3. Why the pain occur especially at night ?

Answer :
The initial stage of CTS is characterized by paresthesia at night, and this is based on
intraneural microvascular insufficiency night due to the increasing pressure on the carpal tunnel
at night. A gradual increase in pressure of tissue fluid reflects the redistribution of body fluids
in the horizontal position, and palmar flexion of the wrist. Should not be forgotten that in
addition there is a vascular pressure drop at night, which is associated with circadian rhythm,
there is also a decrease in perfusion pressure in the carpal tunnel. Symptoms arise due to local
metabolic disorganization on the nerves, resulting in oxygen deficiency secondary to
involvement intraneural microcirculation. The symptoms are reversible when the position of
the wrist, muscles, and posture becomes normal or if surgery on carpal ligament.

8. Differential diagnose

CARPAL TUNNEL SYNDROME

A. Definition
This syndrome is a neuropathic pressure on the median nerve in the carpal
tunnel at the wrist precisely under the flexor retinaculum. Carpal tunnel located in the
central part of the wrist where the bone and ligaments form a narrow tunnel through
which some of the tendons and the median nerve. The bones karpalia form the base and
sides of the tunnel are hard and rigid while the roof is formed by the flexor retinaculum
(transverse carpal ligament and palmar carpal ligament) is strong and arched over the
karpalia bones. Any changes that narrows the tunnel will cause pressure on the most
vulnerable structures in it that the median nerve.
B. Epidemiology
Carpal Tunnel syndrome is a neurological disorder that is a common
occurrence. A survey in California estimates that 515 of 100,000 patients seek medical
attention for carpal tunnel syndrome in 1988. In the Netherlands, reported prevalence
of 220 per 100,000 people.
The incidence of carpal tunnel syndrome in the United States has been estimated
to be about 1-3 cases per 1,000 persons per year with revalensi about 50 cases of 1,000
people in the general population. Middle-aged parents are more likely at risk than
younger people, and women three times more often than men.
National Health Interview Study (NIHS) noted that the CTS is more often on women
than men with ages ranging from 25-64 years, the highest prevalence in women aged >
55 years, usually between 40-60 years. The prevalence of CTS in the general population
has been estimated at 5% for women and 0.6% for men. CTS is a type of neuropathy is
the most common pitfalls. The syndrome is unilateral in 42% of cases (29% right, 13%
left) and 58% bilateral.
CTS developments related to age. Phalen reported the number of cases
increased for each decade of age 59 years, after that, the number of cases in each decade
of decline. Atroshi et al. observed similar age distribution with the highest prevalence
of CTS in men 45-54 and women ages 55-64. Soft and Rudolfer found that cases of
CTS have age distribution with peaks at age 50-54.
Tana et al concluded that the amount of labor can with CTS in several garment
companies in Jakarta as much as 20.3% of respondents with a repetitive biomechanical
movement momentarily high at hand right wrist 74.1%, and 65.5% in the left hand.
Female workers with CTS significantly higher as compared to male workers. There is
no difference between the increase in age, education, employment, hours of work and
repeated biomechanical stress for a moment to the increased occurrence of CTS .

C. ETIOLOGY
The median nerve sensory region vary widely, especially on the volar surface.
And patterns that correspond to variations between the third finger to the fourth finger
radial side of the palm. On the surface of dorsum manus, median nerve sensory area
varies between two to three bars finger distal second, third and fourth. The median
nerve in the carpal tunnel is often squeezed. The median nerve is the nerve most often
injured by direct trauma, often accompanied by a cut wrist. Pressure from n median
resulting in tingling sensation that hurt, too. That paresthesias or hypesthesia of "Carpal
Tunnel sydrome".
There are several key co-morbidity or human factor that could potentially
increase the risk of CTS. The main considerations include advanced age, female gender,
and the presence of diabetes and obesity. Other risk factors include
pregnancy, specific work, injuries due to repetitive motion and cumulative, a strong
family history, medical disorders such as hypothyroidism, autoimmune diseases,
diseases rheumatology, arthritis, kidney disease, trauma, predisposing anatomy in the
wrist and hand, infectious diseases, and abuse substance. People who engage in manual
labor in some occupations have incidence and greater severity.
Some of the causes and factors that influence the incidence of carpal tunnel
syndrome among others:
1. Hereditary: Hereditary neuropathy tends to be pressure palsy, for example
HMSN (Hereditary Motor and sensory neuropathies) type III.
2. Trauma: dislocation, fracture or hematoma in the forearm, wrist and hand
.Sprain wrist. Direct trauma to the wrist.
3. Work: knock or movement wrist flexion and extension are repeated. A secretary
who frequently type, manual workers who often lift heavy weights and musician,
especially a piano player and a guitar player who uses his hands also a lot of the
etiology of carpal turner syndrome.
4. Infection: tenosynovitis, tuberculosis, sarcoidosis.
5. Metabolic: amyloidosis, gout, hypothyroidism - a focal neuropathy press,
particularly carpal tunnel syndrome also occurs due to thickening ligaments, and
tendons of the deposits of a substance called mucopolysaccharides.
6. Endocrine: acromegaly, estrogen or androgen therapy, diabetes mellitus,
hipotiroidi, pregnancy.
7. Neoplasms: a ganglion cyst, lipoma, infiltrating metastases, myeloma.
8. Collagen vascular diseases: rheumatoid arthritis, polymyalgia rheumatica,
scleroderma, systemic lupus erythematosus.
9. Degenerative: osteoarthritis.
10. Latrogenic: radial artery puncture, installation vascular shunt for dialysis,
hematoma, complications of anti-coagulant therapy.
11. The stress factor
 12. Inflammation: Inflammation of the mucous membrane that surrounds the
tendon causes the median nerve pressure and lead to carpal tunnel syndrome.

D. Pathogenesis and Pathophysiology

CTS pathogenesis remains unclear. Several theories have been proposed to
explain the symptoms and impaired nerve conduction studies. The most popular are
mechanical compression, microvascular insufficiency, and vibration theory. According
to mechanical compression theory, symptoms of CTS is due to compression of the
median nerve in the carpal tunnel. The main weakness of this theory is that it explains
the consequences of nerve compression but does not explain the underlying etiology
mechanical compression. Compression is believed to be mediated by factors such as
excessive force, hyperfunction, wrist extension prolonged or repeated.
Insufficiency theory of micro - vascular voiced their that the lack of blood
supply causes the depletion of nutrients and oxygen to the nerves causing it to slowly
lose the ability to transmit nerve impulses. Fibrotic scar tissue and eventually evolved
into the nerve. Depending on the severity of the injury, nerve and muscle changes may
be permanent. Characteristic symptoms of CTS, especially tingling, numbness and
acute pain, along with loss of nerve conduction acute and reversible are considered
symptoms of ischemia. Seiler et al showed (with laser Doppler flowmetry) that normal
blood flow pulsating in the median nerve was restored within 1 minute from the time
the transverse carpal ligament is released. A number of experimental studies support
the theory ischemia due to compression is applied externally and due to increased
pressure in the carpal tunnel. Symptoms will vary according to the integrity of the blood
supply of nerves and systolic blood pressure. Kiernan et al found that the median nerve
conduction slowing can be explained by ischemic compression only and may not
always caused myelinisasi disturbed.
According to vibration theory CTS symptoms could be caused by the effects of
long term use of vibrating tools on the median nerve in the carpal tunnel. Lundborg et
al noted edema epineural on the median nerve in the few days following exposure to
hand-held vibrating tools. Furthermore, similar changes occurred following the
mechanical, ischemic, and chemical trauma.
Another hypothesis of CTS found mechanical and vascular factors play an
important role in the development of CTS. CTS generally occurs chronically where
thickening of the flexor retinaculum that causes pressure on the median nerve. Repeated
 pressure and duration will result in elevation of pressure intrafasikuler. Consequently
intrafasikuler venous blood flow slows down. Congestion that occurs will disrupt
intrafasikuler nutrition followed by anoxia which would damage the endothelium. This
would lead to endothelial damage protein leakage resulting in edema epineural. This
hypothesis explains how complaints of pain and swollen arising mainly at night or early
morning will be reduced after the hand is involved digerakgerakkan or sorted, perhaps
due to the temporary improvement in blood flow. If this condition continues to happen
fibrosis epineural damaging nerve fibers. Eventually nerve atrophy and replaced by
connective tissue resulting in impaired function of the median nerve as a whole.
In addition due to the emphasis that exceeds capillary perfusion pressure will
cause microcirculation disorders and ischemic nerve arise. This ischemic state further
exacerbated by elevated pressure intrafasikuler which caused the continued disruption
of blood flow. The subsequent vasodilatation that causes edema so the blood-nerve
barrier disturbed berkibat there is damage to the nerves.
Research has been done Kouyoumdjian stating CTS occurs due to compression
of the median nerve under the transverse carpal ligament
associated with increased weight and BMI. A low BMI is a good health condition for
the protection of the median nerve function. Workers with a minimum BMI ≥25 more
likely to develop CTS than the jobs that have a lean body weight. American Obesity
Association found that 70% of patients with CTS overweight. Any increase in the value
of IMT 8% increased risk of CTS.

E. Clinical Manifestations
In the early stages the symptoms are generally in the form of sensory
disturbance only. Motor disorders occur only in severe circumstances. The initial
symptoms are usually paresthesias, less feeling (numbness) or taste like electric shock
(tingling) in the fingers 1-3 and half the radial side of the finger 4 in accordance with
the distribution of the median nerve sensory although sometimes seen on all the fingers.
Komar and Ford discussed two forms of carpal tunnel syndrome: acute and
chronic. Acute form have symptoms with severe pain, swollen wrists or hands, cold
hands or finger motion decreases. Loss of finger motion is caused by a combination of
pain and paresis. The chronic form has both sensory dysfunction symptoms that
dominates or lose motor with trophic changes. Pain may be present in the proximal
carpal tunnel syndrome.
 Complaints paresthesias usually more prominent in the evening. Other
symptoms are pain in the hand is also felt heavier at night so
often waking the patient from sleep. The pain is generally somewhat diminished if the
patient massaging or moving his hands or by putting his hand in a higher position. Pain
will also be reduced if the patient more rest his hand.

F. Diagnosis
CTS diagnosis is made only based on clinical symptoms as above
and strengthen the inspection, namely:
1. Physical examination
Checks should be carried out a thorough examination of the patient with
special attention to function, motor, sensory and autonomic hand. Some checks
and provocation tests that can help diagnose CTS is:
a) Phalen's test: Patients were asked to maximum flexion hand. If within 60
seconds symptoms such as CTS, tests supporting the diagnosis. Some
authors argue that the test is very sensitive for the diagnosis of CTS.
b) Torniquet test: In this test installation is done using tensimeter tomiquet
above the elbow with a pressure slightly above the systolic pressure. If
within 1 minute symptoms like CTS, tests supporting the diagnosis.
c) Tinel's sign: This test supports the diagnosis in case of paresthesia or pain
in the median nerve distribution when performed percussion on the carpal
tunnel hand position slightly dorsiflexion.
d) Flick's sign: Patients were asked save yourself the shaking hands or
wiggled his fingers. If the complaint is reduced or disappears shall
support the diagnosis of CTS. It should be remembered that these signs
can also be found in Raynaud's disease.
e) Thenar wasting: On inspection and palpation can be found atrophy thenar
muscles.
f) Assess the strengths and skills and muscle strength either manually or by
means of a dynamometer
g) Wrist extension test: Patients were asked to do an extension to the
maximum hand, should be done simultaneously on both hands so can be
compared. If within 60 seconds symptoms arise such as CTS, then this
test supports the diagnosis of CTS.
 h) Pressure test: the median nerve in the carpal tunnel pressed with your
thumb. When in less than 120 seconds symptoms such as CTS, tests
supporting the diagnosis.
i) Luthy's sign (bottle's sign): Patients asked to put his thumb and forefinger
on the bottle or glass. When the skin on the hands of patients unlikely to
be able to touch the wall with the meeting, the test is declared positive
and supportive diagnosis
j) Examination of sensibility: When people can not distinguish between two
points (two-point discrimination) at a distance of more than 6 mm in the
area of the median nerve, the test is considered positive and support the
diagnosis
k) Examination of autonomic function: In patients considered whether there
are differences in sweat, the skin is dry or slippery confined to the area
of the median nerve innervation. If there is going to support the diagnosis
of CTS.
From the examination of the above provocation test Phalen and Tinel
test is a test that patognomonis for CTS.

2. Examination of neurophysiology (electrodiagnostic)

EMG can show fibrillation, polyphasic, a positive wave and a reduced
number of motor units in the muscles of the thenar. In some cases not found
abnormalities in muscles lumbrikal. EMG may be normal in 31% of cases of
CTS. Conductivity speed Nerves (KHS). In 15-25% of cases, KHS can be
normal. On the other KHS will decrease and distal latency period (distal
latency) sweep, indicating interference with the conduction of nerve in the
wrist. Sensory latency period is more sensitive than motor latency period.

3. Examination of Radiology
X-rays of the wrist can help to see if there are other causes such as a
fracture or arthritis. Plain radiographs of the neck is useful to exclude the
presence of other diseases in the vertebrae. Ultrasound, CT-scan and MRI
performed on a selective case primarily to be operated. ultrasound
conducted to measure the cross-sectional area of the median nerve in the carpal
tunnel proximal sensitive and specific for carpal tunnel syndrome
 4. Laboratory Tests
When the CTS etiology is not clear, for example in young patients
without repetitive hand movements, to do some tests such as blood sugar, blood
thyroid hormone levels or complete.

G. Diagnosis
Diagnosis of CTS among others:
1. Cervical radiculopathy.
2. Thoracic outlet syndrome.
3. Pronator teres syndrome.
4. de Quervain's syndrome.

H. Management
Management of carpal tunnel syndrome depends on the etiology, duration of
symptoms, and the intensity of nerve compression. If the syndrome is a disease
secondary to endocrine diseases, hematology, or other systemic diseases, primary
disease should be treated. Mild cases can be treated with anti
non-steroidal inflammatory drug (NSAID) and use the wrist brace that maintains the
hand in a neutral position for at least 2 months, especially at night or during repeated
movements. Further cases may be treated with local steroid injections that reduce
inflammation. If not effective, and the symptoms are quite disturbing, surgery is often
recommended to relieve compression.
Therefore should CTS therapy were divided into two groups, namely:
1. Direct therapy against CTS
a) Conservative therapy
1. Rest your wrist.
2. The non-steroidal anti-inflammatory drugs.
3. Installation splint at a neutral wrist position. Splint can be fitted
continuously or only at night for 2-3 weeks.
4. Nerve Gliding, namely practice consists of a range of motion (ROM)
exercises of the upper limb and neck that produces tension and
longitudinal movement along the median nerve and the other of the upper
limb. These exercises are based on the principle that the tissue of the
 peripheral nervous system is designed for movement, and that the tension
and nerves glide may have effects on neurophysiology through changes
in vascular flow and axoplasmic. Exercises done is simple and can be
done by the patient after a brief instruction.
5. Injection of steroids. 1-4 dexamethasone or hydrocortisone 10-25 mg 1
mg or methylprednisolone 20 mg or 40 mg injected into the carpal tunnel
using a needle no.23 or 25 at a location 1 cm proximally folding wrist
medial musculus palmaris longus tendon. While the injections can be
repeated in 7 to 10 days for a total of three or four injections ,. Surgery
may be considered if the results are not satisfactory after the treatment
was given 3 injections. Injections should be used with caution for patients
under the age of 30 years.
6. Vitamin B6 (pyridoxine). Some authors suggest that one cause of CTS is
pyridoxine deficiency so that they advocated giving pyridoxine 100-300
mg / day for 3 months. But some other writers argue that the granting of
pyridoxine helpful not even can cause neuropathy when administered in
large doses. But the administration may serve to reduce pain.
7. Physiotherapy. Aimed at improving the vascularization of the wrist.

b) Operative therapy
Surgery is only performed in cases that do not improve with
conservative treatment or if there is severe sensory loss or atrophy thenar
muscles. On bilateral CTS is usually the first operation performed on the
hands of the most painful though bilateral operations can be simultaneously
performed. Another writer stated that the surgery is absolutely necessary
when conservative therapy fails or if there is atrophy of the muscles of the
thenar, while a relative indication that surgery is the loss of sensibility
persistent.
CTS surgery is usually done openly with local anesthesia, but now it has
developed endoscopic surgery techniques. Endoscopic surgery allows early
mobilization patients with minimal scarring, but because of the limited field
operations such action will often lead to surgery complications such as injury
to nerves. Some causes of CTS such as their mass or anomaly or
 tenosynovitis in better carpal tunnel surgery openly.

2. Treatment of the underlying disease state or CTS

Underlying disease state or the occurrence of CTS needs to be
addressed, because if we can not give rise to recurrence CTS back. In a state in
which CTS occurs due to repetitive hand movements have to be adjusted or
prevention. Some efforts should be made to prevent the occurrence of CTS or
prevent relapse among others (13):
a. Reducing the rigid positions on the wrist, repetitive movements, vibration
equipment hand at work.
b. Design work equipment in order to hand in a more natural position when
working.
c. Modification work to facilitate the spatial variations of movement.
d. Changing the method of work for the occasional short breaks and seeking
work rotation.
e. Improving knowledge workers about early symptoms of CTS so that
workers can recognize the symptoms of CTS earlier.

In addition, it is also important to note some of the diseases that often

underlie the occurrence of CTS such as: acute trauma or chronic wrist and the
surrounding area, kidney failure, patients often dihemodialisa, myxedema due
hipotiroidi, acromegaly due to pituitary tumors, pregnancy or use of oral
contraceptives, disease collagen vascular, arthritis, tenosynovitis, wrist
infection, obesity and other diseases that can cause fluid retention or cause an
increase in the content of the carpal tunnel.

I. Prognosis
In mild cases of CTS, with conservative therapy generally good prognosis. If
things do not improve with conservative therapy, the surgery should be performed. In
general, surgery prognosis is also good, but because the operation is only performed on
patients who had been suffering from CTS post operative healing stages.
If after surgery, there was also obtained improvements then reconsidered the
following possibilities:
1. Faulty diagnosis, may trap / pressure on the median nerve is located in a more
proximal.
2. There has been a total breakdown in the median nerve.
3. The new CTS occurred as a result of complications due to the surgery such as
edema, adhesions, infection, hematoma or hypertrophic scarring. Although the
prognosis of CTS with conservative or operative therapy is quite good, but the risk
for recurrence remains. In case of recurrence, the procedure either conservative or
operative treatment can be repeated.
 Refernece :

1. Noor, Zairin. 2012. Gangguan muskuloskeletal 2th edition. Jakarta : salemba medika. Page
345-349
2. Jagga, V. Lehri, A et al. Occupation and its association with Carpal Tunnel syndrome- A
Review. Journal of Exercise Science and Physiotherapy. 2011. Vol. 7, No. 2: 68-78.
 PRONATOR TERES SYNDROME

A. Definition
Pronator teres syndrome is a set of typical symptoms characterized by mild to moderate
pain in the forearm. Pain increases with movement of the elbow, supination and pronation
repetitive and repetitive movements grip. The loss of manual dexterity, mild weaknesses,
paresthesia median nerve can occur, numbness can occur not only on the finger, but can also
occur in the area because terkenanya palms palmar cutaneous nerve area that branched.

B. Epidemyology
Pronator teres syndrome is the second most common cause of median nerve
compression behind carpal tunnel syndrome. It tends to occur in athletics (especially
those with rapid, exertional supination and pronation) and in occupations where the
forearm may be hypertrophied. In addition, anomalies involving the ligament of
Struthers and the course of the median nerve may contribute to median nerve
entrapment.

C. Etiology
The most common cause is entrapment of the median nerve between the two
caput pronator teres muscle. Other causes compression of the nerve from the fibrous
arch of the superficial flexor, or thickening of the bicipital aponeurosis
There are five areas of potential occurrence of neural Bondage
1. Supracondylar Process

Found only approximately 1%

2. Ligament of Struthers
 Under the ligament of Struthers, the network that runs from processus
suprakondiler the distal humerus (ulnar side) to the medial epicondyle.
 At the elbow that is on its way along the pronator teres muscle, so that
there are three places on the passage of nerve compression that can
occur, which is a branch of the biceps tendon and the ulnar insersio
pronator teres muscle.
 In the carpal tunnel in the wrist.

3. Bicipital aponeurosis
4. Among the ulnar and humerus Caput on pronator teres
 5. Aponeurosis arch FDS

D. Clinical Manifestation
The median nerve compression at the elbow: pronator Teres syndrome
 Is a mixture of sensory-motor mononeuropathy.
 Pain in the forearm that is worsened by the attitude of pronation and forced
flexion.
 Tingling in the area of the median nerve.
 Pain in the area pronator teres muscle stimulation or Tinel's sign.
 The existence of mild weakness in the forearm and thenar muscles, or it could
be no weakness.
 The median nerve along with the artery separates the biceps tendon and fascia
of the biceps. Then continues between two insersio of the pronator teres muscle
(on the medial epicondyle and coronoid process of the ulna). In this area median
nerve is localized under the ulnar artery and the fascia of the biceps tendon.
There are more underneath Origin of the flexor digitorum superficialis muscle.

E. Clinical Symptoms
Local symptoms were obtained:
 Heaviness, stiffness or cramping of the hands.
 Tingling sensation in the muscles of the thenar thumb and three fingers on his
side.
 Pain in the area pronator teres muscle in the elbow or forearm when muscles
contract.
 Pain and tingling while doing antagonistic movements like pronation of the
forearm and flexion of the wrist.
 Motor dysfunction of the muscles innervated by the median nerve distal to the
collateral (after leaving the pronator teres muscle innervation); so the pronator
teres muscle dysfunction, but could not hit the muscle pronator quadrates
affected.
 Baal and thicker on the medial side of the thumb and the lateral side of the
index finger.

Arthralgia on elbow
The median nerve plays a major role in the region of the elbow, which
berkolateral the anterior capsule of the ligament apparatus parts. If after fraktus
or dislocated elbow, certain movements still cause pain, then the management
of the median nerve must be considered.

Signs and Symptoms of Sensorik

Pain is the main symptom of SPT. Discomfort felt at the onset of forearm
pronation due to pinched nerves and flexion is often done with a powerful,
usually the initial diagnostic manual. Obtained also the onset of acute pain due
to severe contraction of the forearm. This pain radiates from the region distal to
the anterior elbow to the palms and fingers, also proximally to the shoulder.
Tingling in the thumb and other fingers are innervated normally accompanies
the median nerve pain. But without a test activation / pronator provocation,
sometimes not found. Pain along the proximal portion of the pronator teres
muscle is an important diagnostic sign of the syndrome.

Signs and Symptoms of Motorik

At SPT, worsening of symptoms and sensory mototik not go together. There
is a discrepancy between the motor and sensory symptoms. Of the many
findings of sensory symptoms, only 3 of 39 cases there is also a motor symptoms
(mild thenar muscle atrophy). Just got a little weakness of the flexor pollicis and
Opponens pollicis, although there is pain and sensory deficits on the distribution
 of the median nerve innervation. In theory, in the case of median nerve
compression in the tax return where there are severe sensory deficits, will obtain
minimal weakness (at least) on some of the muscles supplied by the median
nerve, such as radial nerve entrapment syndrome and ulnar. However this is not
found in SPT, and the reason remains unclear.

F. Diagnosis
Diagnosing SPT is not easy because the signs and symptoms overlap with
compression and entrapment neuropathy of the median nerve, among others: Struthers
ligament compression at the top, carpal tunnel syndrome (CTS) below, and the anterior
interosseous nerve lesions in anatomical locations almost the same as the SPT.
Muskulofibrosa tissue from the base of the pronator teres muscle, is one of the findings
of pathological compression during the operation of the SPT, which is also the main
cause of the anterior interosseous nerve syndrome in some cases. When The median
nerve enters the forearm area, then the significant anatomical variations certainly aka
tone. These variations together with minor anatomical variations at the point where the
anterior interosseous nerve departs from the median nerve, is the beginning of an
explanation why fibrous connective tissue of the pronator teres muscle or flexor
digitorum superficialis Akif role in the pathogenesis of SPT and anterior interosseous
nerve syndrome. Both clamping nerve syndrome had similarities to the discovery of
visible pathology during surgery, which is associated with clinical signs and symptoms
including pain and tenderness over the forearm. Although the anterior interosseous
nerve is purely motor, but the onset paralisisnya generally associated with acute pain
and in the forearm, as well as the pain felt over the pronator teres muscle in some cases.
The weakness of the flexor pollicis longus and flexor digitorum profundus of the index
finger, which is a major physical sign of the anterior interosseous nerve syndrome
(AIS), seen at SPT. Clinically, the only criteria that differentiate between SPT and the
anterior interosseous syndrome is a sensory signs are distributed along the median nerve
of the forearm. When there is clearly a sensory deficits, the diagnosis can be confirmed
is the SPT. If the patient has only a subjective ambiguity regarding sensory symptoms
without definite tingling in the median nerve area, after tests pronator and flexor
digitorum superficialis test, then it is very difficult to ascertain whether a tax return or
AIS case with consideration of sensory symptoms. Anatomically, the presence of one
or more muscle paralysis proximal to the base of the anterior interosseous nerve, can
 support the diagnosis of SPT. Pronator teres muscle, the flexor carpi radialis, palmar
longus, and pleksor digitorum superficial, should be examined specifically and
carefully at SPT and SIA.
In accordance neuroanatomy, signs and symptoms of median nerve lesion at the
level of Struthers ligament and pronator teres muscle is almost identical. The difference
is the location of tenderness, muscle responsible namely suprakondilar muscle and
pronator teres muscle, and there is a spur at suprakondylar on radiographs. Struthers
ligament compression syndrome known to be extremely rare, but should still be
included in the list of differential diagnosis of paralysis of the median nerve, as it is
clamping nerve neuropathy can disembuhkan.

G. Physical Examination
Provocative tests specifically on Examination bondage Median Nerve
 The patient stands with the elbow flexed 90 degrees. The examiner places one
hand on the patient's elbow stabilization, and the other hand grasping the hands
of Pasian in a position to shake hands. Patients maintain this position, while
inspectors perform supination of the forearm of patients (forcing patients to
contract the pronator muscle patients). While doing supination movements,
inspectors also carry out extension at the elbow, with a grip to pull the distal.
 If there is pain or discomfort at the moment, it is ascertained that there is
compression of the median nerve by the pronator teres. (The patient should
remain merelaksikan elbow during the test, because of the stiff elbow will be
difficult for the examiner at the time of the extension).
H. Therapy
Management conservatively be applied before considering surgical
intervention. The main goal of treatment is decompression of the median nerve.
Consideration or treatment is effective in relaxing the pronator and flexor muscles, as
well as reducing the mechanical stress on the system fibromuskuler of the forearm. SPT
found in the group of people who work or habit is predominantly excessive use of the
forearm. Thus, it is important to educate the patient is the first step that must be done
in the management of this syndrome.
1. Intervention Non surgery
Conservative management is almost always a top choice early in the
operation, and often obtain positive results. With conservative therapy, 50%
of patients reported relief in 4 months. Others reported that the repair can be
found in the 18 months up to 2.5 years after conservative therapy. Cortisone
injection is done when conservative therapy has not succeeded in improving
the symptoms. The decision to choose surgery / surgical determined within
8 weeks forevermore 6 months after conservative management. The median
nerve decompression generally have a 85-90% possibility to get good
results.
 Management of the types of jobs and hobbies: multiply rest and
adjustments to the activities, if possible, modified total.
 Drugs and dosing neurorehabilitasi exercises to loosen the tension
fibromuscular and to reduce pain.
 Exercise actively and dynamically in the upper limb into
consideration long-term effects when the pain has diminished or
disappeared.

Conservative rehabilitation
Phase 1: Week I-II
Aim:
 Controlling swelling
 The reduction of pain

Intervention:
  Protects the elbow of entrapmen further with the use of
splinting or fixation elbow 900.
 Activities passive ROM carefully.
 Elevation, cooling and compression.
 Modalities and medications for inflammation, swelling
and pain.
 Massage gently nerve.
 Mobilization of soft tissue.
 Maintenance of the condition and stamina.

Phase 2: Week III-IV

Aim:
 Improved flexibility
 Strengthening (in this phase takes extra care to prevent
recurrence)
Intervention:
 The modalities can help to reduce inflammation and pain.
 Exercise wrist flexion and extension should be done.
 After the above exercise can be done well, then continued
with elbow flexion and extension and pronation and
supination slowly.
 Mobilization and massage the soft tissue in the forearm
can begin in areas where there is a suspicion of
entrapmen.
 Start solve this type of exercise and activity, with the
development of the condition and stamina.

Phase 3: Week V-VIII

Aim :
 Independently are able to perform the program at home
 To return to activity in work, recreation, and sport
 Prevention of recurrence
Intervention:
  Education to patients about prevention and management.
 Massaging and sorting nerve to prevent recurrence.
 For an athlete, strengthening and flexibility are essential
components for exercising again.
 Focus on repeated simulations both in sports and work of
the patient

2. Surgery
Exploration and decompression of the median nerve to be done if
the failure of conservative management. Decompression is done with the
anterior approach and a longitudinal incision along the arm. The incision
will start a few centimeters above the supracondylar processus (Struthers
ligament), if the decompression is also needed in the area. However, the
incision can also be made just above the elbow bump up to the middle of
the forearm. Identification very carefully from nerve entrapment area should
really be confident that the surgery only area that it only needs to be opened
for the decompressed. SPT diagnosis must be perfectly upright before
carrying out the operation.

Postoperative rehabilitation
Phase 1: Valid I-XXI
Aim:
 Controlling edema and pain
 Preventing infection at the wound site
 Start trying ROM is active in around the joint
 Reduce the sensitivity of the area of the incision scar tissue
and improve mobility

Intervention:
 Protection of the scar area and monitor drainage.
 Rest, cooling, and elevation of the arm.
 The elbow is positioned slightly flexed (fixation) for 7-10
days.
  Active movement of the fingers, wrists, and shoulders
(hereinafter, including the elbow and forearm).
 Nerve mobilization exercises are gentle and pain free.
 Iontophoresis and modalities needed to reduce inflammation
and pain.
 Mobilization of soft tissue and gently massage to reduce
swelling on network maintenance.

Phase 2: Week IV-VII

Aim:
 The power grip and elbow reaches about 30-50% of the
healthy hand
 Increased active ROM of the forearm and elbow by more than
50% of normal
 Advanced Prevention of adhesions and scar tissue sensitivity
 Independent ADL
 Ensuring appropriate ergonomic exertion (work and leisure)

Intervention:
 Passive Stretch on elbow, forearm, wrist, and shoulder.
 Patient education regarding the prevention of recurrence.
 Exercises that are balanced to the elbows, wrists, forearms,
and shoulders.
 Start a training simulation for both work and leisure

Phase 3: Week VI-XII

Aim:
 The strength adequate to restore the activity and work in full
 Independent management of the symptoms

Intervention:
 Simulation of work activities and sports.
  Progress upper extremity exercises that make up the
resilience to return to work and sports activities. Stretching
exercises and a continuation of phase 1 and 2 in accordance
with the indications.

Trigger Finger

Stenosing tenosynovitis, commonly known as “trigger finger” or “trigger thumb”,

involves the pulleys and tendons in the hand that bend the fingers. The tendons work like long
ropes connecting the muscles of the forearm with the bones of the fingers and thumb. In the
finger, the pulleys are a series of rings that form a tunnel through which the tendons must glide,
much like the guides on a fishing rod through which the line (or tendon) must pass. These
pulleys hold the tendons close against the bone. The tendons and the tunnel have a slick lining
that allows easy gliding of the tendon through the pulleys. Trigger finger/thumb occurs when
the pulley at the base of the finger becomes too thick and constricting around the tendon,
making it hard for the tendon to move freely through the pulley. Sometimes the tendon
develops a nodule (knot) or swelling of its lining. Because of the increased resistance to the
gliding of the tendon through the pulley, one may feel pain, popping, or a catching feeling in
the finger or thumb. When the tendon catches, it produces inflammation and more swelling.
This causes a vicious cycle of triggering, inflammation, and swelling. Sometimes the finger
becomes stuck or locked, and is hard to straighten or bend.

Etiology

Causes for this condition are not always clear. Some trigger fingers are associated with
medical conditions such as rheumatoid arthritis, gout, and diabetes. Local trauma to the
palm/base of the finger may be a factor on occasion, but in most cases there is not a clear cause.

Signs and symptoms

Trigger finger/thumb may start with discomfort felt at the base of the finger or thumb,
where they join the palm. This area is often tender to local pressure. A nodule may sometimes
be found in this area. When the finger begins to trigger or lock, the patient may think the
problem is at the middle knuckle of the finger or the tip knuckle of the thumb, since the tendon
that is sticking is the one that moves these joints.
Treatment

The goal of treatment in trigger finger/thumb is to eliminate the catching or locking and
allow full movement of the finger or thumb without discomfort. Swelling around the flexor
tendon and tendon sheath must be reduced to allow smooth gliding of the tendon. The wearing
of a splint or taking an oral anti-inflammatory medication may sometimes help. Treatment may
also include changing activities to reduce swelling. An injection of steroid into the area around
the tendon and pulley is often effective in relieving the trigger finger/thumb. If non-surgical
forms of treatment do not relieve the symptoms, surgery may be recommended. This surgery
is performed as an outpatient, usually with simple local anesthesia. The goal of surgery is to
open the pulley at the base of the finger so that the tendon can glide more freely.

Active motion of the finger generally begins immediately after surgery. Normal use of
the hand can usually be resumed once comfort permits. Some patients may feel tenderness,
discomfort, and swelling about the area of their surgery longer than others. Occasionally, hand
therapy is required after surgery to regain better use.

De quirvain tendinosis

De Quervain’s tendinosis occurs when the tendons around the base of the thumb are
irritated or constricted. The word “tendinosis” refers to a swelling of the tendons. Swelling of
the tendons, and the tendon sheath, can cause pain and tenderness along the thumb side of the
wrist. This is particularly noticeable when forming a fist, grasping or gripping something, or
when turning the wrist.

Etiology

De Quervain’s tendinosis may be caused by overuse. It also is associated with pregnancy and
rheumatoid disease. It is most common in middle-aged women.

Symptoms

Signs of De Quervain’s tendinosis:

Pain may be felt over the thumb side of the wrist. This is the main symptom. The pain
may appear either gradually or suddenly. Pain is felt in the wrist and can travel up the forearm.
The pain is usually worse when the hand and thumb are in use. This is especially true when
forcefully grasping objects or twisting the wrist. Swelling may be seen over the thumb side
of the wrist. This swelling may accompany a fluid-filled cyst in this region. A “catching” or
“snapping” sensation may be felt when moving the thumb. Pain and swelling may make it
difficult to move the thumb and wrist.

General Examination

To determine whether or not you have De Quervain’s tendinosis, your physician may
ask you to perform the Finkelstein test by placing your thumb against your hand, making a fist
with your fingers closed over your thumb, and then bending your wrist toward your little finger.
If you have De Quervain’s tendinosis, this test is quite painful, causing tendon pain on the
thumb side of the wrist.

Treatment

The goal in treating de Quervain’s tendinosis is to relieve the pain caused by irritation and
swelling.

1. Nonsurgical Treatment
 Splints. Splints may be used to rest the thumb and wrist.
 Anti-inflammatory medication (NSAIDs). These medications can be taken by mouth or
injected into a tendon compartment. This may help reduce swelling and relieve pain.
 Avoiding activities that cause pain and swelling. This may allow the symptoms to go
away on their own.
 Corticosteroids. Injection of corticosteroids into the tendon sheath may help reduce
swelling and pain.
2. Surgical Treatment
Surgery may be recommended if symptoms are severe or do not improve. The goal of
surgery is to open the thumb compartment (covering) to make more room for the irritated
tendons. Regardless of the treatment, normal use of the hand usually can be resumed once
comfort and strength have returned. Your orthopaedic surgeon can advise you on the best
treatment for your situation.
 Reference

3. Soeroso, Joewono. 2015. Ilmu Penyakit Dalam 6th edition Jilid III. Jakarta : interna publishing.
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21th September 2012, cited 1stjuly 2014]. Available from :
http://www.mdguidelines.com/pronator-syndrome
5. Salawati , Liza dan Syahrul. 2014. Carpal tunnel syndrome. the medical journal of the
university medical faculties Syiah kuala. Vol 14 No 1.