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.
 Reference

3. Soeroso, Joewono. 2015. Ilmu Penyakit Dalam 6th edition Jilid III. Jakarta : interna
publishing. Page 3552.
4. Disability Guidelines Al-Shatoury AHA. Pronator teres syndrome. [Internet]. 2012. [Updated
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.