中区防治中心网络医院联合讨论会.ppt

Work-related Carpal Tunnel Syndrome王賢和 MD.PhD職業醫學科Case-M/48季xxCC:referral here under the impression of work related carpal tunnel syndrome.職業病的診斷原則職業病的診斷原則1.疾病的證據2.職業暴露的證據3.符合時序性4.符合人類流行病學已知的證據5.排除其他可能的致病因素3罹病的證據罹病的證據1.Symptoms2.Signs3.Tests SYMPTOMS1.Numbness,2.Tingling pain in the volar aspects of hands3.Weakness in left hand gripping4.Especially noted after work or at night5.Shaking hands to relieve the painsNo sleep disturbance yet Signs1.Tinels sign(+/-):tapping over the median nerve at the wrist causes paresthesias or pain radiating from the wrist to the thumb and the index,the middle and half the ring fingers.2.Phalens test(+/-):bending the wrist forward all the way for 60 seconds results in numbness,tingling,or weakness in a median nerve distribution Atrophy of the thenar muscles(-)Present illness1.Numbness,tingling pain and weakness of hands for 3 years2.Pain could temporarily relieved by the analgesics,traditional massages,herb medicines and local steroid injection.3.Carpal tunnel syndrome was diagnosed at the賢德 hospital on 2011/01/07.4.Referral under the impression of work related disease.Motor Nerve Conduction Study1.Normal amplitude2.Delayed distal latencies of bilateral median nerves.3.Prolong F latencies of bilateral median nerves in F wave study 4.Normal results of ulnar,peroneal and tibial nerves.F wave studySupra-maximal stimulationOrtho-dromic stimulus M wave:muscle contraction.Anti-dromic stimulus the motor neuron cell bodies backfire down towards the muscle small F wave.F-wave study D=the length from the stimulation(wrist crease)to the spine(C7)(for median nerve).F-M=the latency difference between mean F and M Delay=1 millisecondConduction velocity =2D/(F-M-1).Sensory Conduction Study1.Slowing in the palm-wrist conduction of bilateral median nerves 2.Normal results of ulnar and sural nerves.Nerve Conduction Study(NCS)Motor NCS Sensory NCSF-wave study(initially recorded in the foot muscles)H(Hoffmann)-reflex study F-wave study vs.Motor and Sensory coduction studiesThe F-wave latency can be used to derive the conduction velocity of nerve between the limb and spine,whereas the motor and sensory nerve conduction studies evaluate conduction in the segment of the limb.F-wave study is not a reflex.H reflex monosynaptic reflex electrically stimulating the tibial nerve(Ia afferents from muscle spindles),generally in the popliteal fossa,recording from the gastrocnemius-soleus musclesimilar to the Achilles reflex,except that the neuromuscular spindles are bypassed.Hoffmann reflex 1.Square-wave current of short duration and small amplitude2.Early response on EMG:M-wave3.Later responses:H-wave(reflected).4.As the stimulus increases,the M-wave increases and the H-wave decreases.5.At supramaximal stimulus,alpha fibers involved,the H-wave disappears and the F-wave appears.NCV ReportsSlowing at wrist conduction of bilateral median nerves.Diagnosis:carpal tunnel syndrome(CTS)TestsNerve conduction velocity:positiveTherapeutic and diagnostic challenge test:possibly positive.Wrist X-rays:negativeElectromyography:nil.Electromyography(EMG)1.surface EMG 2.intramuscular(needle and fine-wire)EMG.Resting and contracting Occupational CTS(OCTS)職業病的診斷原則職業病的診斷原則1.疾病的證據2.職業暴露的證據3.符合時序性4.符合人類流行病學已知的證據5.排除其他可能的致病因素26工作史工作史1980-1984 友聯鞋業之裁剪作業員1988-1992 偉仲製帽之裁剪作業員工作時,需使用油壓機器將牛皮裁成鞋底或帽子。油壓機上的裁刀常會卡於機台上,需用手腕施力直接拔出或拿鐵鎚(5磅重)用力鎚打敲鬆再拔出.鎚打的頻率約20秒一次，每天持續8小時。工作史工作史-21992-2001 群國工程之營造工人2001-now 無固定雇主之營造工人動鑽打洞,植筋,砌磚,敲磚,扛鐵和粉刷等.每天需重覆地扛起20-30公斤的鐵條並以手腕用力綑綁,約6-7小時.或使用電動鑽打洞約6小時,每1-2秒震動一次.暴露之證據暴露之證據過去擔任皮革裁剪作業員時,以及擔任營造勞力工作時,皆需經常重覆地以手腕用力地扭轉或接觸高頻震動等.工作場所評估：目前無固定雇主及工作場所.其中一次的工作現場照片如下：職業病的診斷原則職業病的診斷原則1.疾病的證據2.職業暴露的證據3.符合時序性4.符合人類流行病學已知的證據5.排除其他可能的致病因素32時序性時序性1980-1992 裁剪皮革1992now營造工作,砌磚,粉刷,鋼筋組合,植筋,敲磚和電動鑽打洞等。於2008年開始出現雙手腕酸痛、無力和麻的情形職業病的診斷原則職業病的診斷原則1.疾病的證據2.職業暴露的證據3.符合時序性4.符合人類流行病學已知的證據5.排除其他可能的致病因素34Reviews1.The median nerve is formed from parts of the medial and lateral cords of the brachial plexus.2.It continues down the arm to enter the forearm with the brachial artery.3.It originates from the brachial plexus with roots from C5,C6,C7,C8,&T1.Carpal Tunnel Syndrome1.Median nerve compression at the wrist is the most common peripheral nerve entrapment disorder.2.Constellation of specific symptoms and signs,described as CTS.3.Annual incidence in the general population=1/1000 Epidemiology of CTS1.most often in people 30 to 60 years old2.more common in women than mon in people who perform repetitive motions of the hand and wrist.Repetitive motions of the hand and wristTyping on a computer keyboardSewing Driving Assembly line work Painting Writing Use of hand tools that vibrate Sports such as racquetball or handball Playing some musical instrumentsWork-related CTSmost often associated with activities requiring extensive,forceful,repeated,or prolonged use of the hands and wrists,1.(NIOSH Publication no.97141.US Department of Health and Human Services,1997)2.(Palmer KT et al.Occup Environ Med 2007;57:5766)。職業性腕隧道症候群職業性腕隧道症候群工作時,手腕必須1.經常反覆地動作,2.經常持續地以一種不自然的姿勢工作,3.或經常用力地作出扭轉的動作等長時間累積的傷害造成手腕部軟組織的病變或功能異常,以及造成附近肌腱的發炎和週邊神經之壓迫.Occupational Carpal Tunnel Syndrome(OCTS)1.Forceful hand use,particularly if repeated for prolonged periods 2.Constant firm gripping of objects 3.Moving or using the hand and wrist against resistance or with force 4.Exposing the hand and wrist to strong regular vibrations 5.Regular or intermittent pressure on the wrist Work Exposures and the Probability of Work-Relatedness Exposure Examples of types of jobs Probability of work-relatedness Combinations of high force with high repetition and awkward posture;regular strong vibrations Seafood,fruit,or meat processing or canning,carpentry,roofing,dry-wall installation,boat building,book binding High,Relative risk 4 Medium-high force,high repetition or awkward posture alone,on a nearly continuous basis Dental hygienists,wood products production Medium,Relative risk 2-4 Low force or medium-low repetition alone,on an intermittent basis Computer or keyboard use Low,Relative risk 2 職業病的診斷原則職業病的診斷原則1.疾病的證據2.職業暴露的證據3.符合時序性4.符合人類流行病學已知的證據5.排除其他可能的致病因素44 過去病史過去病史1.過去無手部的重大外傷、痛風、甲狀腺疾病、痛風、自體免疫疾病糖尿病和關節炎等可能會造成腕隧道症候群之相關病史。2.2011年曾由鷹架跌落，胸部挫傷，但未傷及手部。Risk factors for CTS1.inflammatory or non-inflammatory arthropathies,2.recent or remote wrist trauma or fractures,3.diabetes mellitus,4.obesity,5.hypothyroidism,6.pregnancy,7.genetic factors.Medical problems associated with CTSFracturesand arthritis of the wrist Acromegaly DiabetesAlcoholismHypothyroidismKidney failure and dialysis Pregnancy InfectionsObesity Rheumatoid arthritis,systemic lupus erythematosus(SLE),and slcerodermaOCUPATIONAL DISEASEon a more probably than not basis(greater than 50%)that the workplace activities(exposure)in an individual case contributed to the development or worsening of the condition(outcome).SummaryDx;臨床徵狀及神經傳導檢查皆符合腕隧道症候群的診斷認定基準Exposure:過往至今的工作(repeated and forceful works),皆明顯地增加罹患腕隧道症候群的機會Time sequence:1980起工作30年,於2008年開始出現雙手腕酸痛,無力和麻的情形,合乎危害暴露在前,發病在後之時序性。可合理地排除其他非職業因素造成之腕隧道症候群之可能。Thus,此疾病由職業引起之可能性大於50。診斷基準診斷基準勞工保險職業病種類表之3.4壓迫造成之神經麻痺：包括職業性腕道症候群等。診斷：work related carpal tunnel syndrome,bilateral(雙側職業性腕隧道症候群)後續處理後續處理個案因經濟上之需求,目前仍需持續地工作.1.衛教2.職能治療3.藥物4.手術Education1.Avoid sleeping on wrists.2.Hot and cold compresses3.Take frequent breaks when typing and always stop if tingling or pain.4.Avoid or reduce the number of repetitive wrist movements whenever possible.Occupational Therapy1.Wearing a neutral position wrist splint at night 2.Wearing a splint intermittently during work 3.Ergonomic aids,such as split keyboards,keyboard drawers,cushioned mouse pads,and wrist braces.4.Job modification5.Forearm/wrist stretching home exercise6.Referral to an occupational therapistMEDICATIONSCyclo-oxygenase(COX)inhibitors1.Nonselective:ibuprofen or naproxen.2.COX-2 selective:celecoxib Local steroid injections into the carpal tunnel for short term relief.PrognosisSymptoms often improve with treatment,but more than 50%of cases eventually require surgery.Surgery is often successful,but full healing can take monthsSURGERYCarpal tunnel release1.Release of the transverse carpal ligament2.Open or endoscopic approach3.Decompression of the median nerve at the wristRevision after 6 months if worseningPossible ComplicationsIf untreated,the nerve can be damaged,causing permanent weakness,numbness,and tingling.The END