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Old 04-23-2012
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Rheumatology/Orthopedics Carpal Tunnel Syndrome; Next Best Step

A 48-year-old operating room (OR) nurse comes complaining of hand weakness. She has to tightly hold things in the OR for a long period of time, and at least 3 to 4 times in the last couple of months, she has dropped different things on the floor. In the morning, she noticed tingling in the first 3 fingers of both her hands, which sometimes goes away after shaking them. This tingling comes on also when she drives. She has full strength in all her muscle groups, except mild weakness extending her thumb bilaterally. There is no thenar eminence atrophy. Tinel sign and Phalen are positive at the wrist bilaterally. Her thyroid stimulating hormone TSH is 1.2. What is the next step in management?

A. Electromyography
B. Magnetic resonance imaging (MRI) of the cervical spine
C. MRI of the brachial plexus
D. Physical therapy
E. Surgical decompression



personally, i can see this q in exam...
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Old 04-23-2012
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E. Surgical decompression
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A. Electromyography
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E. Surgical decompression
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Old 04-23-2012
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Isnt the first step in management of Carpal Tunnel a splint? So shudnt the answer be physical therapy??
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Old 04-23-2012
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Quote:
Originally Posted by iceman_purav View Post
Isnt the first step in management of Carpal Tunnel a splint? So shudnt the answer be physical therapy??
I too think the same
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Old 04-23-2012
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-ANS A.,the electromyography +physicalfinding=diadnostic creterion for cts,also it assess the severity(so detremin surgry vs physical),also it roule out neurological condition.
.btw(acromegaly&hypothyrodism are the most comon cause of bilater cts).
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Old 04-24-2012
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isnt EMG done for surgical candidates..
ans is EMG in qbank.
i doubt it
checked kaplan surgery they say do splint.
in real exam i would splint this patient.
comments?
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Old 04-24-2012
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Quote:
Originally Posted by tyagee View Post
isnt EMG done for surgical candidates..
ans is EMG in qbank.
i doubt it
checked kaplan surgery they say do splint.
in real exam i would splint this patient.
comments?
Yes i agree with u..whenever any condition causing functional or occupational impairment ..we have to treat that condition immediately if diagnosis is clear.
May be next step we can go for EMG but diagnosis is clear so i think surgery over EMG is suitable..
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Old 04-25-2012
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Question asks "What is the next step in management?"


"She has full strength in all her muscle groups, except mild weakness extending her thumb bilaterally. There is no thenar eminence atrophy".

Is it possible that the pathology lies higher up since the long thumb extensors are not innervated by Median nerve but by Radial nerve? hence the need to confirm the diagnosis first by EMG.


Quote:
Electrodiagnostic testing (electromyography and nerve conduction velocity) can objectively verify the median nerve dysfunction. If these tests are normal, carpal tunnel syndrome is either absent or very, very mild.
Other conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if history and physical examination suggest CTS, patients will sometimes be tested electrodiagnostically with nerve conduction studies and electromyography.

In studies of diagnostic accuracy, the sensitivity of the Phalen's maneuver ranged from 51% to 91% and its specificity from 33% to 88%. Using the low end of the figures, this means it produces a positive result in over half people with carpal tunnel syndrome, but 2/3 of individuals without carpal tunnel syndrome will have a positive test also. Clearly if the lower end of the figures are both correct, the test is useless! But that seems unlikely as the test would have been abandoned long ago if more healthy people got a positive test than people with the disease.
Phalen's maneuver is more sensitive than Tinel's sign
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