1. Presenting a medical topic to colleagues
Wim Willems
Craiova, September 2011

2. Program Who is everybody?
What makes a medical presentation good / what makes it bad?
A medical program: carpal tunnel syndrome
Rules & take home messages

3. What makes a training good / bad?
Tell your colleagues about a training / seminar that was really bad and didn’t teach you anything. Why was it bad?
Tell your colleagues about a training / seminar that was really good and educational. Why was it good?
In drietallen deze vraag bespreken en plenair inventariseren en opschrijven. Dit is het begin van de take home messages

4. Rule 1 – avoid boredom
Inventariseren hoe je verveling kunt voorkomen

5. Rules to avoid boredom Keep it small Start with the needs of the group
Use the knowledge that the group has already
Be interactive (little groups, avoid monologue)
Change methods (presentation, quiz, case history, discussion regarding statements, skills)

6. Rules to avoid boredom Keep it small Start with the needs of the group
Use the knowledge that the group has already
Be interactive (little groups, avoid monologue)
Change methods (presentation, quiz, case history, discussion of statements, skills)

7. Keep it small
Carpal tunnel syndrome

8. Start with the needs of the group
What do you want to know?
De vragen inventariseren & daarna vergelijken met Nederlandse huisartsen

9. What do Dutch GP’s want to know?
Is it necessary to perform an EMG to establish the diagnosis CTS ?
Is it necessary to have positive tests like Tinel, Phalen etcetera ?
Are injections with corticosteroids helpful ?
Can I give an injection with corticosteroids myself ? What dosage should I give? How can I do this safely ? How often can I do this ?

10. Mrs A has no carpal tunnel syndrome
Quiz 1
Mrs A, 53 years old, complains of nightly tingling in her right hand which wakes her up. When you examine her you find nothing abnormal. The tests of Tinel and Phalen are negative.
Mrs A has no carpal tunnel syndrome
Correct / Incorrect

11. Mrs A has no carpal tunnel syndrome
Quiz 2
Mrs A, 53 years old, complains of nightly tingling in her right hand which wakes her up. You refer her for an EMG: this is negative (no nerve conduction abnormality).
Mrs A has no carpal tunnel syndrome
Correct / Incorrect

12. Quiz 3
Where is the carpal tunnel ?

13. “Painful nightly tingling”
Female, 52 years
Wakes up in the early morning with painful tingling in the hand (thumb / index)
Flapping of hand eases complaints

14. Carpal tunnel syndrome
Female, 52 years
Wakes up in the early morning with painful tingling in the hand (thumb / index)
Flapping of hand eases complaints
What do you do in Romania?

15. Carpal tunnel syndrome

16. Epidemiology Open population (history + nerve conduction examination):
Female: 9 %
Male: 0,6%
Peak between year

17. Risk factors Weight Pregnancy Diabetes mellitus Hypo/hyperthyreoidy
Ovariectomy
Anatomic deviation (traumatic / RA / congenital)
Work related

18. Natural course ¼ - 1/3 significant improvement > 1 year
After pregnancy 50% without complaints

19. Pathofysiology Narrow tunnel compression n. medianus in carpal tunnel
90% idiopatic

20. Diagnosis = history ! Dutch consensus (CBO 2006) / guideline NHG 2009:
Nightly tingling
Median nerve area
Sleep disturbance
Other tingling / pains
Flapping (Flick sign)
Advanced stages: tingling during the day

21. Sensory innervation N. Medianus

22. Atypical localisations tingling sensations
Often outside median nerve area
Sometimes ulnar nerve area

23. Provocation tests:
CBO 2006 / NHG 2009:
Limited usefulness

24. Diagnostic tests CTS test sensitivity specificity Tinel 0.25-0.60
Phalen
Flick sign
0.93
0.96
Square wrist sign
Pressure provocation test
Tourniquet test

25. Tests Tinel: percussion median nerve Phalen: flexion during 60 seconds
Further: -sensory loss median nerve area
-thenar dystrophy
-dry skin (thumb / index / middle finger)

26. Neurophysiological examination
Verification of clinical diagnosis prior to operation
sensitivity
specificity
EMG
60-82
95-100%

27. Limitation EMG: No golden standard 10-15% false negative
No relation between complaints and results
Results not predictive for therapy
Value unclear for primary health care

28. Treatment

29. Splint Day and night Short term effective
Minor complaints / recent onset

30. Surgery: Highly effective Major / recurrent complaints. Patient’s wish
Open / endoscopic
Success: 75-90%
Complications: damage to nerve, pain, scar, complex regional pain syndrome)

31. Corticosteroid injection
Short term effectiveness +
50% without complaints after one year
Diagnostic use?

32. Referral Insufficient reaction to symptomatic treatment (2 injectons)
Common sense
Diagnostic uncertainty
Severe complaints

33. Corticosteroid injection
Several techniques
Safe
Effective
Tradition / experience / authority determines technique 33

34. Medicament / Dosage
Most common: Triamcinolonacetonide 10 mg/ml (Kenacort® A10), or methylprednisolonacetaae (Depo-Medrol®) 40 mg/ml
Volume: 1-2ml
Interval between injections: 1-3 weeks
Effectiveness: 1st injection 80%, after 2 injections 15%, after 3 injections 5%

35. Needle? -light blue (0,5x25mm) -green (0,8x40mm)
-orange/ light brown (0,45x23mm)
-light blue (0,5x25mm)
-green (0,8x40mm)

36. Localisation carpal tunnel
Os pisiforme
Os scaphoideum

37. m. Palmaris longus

38. Tendon m. Palmaris longus
Absent tendon: ulnar to median axis

39. Localisation insertion
ulnar to tendon m. palmaris longus
3-4 cm before distal wrist line 3

40. Injection underneath retinaculum
Angle 30 degrees

41. Hygiene Wash hands, wear gloves or disinfect fingers
Once-only ampoules
Change needles
Disinfect skin

42. Side effects and complications
-flushing: 1 day after injection
-steroid-flare hours
-menstruation problems
-hyperglycemia
-locale effects: redness, atrophy fatty tissue, hypopigmentation
Complications
-very rare, case-reports
-tendon ruptures, median neuritis (CTS), local infection

43. Take home messages
Organize and prepare your own training for yourself and for your colleagues
Keep it small
Try to answer only questions that have immediate consequences for your everyday practice
Do it yourself – specialists can tell you only what is important to them

44. Take home messages
Organize and prepare your own training for yourself and for your colleagues
Keep it small
Try to answer only questions that have immediate consequences for your everyday practice
Do it yourself – specialists can tell you only what is important to them

45. Take home messages
Organize and prepare your own training for yourself and for your colleagues
Keep it small
Try to answer only questions that have immediate consequences for your everyday practice
Do it yourself – specialists can tell you only what is important to them

46. Take home messages
Organize and prepare your own training for yourself and for your colleagues
Keep it small
Try to answer only questions that have immediate consequences for your everyday practice
Do it yourself – specialists can tell you only what is important to them

47. Take home messages
Organize and prepare your own training for yourself and for your colleagues
Keep it small
Try to answer only questions that have immediate consequences for your everyday practice
Do it yourself – specialists can tell you only what is important to them

48. Material

49. Did you see this? Did it work?
Keep it small
Start with the needs of the group
Use the knowledge that the group has already
Be interactive (little groups, avoid monologue)
Change methods (presentation, quiz, case history, discussion regarding statements, skills)

50. Va Mulţumesc, la revedere