% of patients have complete resolution after operative treatment - Persistence of triggering is more common than recurrence - Trigger release should be done with a local block so that the cessation of triggering of a particular finger can be evaluated - Some adjacent finger triggering may become obvious only after a given finger is released; both can be released at the same surgical -The safety and effectiveness of percutaneous trigger finger release using a needle or a push knife are documented - Incomplete pulley release and damage to the flexor tendons and digital nerves, especially in the index finger and thumb, remain of some concern with this technique ... to 58% - More than half of patients may have “aberrant” or duplicated tendons (usually the abductor pollicis longus) - These tendons sometimes insert more proximally and medially than usual, into... The response to injection treatment has been reported to be faster in men and in patients older than 40 years old Care should be taken not to inject directly into the nerve Injection also can... branch of the nerve that supplies most of the intrinsic muscles A space-occupying lesion, such as a ganglion or tumor, can cause compression in this area True or false aneurysm of the ulnar artery