Transcript Document

Carpal Tunnel Syndrome
A New Care Pathway
Format
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Introduction
(5mins)
Current Rheumatology issues (15mins)
Current Orthopaedic Issues (10mins)
Introduction to pathway
(5mins)
Pairs to consider pathway (10mins)
Questions/ comments to panel (10mins)
SL
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ND
SL
ALL
ALL
Burden of disease
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Incidence of one new case per 1,000
population per year suggests:
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140 new cases per year in PCT
2 new cases per GP per year
Prevalence of 3% suggests:
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4,000 cases in PCT
60 cases per GP
Health care activity data
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85 episodes of carpal tunnel decompression in
2003
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75% (64) SACH
11% (9) QE2
5% (4) HHGH
2% (2) Stoke Mandeville
Rheumatology aspects
CARPAL TUNNEL SYNDROME.
West Herts Hospitals Trust. SACH 2005. Adam Young
1. Background.
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Common
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Prevalence ~3%
Incidence ~ 52/100,000 person yrs for men
149/100,000 person yrs for women
Painful and or unpleasant condition. Acute>chronic.
Loss of function e.g. work disability
Diagnosis made clinically in majority
Conservative treatment effective in majority
CTS
2. Problems
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Diagnostic difficulties – figures for this in primary
care not known
Under and or inappropriate treatment in 1ry/2ry
care
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e.g. results of West Herts primary care audit project
showed that ~50% patients with diagnosis of CTS were
offered NO treatment while waiting for 2ry care opinion
Waiting lists for diagnosis and treatment in
secondary care.
CTS
3. Guidelines
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Guidelines for diagnosis & management of
CTS
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1995 Rheumatology guidance/advice enclosed
CTS
4. One stop Clinical assessment/NCS/EMG clinic
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Developed at SACH from 1995 in Dept
Rheumatology
All GP letters triaged by AY
Standard clinic assessment +/- NCS/EMG
Management initiated & further advice given to GP
1 Clinic/week at SACH & 0.5 clinic/wk at HHGH
EMG database generated tables which reflect
current service figures are enclosed:
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Reasons for referral by year i.e. 2000 to 2004 (n & %)
Reasons for referral by source of referral (n & %) relevant
to CTS
One stop Clinical assessment/NCS/EMG clinic
SACH EMG database tables
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These show Rheumatology Dept performs
350-420 studies/year
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75-82% are CTS referrals, of which
8% from Hand Surgeons
22% from orthopaedics
67% from one stop NCS/EMG clinic
Orthopaedic aspects
CTS Care Pathway
CARPAL TUNNEL SYNDROME (CTS)
GUIDELINES
BACKGROUND
 Incidence: - Common - about 1 new case per 1,000
people/ year
 Prevalence: About 3% of population
 Gender ratio:Up to 4 times more common in women
 Age: women – peak 45-54, men - increase with age
 Aetiology/ risk factors – idiopathic (most),
pregnancy, contraceptive pill, hypothyroidism, wrist
fracture, rheumatoid arthritis, heart failure,
occupational, peripheral neuropathies
 Pathogenesis: neuropathy of median nerve due to
compression as it passes under the deep transverse
ligament of the wrist
SYMPTOMS
 Dull aching discomfort in the hand, forearm or
upper arm
 Tingling, numbness, burning or pain in at least two
of: thumb, index and middle fingers
 Patient may flick or shake wrist to bring about
relief
 Pain common at night (with sleep), provocative
factors include sustained arm or hand positions and
after repetitive actions of the hand or wrist
 May cause “clumsiness”
 Dry skin, swelling or colour changes in the hand
CLINICAL SIGNS
INVESTIGATIONS
 Physical examination may be normal
 Symptoms elicited by tapping or direct pressure over the median
nerve at the wrist (Tinel’s sign) or forced flexion or extension at
the wrist for 1-2 minutes (Phalen’s sign)
 Sensory loss in median nerve distribution
 Weakness or atrophy in the thenar muscles
 Dry skin on the thumb, index or middle fingers
MANAGEMENT
MILD SYMPTOMS, NO CLINICAL SIGNS
Consider each of the following. Prognosis good –
most improve, if not see next 
 Simple analgesia initially
 Wrist splints – day and night, refer Physio
SACH for wrist splints
 Occupational therapy if occupationally related
– West Herts OT dept
 Weight reduction – link to dietetics services
 NSAIDs if simple analgesia not effective
Consider the following, only if clinically
indicated (not routine)
 TFTs
 U+E’s
 Glucose
 B12, Folate
 Rheumatoid factor
MODERATE SYMPTOMS AND SENSORY SIGNS
 As box left and:
 Cortisone injection (once only) - details and
hypertext link (training)
 If no response or poor prognosis (e.g. if
symptoms for more than one year), see
below
SEVERE SYMPTOMS/ INADEQUATE IMPROVEMENT/ ATYPICAL PRESENTATION/ UNCERTAIN
DIAGNOSIS
If poor response or:
 Wasting or weakness of thenar muscle
 If dual pathology suspected at cervical spine level and wrist (double crush syndrome)
 If surgical exploration and/or decompression is considered
 REFER TO ONE STOP RHEUMATOLOGY/ NERVE CONDUCTION STUDY CLINIC (SACH)
details and hypertext link referral form
 PATIENT WILL BE SENT DIRECTLY TO DAY CASE DECOMPRESSION SURGERY IF
INDICATED
CARE PATHWAY FOR PATIENTS WITH CARPAL TUNNEL SYNDROME (CTS)
1
PATIENT PRESENTS TO GP
Patient presents to GP with symptoms suggestive of CTS (see guideline)
GP management (see guideline)
 Clinical assessment
 Investigations if clinically indicated
 Simple Analgesia/ NSAIDs
 Wrist splints (direct referral to collect splint required, without physio)
 Injection, once only [by skilled practitioner in surgery or neighbouring surgery (minor
surgery enhanced service]
Referral by GP using template or letter with information
required, copy to patient
Current wait of 6-8 weeks
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PATIENT SEEN IN ONE-STOP-SHOP RHEUMATOLOGY NCS CLINIC
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Clinical assessment by Consultant, clinical assistant or SpR
Nerve conduction studies (for all patients suspected as having CTS) – 15-30 minutes (Patients with
normal NCS would not be referred through this pathway for surgery)
 Assessment of need for surgery or other treatments
 Rheumatologist’s assessment of suitability for local anaesthetic day case surgery without prior
orthopaedic OP appt (see surgery guidelines, pre-op assessment questionnaire, examination (e.g.
BMI, BP))
 Explanation about surgery and information leaflet +/- video given to patient (including what to
expect on day of surgery, pain swelling etc after surgery, driving, work, suture removal)
 Referral/ booking for surgery (Routine and urgent in cases of muscle wasting etc)
 Letter to GP with copy to patient
NOTE:
Patients can
pull out of
the pathway
at any stage
Current wait of 6-16 weeks, less if urgent
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PATIENT ATTENDS FOR DAY-CASE SURGERY
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Meet consultant
Further explanation, questions answered
Consent obtained
Surgery site marked
Operation carried out
Dressing
Instruction to patient and carer
Analgesia given
Sickness certification for work
Further patient information leaflet given
Telephone number for help/ advice
Letter to GP, copied to patient
Follow-up appointment booked
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PATIENT ATTENDS FOR POST OP
REVIEW (Consultant/ GP)
(6-10 days)
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See consultant/ GP
Dressing taken down
Operation site inspected
Sutures removed
Instructions
Leaflet
Analgesia
Sickness Certification
Telephone number for help/ advice
Pairs to consider pathway
Questions and Comments to panel