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Disorders of Hands and Feet


Maria Carmela L. Domocmat, RN, MSN
Instructor
Northern Luzon Adventist College
2

                            Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Disorders of Hands and Feet
Disorders of the hand                    Additional Problems of foot
• Carpal Tunnel Syndrome                  •   Tarsal tunnel syndrome
• Dupuytren’s Contracture                 •   Plantar Fasciitis
• Ganglion                                •   Corn
                                          •   Callus
                                          •   Ingrown Nail
                                          •   Hypertrophic Ungual Labium
3

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
4

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Carpal Tunnel Syndrome (CTS)
• common condition in which the median nerve
  in the wrist becomes compressed, causing
  pain and numbness
• most common repetitive strain injury (RSI) –the
  fastest growing type of occupational injury
5

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
6

                  Maria Carmela L. Domocmat, RN, MSN   9/4/2011




carpal tunnel
o a rigid canal lying between the carpal
  bones and a fibrous tissue sheet called the
  flexor retinaculum
o a group of nine tendons enveloped by
  synovium share space with the median
  nerve in the carpal tunnel
o when the synovium becomes swollen or
  thickened, the nerve is compressed
7

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
8

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
9

                     Maria Carmela L. Domocmat, RN, MSN   9/4/2011




• median nerve
  o supplies motor, sensory, and autonomic
    function for the 1st three digits of the hand
    and the palmar aspect of the 4th digit
  o bcoz of its proximity to other structures
       wrist flexion causes nerve impingement against
       the flexor retinaculum
       extension causes increased pressure in distal
       portion of carpal tunnel
10

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
11

                  Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Etiology
o Causes of Acute CTS – rare
    excessive hand exercise
    edema or hemorrhage into carpal tunnel
    thrombosis of median artery
12

                  Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Etiology
o common complication of certain metabolic
  and connective tissue diseases
   ex: synovitis in RA – hypertrophied synovium
   compresses median nerve
   DM – inadequate blood supply can cause
   median nerve neuropathy, or dysfunction,
   resulting in CTS
13

                      Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Etiology
o repetitive strain injury
    job requiring repetitive hand actitivites involving
    pinch or grasp during wrist flexion (factory
    workers, computer operators, jackhammer
    operators)
o overuse in sports activities
    golf, tennis, racquetball
o familial or congenital, manifesting in
  adulthood
o space-occupying lesions (ganglia, tophi,
  lipomas)
14

                 Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Incidence/prevalence
o peaks between 30 and 60 yrs
o but children are adolescents are getting
  common –due to use of computer
o women – 5 times more common
o affects dominant hand, but can occur both
  hands simultaneously
15

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Prevention
o if use computer regularly
    use appropriate ergonomically designed work
    stations
    take regular breaks
    if beginning symptoms – tell medical attention
16

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Assessment
o numbness and pain on hand
o pain
   worse at night as result of flexion or direct
   pressure during sleep
   may radiate to arm, shoulder and neck, or
   chest
o paresthesia (painful tingling)
o sensory changes – usually precedes motor
  manifestations by weeks or months
17

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
18

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
19

                     Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Assessment
o (+) Phalen’s wrist test or Phalen’s
  maneuver
    ask client to relax wrist into flexion
    or place he back of hands together and flex
    both wrists simultaneously
    (+) paresthesia in median nerve distribution
    (palmar side of thumb, index, and middle
    finger, radial half of ring finger) within 60 secs
20

                Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Phalen’s test
21

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Assessment
o Tinel’s sign
    tap lightly over the area of median nerve in
    wrist
    if test is unsuccessful – a BP cuff can be placed
    on upper arm and inflated to clients systolic
    pressure;
    result – pain and tingling
22

               Maria Carmela   9/4/2011

               L. Domocmat,
                   RN, MSN



Tinel’s sign
23

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Assessment
o motor changes
   weak pinch, clumsiness, difficulty with fine
   movements
   progress to muscle weakness and wasting
   (muscle atrophy)
   assess task performance
    • assess pinching ability by asking client to
      perform a fine-movement task (ex:
      threading a needle)
24

                  Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Assessment
o strenuous hand activity worsens the
  subjective complaints
o wrist swelling
o autonomic changes
    skin discoloration
    nail changes (e.g., brittleness)
    increased or decreased palmar sweating
25

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Dx tests
o routine x-rays
    to visualize bone changes, space-occupying
    lesions, synovitis
o for uncertain definitive dx:
    EMG – reveals nerve dysfunction b4 muscle
    atrophy
    MRI – enlarged median nerve within carpal
    tunnel
    UTZ – newest technique
26

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Management
o nonsurgical mgmt
   drug therapy
    • NSAIDs
    • inject corticosteroid directly into carpal
      tunnel – weekly or monthly
   immobilization
    • splint to immobilize wrist – during day or
      during night, or both
27

                  Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Management
o surgical mgmt
   to relieve pressure on median artery by
   providing nerve decompression
   Open Carpal Tunnel Release (OCTR)
   Endoscopic Carpal Tunnel Release (ECTR)
   synovectomy when synovitis is caused by RA
     • removal of excess synovium thru a small
       inner-wrist incision
   removal of space-occupying lesions
28

                 Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Management
 postop care
  • ECTR – less invasive but pain and
    numbness longer time postop
  • monitor VS
  • check dressing carefully for drainage and
    tightness
  • elevate above the heart for several days
    postop – reduce swelling from surgery
  • check neurovascular status of digits q hr
29

                 Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Management
 postop care
  • hand movements – including lifting heavy
    objects – restricted for 4 to 6 wks postop
  • encourage t o move all fingers of affected
    hand frequently
  • teach client to expect weakness and
    discomfort for weeks or perhaps months
30

                 Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Management
 postop care
  • offer pain meds
  • multiple operations and other treatments –
    common
  • may need assistance with routine daily
    tasks or even self-care activities
31

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
32

                      Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Dupuytren’s contracture or
deformity
• slowly progressive contracture of the palmar
  fascia, resulting in flexion of 4th or 5th digit of
  hand
33

                     Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Dupuytren’s contracture or
deformity
• common problem
• can be bilateral
• cause:
 • unknown
• incidence:
 • older men, tend to occur in families
34

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
35

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Dupuytren’s contracture or
deformity
• Treatment
   o when function becomes impaired, surgical
     release is required
   o partial or selective fasciectomy
   o splint application - post removal of dressing
     and drain
• nursing care
   o same with carpal tunnel repair
36

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
37

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Ganglion
• a round, cystlike lesions
• often overlying wrist joint or tendon
• synovium surrounding the tendon
  degenerates, allow tendon sheath tissue to
  become weak and distended
38

           Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Ganglion
39

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Ganglion
• painless on palpation, but can cause joint
  discomfort after prolonged joint use or minor
  trauma (ex: strain)
• can disappear and then recur
• common: 15 to 50 yrs old
40

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Ganglion
• treatment:
 • although fluid within lesion can be aspirated,
   total excision is preferred
41




Other problems of foot
                   Maria Carmela   9/4/2011

                   L. Domocmat,
                       RN, MSN
42

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
43

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
44

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Tarsal tunnel syndrome
• the ankle version of carpal tunnel syndrome
  (CTS)
• posterior tibial nerve in the ankle becomes
  compressed, resulting in loss of sensation and
  pain in a portion of the foot
45

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
46

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Tarsal tunnel syndrome
• median and lateral plantar branches, which
  supply the sole of the and distal phalanges, are
  affected by nerve compression

• dx and treatment: same with CTS
47

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
48

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Plantar fasciitis
• an inflammation of the plantar fascia, which is
  located in the area of the arch of the foot
• common: middle-aged and older adults,
  athletes esp runners
49

                                               Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Plantar fasciitis




 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19568.jpg
50

                       Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Plantar fascia
• A very thick band of tissue that covers the bones on
  the bottom of the foot.
• extends from the heel to the bones of the ball of the
  foot and acts like a rubber band to create tension
  which maintains the arch of the foot.
• If the band is long it allows the arch of the foot to be
  low, which is most commonly known as having a flat
  foot.
• A short band of tissue causes a high arch.
• This fascia can become inflamed and painful in
  some people, making walking more difficult.
51

                       Maria Carmela L. Domocmat, RN, MSN          9/4/2011




Plantar fascia




          http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19567.jpg
52

                  Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Risk factors
o Foot arch problems (both flat feet and high
  arches)
o Obesity or sudden weight gain
o Long-distance running, especially running
  downhill or on uneven surfaces
o Sudden weight gain
o Tight Achilles tendon (the tendon connecting
  the calf muscles to the heel)
o Shoes with poor arch support or soft soles
53

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




s/s:
• The most common complaint is pain and
  stiffness in the bottom of the heel. The heel
  pain may be dull or sharp. The bottom of the
  foot may also ache or burn.
54

                      Maria Carmela L. Domocmat, RN, MSN   9/4/2011




s/s
o The pain is usually worse:
      In the morning when you take r first steps
      After standing or sitting for a while
      When climbing stairs
      After intense activity
o The pain may develop slowly over time, or
  suddenly after intense activity.
55

                     Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Treatment
o conservative treatment:
    rest
    ice - at least twice a day for 10 - 15 minutes,
    more often in the first couple of days.
    stretching exercises
    strapping of foot to maintain arch
    orthotics
56

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Treatment
o conservative treatment:
    heel stretching exercises
    resting as much as possible for at least a week
    shoes with good support and cushions
    wear heel cup, felt pads in the heel area, or
    shoe inserts
    use night splints to stretch the injured fascia
    and allow it to heal.
57

                     Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Treatment
o If these treatments do not work, doctor may
  recommend:
    Wearing a boot cast, which looks like a ski boot,
    for 3-6 weeks. It can be removed for bathing.
    Custom-made shoe inserts (orthotics)
    Steroid shots or injections into the heel
    NSAIDs or steroids
    endoscopic surgery – to remove inflamed tissue
    may be required
58

            Maria Carmela   9/4/2011

            L. Domocmat,
                RN, MSN



Boot cast
59

            Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Orthotics
60

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Expectations (prognosis)
o Nonsurgical treatments almost always
  improve the pain.
• Treatment can last from several months to 2
  years before symptoms get better. Most
  patients feel better in 9 months. Some people
  need surgery to relieve the pain.
61

                 Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Complications
o Pain may continue despite treatment.
o Some may need surgery.
62

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
63

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Corn
• induration and thickening of skin
   caused by friction and pressure,
   painful conical mass
 • appear as a horny thickening of the
   skin on the toes.
 • this thickening appears as a cone
   shaped mass pointing down into
   the skin.
64

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
65

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Types of Corn
o Hard corns
   most common
   are concentrated areas of dry, hardened skin
   about the size of a pea
   usually located on the outer surface of the little
   toe or on the upper surface of the other toes,
   but can occur between the toes
   may develop within a broader area of callused
   skin
   sometimes called digital corns
66

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Types of Corn
o Soft corns
    are white and rubbery
    can be extremely painful and tend to develop
    between toes
    are like hard corns that have been softened by
    continual exposure to moisture, usually because
    you don’t dry between toes properly or from sweat.
    may form opposite one another and are known as
    ‘kissing lesions’.
    Sometimes, soft corns can become infected by
    bacteria or fungi.
67

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Other, rarer types of corn include:
• seed corns
 ▫ may appear as one corn or as clusters of small
   corns on the bottom foot; they are usually
   painless
• vascular corns
 ▫ occur in blood vessels and bleed if cut
• fibrous corns
 ▫ are corns that have been around for a long time
   and have become attached to the deeper layers
   of your skin, sometimes causing pain
68

                     Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Causes of corns
o Corns are caused by constant pressure on a
  bony area of foot. This can happen for a
  number of different reasons. These include:
    poorly fitting footwear – for example, shoes that
    are too small, cramp toes or have uneven soles;
    this is the most common cause of corns
    being very active – doing lots of exercise can put
    pressure on feet
    prominent bones – these can press against shoes
69

                     Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Causes of corns
o Corns are caused by constant pressure on a
  bony area of foot. This can happen for a
  number of different reasons. These include:
    a misshapen foot because foot or toes have
    developed unusually –may have a toe that is
    overly curved or a particular bone that is too short
    poorly healed fractures – if have broken a toe or
    another bone in foot, it may have set out of place
    causing foot to press against shoe
70

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Corn
• Treatment:
 • surgical removal by podiatrist
71

                 Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Prevention of corns
o wearing sensible, low-heeled footwear
  (maximum 4cm heel) with a rounded toe
o not wearing slip-on shoes because these
  cause feet to move forward and squash
  toes
o not wearing court shoes because they
  don’t support feet and can cramp toes
72

           Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Corn pad
73

                  Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Prevention of corns
o drying properly between toes
o losing excess weight – this will help to
  reduce pressure on feet
o If already have a corn, apply an antifungal
  or antibacterial powder after washing foot
  to help prevent it becoming infected.
74

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
75

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
76

                      Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Callus
• flat, poorly defined mass on the sole over a
   bony prominence caused by pressure
 • When skin is exposed to lots of pressure or
   friction, the keratin layer thickens to protect it,
   and develops into a callus.
 • Although calluses can cover a wide area, they
   aren't usually painful.
77

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Callus
• Treatment:
   o padding and lanolin creams
   o overall good skin hygiene
78

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




• Self treatment or management of corns and
  callus includes:
 ▫ following the advice of a Podiatrist
 ▫ proper fitting of footwear
 ▫ proper foot hygiene and the use of emollients to
   keep the skin in good condition
79

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
80

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Ingrown Nail
• nail silver penetration of the skin, causing
  inflammation
• occurs when the edge of the nail grows down
  and into the skin of the toe. There may be pain,
  redness, and swelling around the nail.
81

             Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Anatomy of a toenail
82

                     Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Ingrown Nail
• AKA:
 ▫   Onychocryptosis
 ▫   Unguis incarnatus
 ▫   Nail avlusion
 ▫   Matrix excision
83

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Causes, incidence, and risk factors
• An ingrown toenail can result from a number of
  things,
• but poorly fitting shoes and toenails that are
  not trimmed properly are the most common
  causes.
• The skin along the edge of a toenail may
  become red and infected.
• The great toe is usually affected, but any
  toenail can become ingrown.
84

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
85

                     Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Causes, incidence, and risk factors
• Ingrown toenails may occur when extra
  pressure is placed on toe.
• Most commonly, this pressure is caused by
  shoes that are too tight or too loose.
• If walk often or participate in athletics, a shoe
  that is even a little tight can cause this
  problem.
• Some deformities of the foot or toes can also
  place extra pressure on the toe.
86

              Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Infected ingrown toenail
87

                     Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Causes, incidence, and risk factors
o Nails that are not trimmed properly can also
  cause ingrown toenails.
    When toenails are trimmed too short or the edges
    are rounded rather than cut straight across, the
    nail may curl downward and grow into the skin.
    Poor eyesight and physical inability to reach the
    toe easily, as well as having thick nails, can make
    improper trimming of the nails more likely.
    Picking or tearing at the corners of the nails can
    also cause an ingrown toenail.
88

                     Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Causes, incidence, and risk factors
• Some people are born with nails that are
  curved and tend to grow downward. Others
  have toenails that are too large for their toes.
  Stubbing your toe or other injuries can also
  lead to an ingrown toenail.
89

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Treatment
• If have diabetes, nerve damage in the leg or
  foot, poor blood circulation to foot, or an
  infection around the nail, go to the doctor right
  away.
• Do NOT try to treat this problem at home
  (Bathroom treatment)
90

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Treatment
o To treat an ingrown nail at home:
    Soak the foot in warm water 3 to 4 times a day
    if possible. Keep the toe dry, otherwise.
    Gently massage over the inflamed skin.
    Place a small piece of cotton or dental floss
    under the nail. Wet the cotton with water or
    antiseptic.
91

                       Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Treatment
  may trim the toenail one time, if needed. When
  trimming toenails:
    Consider briefly soaking your foot in warm water to
    soften the nail.
    Use a clean, sharp trimmer.
    Trim toenails straight across the top. Do not taper or
    round the corners or trim too short. Do not try to cut
    out the ingrown portion of the nail. This will only make
    the problem worse.
    Consider wearing sandals until the problem has gone
    away. Over-the-counter medications that are placed
    over the ingrown toenail may help some with the pain
    but do not treat the problem.
92

               Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Proper and improper toenail trimming.
93

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Treatment
 If this does not work and the ingrown nail gets
 worse, see family doctor, a foot specialist
 (podiatrist) or a skin specialist (dermatologist).
 removal of silver by podiatrist
94

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




partial nail avulsion
 o If ingrown nail does not heal or keeps coming
   back, doctor may remove part of the nail.
 o Numbing medicine is first injected into the toe.
 o Using scissors, your doctor then cuts along the
   edge of the nail where the skin is growing over.
   This portion of the nail is then removed. This is
   called a partial nail avulsion.
 o It will take 2 to 4 months for the nail to regrow
95

                  Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Sometimes doctor will use a chemical,
electrical current, or another small surgical cut
to destroy or remove the area from which a new
nail may grow.
antibiotic ointment - If the toe is infected
96

                   Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Prevention
• Wear shoes that fit properly.
• Shoes worn every day should have plenty of
  room around toes.
• Shoes that wear for walking briskly or for
  running should have plenty of room also, but
  not be too loose.
97

                  Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Prevention
o When trimming toenails:
   Considering briefly soaking foot in warm
   water to soften the nail.
   Use a clean, sharp nail trimmer.
   Trim toenails straight across the top. Do not
   taper or round the corners or trim too short.
   Do not pick or tear at the nails.
   Keep the feet clean and dry. People with
   diabetes should have routine foot exams and
   nail care.
98

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
99

Maria Carmela L. Domocmat, RN, MSN   9/4/2011
100

                      Maria Carmela L. Domocmat, RN, MSN   9/4/2011




Hypertrophic Ungual Labium
•   chronic hypertrophy of nail lip
•   caused by improper nail trimming
•   results from untreated ingrown toenail
•   treatment:
     o surgical removal of necrotic nail and skin
     o treatment of secondary infection
101

                    Maria Carmela L. Domocmat, RN, MSN   9/4/2011




References
• Ignatavicius and Workman (2006). Medical surgical
  nursing [5th ed]. Singapore: Elsevier.
• http://www.epodiatry.com/corns-callus.htm
• http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH
  0004438/
• http://www.bupa.co.uk/individuals/health-
  information/directory/c/corns
• http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH
  0002217/
• http://orthoinfo.aaos.org/topic.cfm?topic=a00154

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Disorders of hands and feet

  • 1. Disorders of Hands and Feet Maria Carmela L. Domocmat, RN, MSN Instructor Northern Luzon Adventist College
  • 2. 2 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Disorders of Hands and Feet Disorders of the hand Additional Problems of foot • Carpal Tunnel Syndrome • Tarsal tunnel syndrome • Dupuytren’s Contracture • Plantar Fasciitis • Ganglion • Corn • Callus • Ingrown Nail • Hypertrophic Ungual Labium
  • 3. 3 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 4. 4 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Carpal Tunnel Syndrome (CTS) • common condition in which the median nerve in the wrist becomes compressed, causing pain and numbness • most common repetitive strain injury (RSI) –the fastest growing type of occupational injury
  • 5. 5 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 6. 6 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 carpal tunnel o a rigid canal lying between the carpal bones and a fibrous tissue sheet called the flexor retinaculum o a group of nine tendons enveloped by synovium share space with the median nerve in the carpal tunnel o when the synovium becomes swollen or thickened, the nerve is compressed
  • 7. 7 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 8. 8 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 9. 9 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 • median nerve o supplies motor, sensory, and autonomic function for the 1st three digits of the hand and the palmar aspect of the 4th digit o bcoz of its proximity to other structures wrist flexion causes nerve impingement against the flexor retinaculum extension causes increased pressure in distal portion of carpal tunnel
  • 10. 10 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 11. 11 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Etiology o Causes of Acute CTS – rare excessive hand exercise edema or hemorrhage into carpal tunnel thrombosis of median artery
  • 12. 12 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Etiology o common complication of certain metabolic and connective tissue diseases ex: synovitis in RA – hypertrophied synovium compresses median nerve DM – inadequate blood supply can cause median nerve neuropathy, or dysfunction, resulting in CTS
  • 13. 13 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Etiology o repetitive strain injury job requiring repetitive hand actitivites involving pinch or grasp during wrist flexion (factory workers, computer operators, jackhammer operators) o overuse in sports activities golf, tennis, racquetball o familial or congenital, manifesting in adulthood o space-occupying lesions (ganglia, tophi, lipomas)
  • 14. 14 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Incidence/prevalence o peaks between 30 and 60 yrs o but children are adolescents are getting common –due to use of computer o women – 5 times more common o affects dominant hand, but can occur both hands simultaneously
  • 15. 15 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Prevention o if use computer regularly use appropriate ergonomically designed work stations take regular breaks if beginning symptoms – tell medical attention
  • 16. 16 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Assessment o numbness and pain on hand o pain worse at night as result of flexion or direct pressure during sleep may radiate to arm, shoulder and neck, or chest o paresthesia (painful tingling) o sensory changes – usually precedes motor manifestations by weeks or months
  • 17. 17 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 18. 18 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 19. 19 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Assessment o (+) Phalen’s wrist test or Phalen’s maneuver ask client to relax wrist into flexion or place he back of hands together and flex both wrists simultaneously (+) paresthesia in median nerve distribution (palmar side of thumb, index, and middle finger, radial half of ring finger) within 60 secs
  • 20. 20 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Phalen’s test
  • 21. 21 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Assessment o Tinel’s sign tap lightly over the area of median nerve in wrist if test is unsuccessful – a BP cuff can be placed on upper arm and inflated to clients systolic pressure; result – pain and tingling
  • 22. 22 Maria Carmela 9/4/2011 L. Domocmat, RN, MSN Tinel’s sign
  • 23. 23 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Assessment o motor changes weak pinch, clumsiness, difficulty with fine movements progress to muscle weakness and wasting (muscle atrophy) assess task performance • assess pinching ability by asking client to perform a fine-movement task (ex: threading a needle)
  • 24. 24 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Assessment o strenuous hand activity worsens the subjective complaints o wrist swelling o autonomic changes skin discoloration nail changes (e.g., brittleness) increased or decreased palmar sweating
  • 25. 25 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Dx tests o routine x-rays to visualize bone changes, space-occupying lesions, synovitis o for uncertain definitive dx: EMG – reveals nerve dysfunction b4 muscle atrophy MRI – enlarged median nerve within carpal tunnel UTZ – newest technique
  • 26. 26 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Management o nonsurgical mgmt drug therapy • NSAIDs • inject corticosteroid directly into carpal tunnel – weekly or monthly immobilization • splint to immobilize wrist – during day or during night, or both
  • 27. 27 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Management o surgical mgmt to relieve pressure on median artery by providing nerve decompression Open Carpal Tunnel Release (OCTR) Endoscopic Carpal Tunnel Release (ECTR) synovectomy when synovitis is caused by RA • removal of excess synovium thru a small inner-wrist incision removal of space-occupying lesions
  • 28. 28 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Management postop care • ECTR – less invasive but pain and numbness longer time postop • monitor VS • check dressing carefully for drainage and tightness • elevate above the heart for several days postop – reduce swelling from surgery • check neurovascular status of digits q hr
  • 29. 29 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Management postop care • hand movements – including lifting heavy objects – restricted for 4 to 6 wks postop • encourage t o move all fingers of affected hand frequently • teach client to expect weakness and discomfort for weeks or perhaps months
  • 30. 30 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Management postop care • offer pain meds • multiple operations and other treatments – common • may need assistance with routine daily tasks or even self-care activities
  • 31. 31 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 32. 32 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Dupuytren’s contracture or deformity • slowly progressive contracture of the palmar fascia, resulting in flexion of 4th or 5th digit of hand
  • 33. 33 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Dupuytren’s contracture or deformity • common problem • can be bilateral • cause: • unknown • incidence: • older men, tend to occur in families
  • 34. 34 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 35. 35 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Dupuytren’s contracture or deformity • Treatment o when function becomes impaired, surgical release is required o partial or selective fasciectomy o splint application - post removal of dressing and drain • nursing care o same with carpal tunnel repair
  • 36. 36 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 37. 37 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Ganglion • a round, cystlike lesions • often overlying wrist joint or tendon • synovium surrounding the tendon degenerates, allow tendon sheath tissue to become weak and distended
  • 38. 38 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Ganglion
  • 39. 39 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Ganglion • painless on palpation, but can cause joint discomfort after prolonged joint use or minor trauma (ex: strain) • can disappear and then recur • common: 15 to 50 yrs old
  • 40. 40 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Ganglion • treatment: • although fluid within lesion can be aspirated, total excision is preferred
  • 41. 41 Other problems of foot Maria Carmela 9/4/2011 L. Domocmat, RN, MSN
  • 42. 42 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 43. 43 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 44. 44 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Tarsal tunnel syndrome • the ankle version of carpal tunnel syndrome (CTS) • posterior tibial nerve in the ankle becomes compressed, resulting in loss of sensation and pain in a portion of the foot
  • 45. 45 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 46. 46 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Tarsal tunnel syndrome • median and lateral plantar branches, which supply the sole of the and distal phalanges, are affected by nerve compression • dx and treatment: same with CTS
  • 47. 47 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 48. 48 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Plantar fasciitis • an inflammation of the plantar fascia, which is located in the area of the arch of the foot • common: middle-aged and older adults, athletes esp runners
  • 49. 49 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Plantar fasciitis http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19568.jpg
  • 50. 50 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Plantar fascia • A very thick band of tissue that covers the bones on the bottom of the foot. • extends from the heel to the bones of the ball of the foot and acts like a rubber band to create tension which maintains the arch of the foot. • If the band is long it allows the arch of the foot to be low, which is most commonly known as having a flat foot. • A short band of tissue causes a high arch. • This fascia can become inflamed and painful in some people, making walking more difficult.
  • 51. 51 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Plantar fascia http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19567.jpg
  • 52. 52 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Risk factors o Foot arch problems (both flat feet and high arches) o Obesity or sudden weight gain o Long-distance running, especially running downhill or on uneven surfaces o Sudden weight gain o Tight Achilles tendon (the tendon connecting the calf muscles to the heel) o Shoes with poor arch support or soft soles
  • 53. 53 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 s/s: • The most common complaint is pain and stiffness in the bottom of the heel. The heel pain may be dull or sharp. The bottom of the foot may also ache or burn.
  • 54. 54 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 s/s o The pain is usually worse: In the morning when you take r first steps After standing or sitting for a while When climbing stairs After intense activity o The pain may develop slowly over time, or suddenly after intense activity.
  • 55. 55 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Treatment o conservative treatment: rest ice - at least twice a day for 10 - 15 minutes, more often in the first couple of days. stretching exercises strapping of foot to maintain arch orthotics
  • 56. 56 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Treatment o conservative treatment: heel stretching exercises resting as much as possible for at least a week shoes with good support and cushions wear heel cup, felt pads in the heel area, or shoe inserts use night splints to stretch the injured fascia and allow it to heal.
  • 57. 57 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Treatment o If these treatments do not work, doctor may recommend: Wearing a boot cast, which looks like a ski boot, for 3-6 weeks. It can be removed for bathing. Custom-made shoe inserts (orthotics) Steroid shots or injections into the heel NSAIDs or steroids endoscopic surgery – to remove inflamed tissue may be required
  • 58. 58 Maria Carmela 9/4/2011 L. Domocmat, RN, MSN Boot cast
  • 59. 59 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Orthotics
  • 60. 60 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Expectations (prognosis) o Nonsurgical treatments almost always improve the pain. • Treatment can last from several months to 2 years before symptoms get better. Most patients feel better in 9 months. Some people need surgery to relieve the pain.
  • 61. 61 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Complications o Pain may continue despite treatment. o Some may need surgery.
  • 62. 62 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 63. 63 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Corn • induration and thickening of skin caused by friction and pressure, painful conical mass • appear as a horny thickening of the skin on the toes. • this thickening appears as a cone shaped mass pointing down into the skin.
  • 64. 64 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 65. 65 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Types of Corn o Hard corns most common are concentrated areas of dry, hardened skin about the size of a pea usually located on the outer surface of the little toe or on the upper surface of the other toes, but can occur between the toes may develop within a broader area of callused skin sometimes called digital corns
  • 66. 66 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Types of Corn o Soft corns are white and rubbery can be extremely painful and tend to develop between toes are like hard corns that have been softened by continual exposure to moisture, usually because you don’t dry between toes properly or from sweat. may form opposite one another and are known as ‘kissing lesions’. Sometimes, soft corns can become infected by bacteria or fungi.
  • 67. 67 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Other, rarer types of corn include: • seed corns ▫ may appear as one corn or as clusters of small corns on the bottom foot; they are usually painless • vascular corns ▫ occur in blood vessels and bleed if cut • fibrous corns ▫ are corns that have been around for a long time and have become attached to the deeper layers of your skin, sometimes causing pain
  • 68. 68 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Causes of corns o Corns are caused by constant pressure on a bony area of foot. This can happen for a number of different reasons. These include: poorly fitting footwear – for example, shoes that are too small, cramp toes or have uneven soles; this is the most common cause of corns being very active – doing lots of exercise can put pressure on feet prominent bones – these can press against shoes
  • 69. 69 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Causes of corns o Corns are caused by constant pressure on a bony area of foot. This can happen for a number of different reasons. These include: a misshapen foot because foot or toes have developed unusually –may have a toe that is overly curved or a particular bone that is too short poorly healed fractures – if have broken a toe or another bone in foot, it may have set out of place causing foot to press against shoe
  • 70. 70 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Corn • Treatment: • surgical removal by podiatrist
  • 71. 71 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Prevention of corns o wearing sensible, low-heeled footwear (maximum 4cm heel) with a rounded toe o not wearing slip-on shoes because these cause feet to move forward and squash toes o not wearing court shoes because they don’t support feet and can cramp toes
  • 72. 72 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Corn pad
  • 73. 73 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Prevention of corns o drying properly between toes o losing excess weight – this will help to reduce pressure on feet o If already have a corn, apply an antifungal or antibacterial powder after washing foot to help prevent it becoming infected.
  • 74. 74 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 75. 75 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 76. 76 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Callus • flat, poorly defined mass on the sole over a bony prominence caused by pressure • When skin is exposed to lots of pressure or friction, the keratin layer thickens to protect it, and develops into a callus. • Although calluses can cover a wide area, they aren't usually painful.
  • 77. 77 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Callus • Treatment: o padding and lanolin creams o overall good skin hygiene
  • 78. 78 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 • Self treatment or management of corns and callus includes: ▫ following the advice of a Podiatrist ▫ proper fitting of footwear ▫ proper foot hygiene and the use of emollients to keep the skin in good condition
  • 79. 79 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 80. 80 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Ingrown Nail • nail silver penetration of the skin, causing inflammation • occurs when the edge of the nail grows down and into the skin of the toe. There may be pain, redness, and swelling around the nail.
  • 81. 81 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Anatomy of a toenail
  • 82. 82 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Ingrown Nail • AKA: ▫ Onychocryptosis ▫ Unguis incarnatus ▫ Nail avlusion ▫ Matrix excision
  • 83. 83 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Causes, incidence, and risk factors • An ingrown toenail can result from a number of things, • but poorly fitting shoes and toenails that are not trimmed properly are the most common causes. • The skin along the edge of a toenail may become red and infected. • The great toe is usually affected, but any toenail can become ingrown.
  • 84. 84 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 85. 85 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Causes, incidence, and risk factors • Ingrown toenails may occur when extra pressure is placed on toe. • Most commonly, this pressure is caused by shoes that are too tight or too loose. • If walk often or participate in athletics, a shoe that is even a little tight can cause this problem. • Some deformities of the foot or toes can also place extra pressure on the toe.
  • 86. 86 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Infected ingrown toenail
  • 87. 87 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Causes, incidence, and risk factors o Nails that are not trimmed properly can also cause ingrown toenails. When toenails are trimmed too short or the edges are rounded rather than cut straight across, the nail may curl downward and grow into the skin. Poor eyesight and physical inability to reach the toe easily, as well as having thick nails, can make improper trimming of the nails more likely. Picking or tearing at the corners of the nails can also cause an ingrown toenail.
  • 88. 88 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Causes, incidence, and risk factors • Some people are born with nails that are curved and tend to grow downward. Others have toenails that are too large for their toes. Stubbing your toe or other injuries can also lead to an ingrown toenail.
  • 89. 89 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Treatment • If have diabetes, nerve damage in the leg or foot, poor blood circulation to foot, or an infection around the nail, go to the doctor right away. • Do NOT try to treat this problem at home (Bathroom treatment)
  • 90. 90 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Treatment o To treat an ingrown nail at home: Soak the foot in warm water 3 to 4 times a day if possible. Keep the toe dry, otherwise. Gently massage over the inflamed skin. Place a small piece of cotton or dental floss under the nail. Wet the cotton with water or antiseptic.
  • 91. 91 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Treatment may trim the toenail one time, if needed. When trimming toenails: Consider briefly soaking your foot in warm water to soften the nail. Use a clean, sharp trimmer. Trim toenails straight across the top. Do not taper or round the corners or trim too short. Do not try to cut out the ingrown portion of the nail. This will only make the problem worse. Consider wearing sandals until the problem has gone away. Over-the-counter medications that are placed over the ingrown toenail may help some with the pain but do not treat the problem.
  • 92. 92 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Proper and improper toenail trimming.
  • 93. 93 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Treatment If this does not work and the ingrown nail gets worse, see family doctor, a foot specialist (podiatrist) or a skin specialist (dermatologist). removal of silver by podiatrist
  • 94. 94 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 partial nail avulsion o If ingrown nail does not heal or keeps coming back, doctor may remove part of the nail. o Numbing medicine is first injected into the toe. o Using scissors, your doctor then cuts along the edge of the nail where the skin is growing over. This portion of the nail is then removed. This is called a partial nail avulsion. o It will take 2 to 4 months for the nail to regrow
  • 95. 95 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Sometimes doctor will use a chemical, electrical current, or another small surgical cut to destroy or remove the area from which a new nail may grow. antibiotic ointment - If the toe is infected
  • 96. 96 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Prevention • Wear shoes that fit properly. • Shoes worn every day should have plenty of room around toes. • Shoes that wear for walking briskly or for running should have plenty of room also, but not be too loose.
  • 97. 97 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Prevention o When trimming toenails: Considering briefly soaking foot in warm water to soften the nail. Use a clean, sharp nail trimmer. Trim toenails straight across the top. Do not taper or round the corners or trim too short. Do not pick or tear at the nails. Keep the feet clean and dry. People with diabetes should have routine foot exams and nail care.
  • 98. 98 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 99. 99 Maria Carmela L. Domocmat, RN, MSN 9/4/2011
  • 100. 100 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 Hypertrophic Ungual Labium • chronic hypertrophy of nail lip • caused by improper nail trimming • results from untreated ingrown toenail • treatment: o surgical removal of necrotic nail and skin o treatment of secondary infection
  • 101. 101 Maria Carmela L. Domocmat, RN, MSN 9/4/2011 References • Ignatavicius and Workman (2006). Medical surgical nursing [5th ed]. Singapore: Elsevier. • http://www.epodiatry.com/corns-callus.htm • http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 0004438/ • http://www.bupa.co.uk/individuals/health- information/directory/c/corns • http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 0002217/ • http://orthoinfo.aaos.org/topic.cfm?topic=a00154