‹nmeli Hastalarda Yaflflam Kalitesini Etkileyen ... - FTR Dergisi

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23. Ulusal Fiziksel T›p ve Rehabilitasyon Kongresi / 23 rd National Physical Medicine & Rehabilitation Congress
Türk Fiz Rehab Derg 2011:57Özel Say›; 1-334 /Turk J Phys Med Rehab 2011:57Suppl; 1-334
P-042
Kompleks Bölgesel A¤r› Sendromu Tip II’nin Efllik Etti¤i
Karpal Tünel Sendromu
Nilgün fiimflir Atalay 1, Nuray Akkaya 1, Selcen Alkan 2, Füsun fiahin 1
1 Pamukkale Üniversitesi T›p Fakültesi Fizik Tedavi ve Rehabilitasyon Anabilim Dal›, Denizli
2 Denizli Devlet Hastanesi Fizik Tedavi ve Rehabilitasyon Klini¤i, Denizli
G‹R‹fi: Karpal tünel sendromu (KTS), median sinirin karpal tünel içinde s›k›flmas› sonucu, parmaklarda
a¤r›, parestezi ve hipoestezi ile bulgu veren tuzak nöropatisidir. Karpal tünel
gevfletme operasyonu yap›lan hastalarda kompleks bölgesel a¤r› sendromu (KBAS) geliflebildi¤ini
bildiren yay›nlar olmas›na ra¤men, opere edilmemifl ve tedavi almam›fl KTS vakalar›nda
KBAS komplikasyonu s›k bildirilen bir durum de¤ildir. Bu olgu sunumunda EMG’sinde ileri
derecede KTS tan›s› alan hastam›zda operasyon öncesi saptanan KBAS klini¤i tan›mland›.
OLGU: Otuz befl yafl›nda, kad›n hasta, yaklafl›k 2 ay önce bafllayan sa¤ el ilk 3 parmakta hissizlik,
güçsüzlük, özellikle geceleri olan uyuflma ve bu flikayetlerden 3 hafta sonra bafllayan el
bile¤inde fliddetli a¤r› yak›nmas› ile baflvurdu. Hastan›n öyküsünde tarlada çal›flma, elini afl›r›
kullan›m mevcuttu. Muayenesinde elde ödem, s›cakl›k art›fl›, terleme, el bile¤i ve metakarpofalangeal
(MKF) eklemlerde presyonla belirgin a¤r›s› vard›. Bafl parmak abduksiyonu kas gücü
-4/5 de¤erinde olup çok a¤r›l› idi. Tinel, Phalen ve ters Phalen testlerinde pozitiflik mevcuttu.
Görsel Analog Skalas› (GAS) ile hastan›n a¤r› fliddeti de¤erlendirildi¤inde GAS de¤eri 9
idi. Hastan›n üst ekstremite dizabilitesini de¤erlendiren Disability of Arm, Shoulder and Hand
Questionnaire kullan›ld›¤›nda de¤eri 75 idi. Yap›lan EMG’si ileri düzeyde KTS ile uyumlu idi. Çekilen
Tc-99m MDP üç fazl› kemik sintigrafisinde görülen de¤ifliklikler KBAS lehine yorumland›.
Laboratuvar incelemesi normaldi. Bu verilerle KBAS tan›s› konulan hastaya 3 hafta sürede
azalt›larak kesilecek flekilde 30 mg prednizolon baflland›. Z›t banyo ve aktif eklem hareket
aç›kl›¤› egzersizleri tarif edildi. Tedavi bitiminde hastan›n elindeki ödem, k›zar›kl›k, terleme
bulgular› gerilemiflti. El bilek ve MKF eklemlerdeki presyonla GAS’› 1'di. Ancak parmaklardaki
uyuflma, klinik testlerindeki pozitiflik halen devam ediyordu. Hastan›n a¤r›s› azald›ktan sonraki
kas gücü -5/5 de¤erinde idi. EMG bulgular› da göz önünde tutularak hasta operasyona yönlendirildi.
Operasyon sonras› hastan›n mevcut flikayetleri tamamen geriledi.
SONUÇ: S›k rastlanan ve elektrofizyolojik testlerle kolayl›kla tan› konabilen KTS’ye efllik eden
klinik bulgular varl›¤›nda KBAS tan›s›ndan flüphelenilmesi oluflabilecek deformitelerin önlenmesi
aç›s›ndan önemlidir.
Anahtar Kelimeler: Karpal tünel sendromu, kompleks bölgesel a¤r› sendromu, tedavi
P-043
Kum Torbas›na Yumruk Atma Sonras› Geliflen Kanat Skapula
Nilgün fiimflir Atalay, Sibel Konukcu, Özlem Ercido¤an, Füsun fiahin
Pamukkale Üniversitesi T›p Fakültesi Fizik Tedavi ve Rehabilitasyon Anabilim Dal›, Denizli
G‹R‹fi: Kanat skapula (KS), skapulan›n medial kenar›n›n veya inferior aç›s›n›n gö¤üs
duvar›ndan uzaklaflmas›d›r. KS, nörolojik hasarlanma, kemik veya periskapuler yumuflak dokudaki
patolojik de¤iflikliklere ya da glenohumeral ve subakromial patolojilere ba¤l› olarak
oluflabilir. Uzun torasik sinirin; direkt kompresyonu, tekrarlayan gerilme yaralanmalar›, künt
travma, nevraljik brakial pleksus amyotrofi veya toraksa yönelik operasyonlarda hasar› serratus
anterior kas›n›n güçsüzlü¤üne yol açarak kanat skapula ile sonuçlanabilir. Bu olguda kum
torbas›na yumruk atma sonras› izole uzun torasik sinir hasar›na ba¤l› geliflen kanat skapula
klini¤i tan›mlanm›flt›r.
OLGU: Yirmi bir yafl›nda erkek, üniversite ö¤rencisi olan hasta, 4 ay önce oyun salonunda güç
denemesi için kum torbas›na yumruk atma sonras›nda sa¤ omuzda fliddetli a¤r› flikayeti bafllam›fl.
Bu flikayet ile bu sürede birçok hekime baflvuran hastaya omuz X-Ray ve manyetik rezonans
görüntülemesi yap›lm›fl, sonuçlar› normal olarak belirtilerek kas zorlanmas› tan›s›yla
NSA‹‹ ve miyorelaksan verilmifl, ancak flikayetleri tam olarak geçmeyince ortopedi taraf›ndan
fizik tedavi amac›yla poliklini¤imize yönlendirilmiflti. Hastan›n muayenesinde inspeksiyonda
sa¤da belirgin kanat skapulas› mevcuttu. Sa¤ üst ekstremite aktif ve pasif eklem hareketleri
aç›k, a¤r›l›, serratus anterior kas gücü 1/5 iken di¤er kas güçleri tam, derin tendon refleksleri
normoaktif, duyu defisiti yoktu. ‹mpingement testleri ve glenohumeral instabilite testlerinde
özellik saptanmad›. Di¤er ekstremitelerin nörolojik muayeneleri normaldi. Hastan›n özgeçmiflinde
özellik yoktu. Laboratuvar incelemesinde tam kan say›m›, sedimentasyon ve CRP normaldi.
Hastan›n yap›lan EMG’sinde sa¤da serratus anterior kas›nda akut spontan aktiviteler
(pozitif keskin dalga, fibrilasyon potansiyelleri), interferansta azalma saptand›. Di¤er incelenen
kaslar ve üst ekstremite sinir iletim çal›flmalar› normaldi. Bu bulgularla uzun torasik sinirin
k›smi subakut aksonal dejenerasyonu olarak raporland›. Bu verilerle fizik tedavi rehabilitasyon
program›na al›nan hastaya omuz eklem hareket aç›kl›¤› ve serratus anteriora güçlendirme
egzersizleri verildi. Hasta takibe al›nd›.
SONUÇ: Farkl› tan›larla kar›flabilen ve gözden kaçabilen bu klinik patolojinin nedenlerinin
ortaya konmas› olusabilecek komplikasyonlar›n önlenmesi aç›s›ndan çok önemlidir.
Anahtar Kelimeler: Kanat skapula, uzun torasik sinir, periferik sinir yaralanmas›
P-042
Carpal Tunnel Syndrome Accompanied with Complex Regional Pain
Syndrome Type II
Nilgün fiimflir Atalay1, Nuray Akkaya1, Selcen Alkan2, Füsun fiahin1 1Pamukkale University Medical School Department of
Physical Medicine and Rehabilitation, Denizli
2Denizli Government Hospital, Physical Medicine and Rehabilitation Clinic, Denizli
INTRODUCTION: Carpal tunnel syndrome (CTS) is an entrapment neuropathy with pain in the
fingers, paresthesia and hypoesthesia as a result of the compression of the median nerve.
Although there are publications stating that carpal tunnel relaxation surgery can cause complex
regional pain syndrome (CRPS), CRPS complication is rare in patients who are not treated
or not operated for CTS. In this case presentation, CRPS was clinically determined before
the operation in a patient diagnosed as advanced carpal tunnel syndrome on electrodiagnostic
investigation.
CASE: Thirty-five year-old female patient applied with weakness, numbness in first 3 fingers
of right hand, especially at night, starting approximately 2 months ago, and severe pain on
right wrist 3 weeks after the onset of the symptoms. Patient’s history showed agricultural
work and extreme uses of hand. On the examination, edema on the hand, increased heat,
sweating, pain with pressure on wrist and metacarpophalangeal (MCP) joints were found.
Thumb abduction muscle strength was -4/5 and painful. Tinnel, Phalen and Reverse Phalen
tests showed positive results. Visual Analogue Scale (VAS) was 9 in severity of pain. In evaluating
disability of the patient's upper limb, Disability of Arm, Shoulder and Hand
Questionnaire was used, and the score was found 75. EMG showed positive correlation with
advanced CTS. Three-phased bone scintigraphy with Tc-99m MDP results were interpreted
as CRPS. Laboratory tests were normal. Prednisolon starting from 30 mg was given to the
patient, stopped at the end of the third week by decremental dose regimen with the diagnosis
of CRPS. Contrast bath and active range of motion exercises were explained to the
patient.. At the end of the treatment, edema of the hand, redness and sweating symptoms
had decreased. Wrist and MCP joint VAS score with pressure were one. Numbness in fingers
and positive results of clinical tests have still continued. Her muscle strength was -5/5 after
the relief of pain. Patient was advised for operation according to EMG results. All complaints
regressed completely after the surgery.
CONCLUSIONS: Suspecting of CRPS accompanied to CTS, which is generally seen and
can be easily diagnosed with electrophysiological tests, can reduce or prevent possible
deformities
Keywords: Carpal tunnel syndrome, complex regional pain syndrome, treatment
P-043
Winged Scapula which Occurred After Punching a Sand Bag
Nilgün fiimflir Atalay, Sibel Konukcu, Özlem Ercido¤an, Füsun fiahin
Pamukkale University Medical School Department of Physical
Medicine and Rehabilitation, Denizli
INTRODUCTION: Winged scapula (WS) is moving away of scapula’s medial border or inferior
angle from thorax wall. WS can be caused by neurological trauma, pathological changes in
bone or pericapsular soft tissue or glenohumeral and subacromial pathologies. Direct compression
to the long thoracic nerve, repeated tensile trauma, blunt trauma, neuralgic brachial
plexus amyotrophy or surgeries on thorax can lead to the weakness in the serratus anterior
muscle, thus resulting in WS. In this case, WS clinical manifestation due to the isolated long
thoracic nerve damage after punching the sandbag was explained.
CASE: Twenty-one year old male patient, university student presented with the complaint of
severe pain in right shoulder which began after punching a sandbag 4 months ago in the
gym. Consulting to many physicians because of this pain, his X-ray and magnetic resonance
imagining the results were normal and he was diagnosed as muscle strain thus NSAID and
myorelaxatings were given. His pain did not decrease. He consulted orthopedics from where
he was referred to our clinic. His physical examination determined visible winged scapula on
the right. Right upper limb active and passive range of motion were normal but with pain.
Serratus anterior muscle strength was 1/5 whereas other muscle strengths were normal,
deep tendon reflexes were normoactive, sensory deficit was not determined. Pathologic findings
were not detected in the impingement tests and glenohumeral instability tests.
Neurological examinations of other extremities were normal. The patient had no other feature
in history. In laboratory tests, complete blood count, sedimentation rate and CRP were
normal. EMG showed acute spontaneous activities (positive sharp wave, fibrillation potentials)
and decrease in interference on right serratus anterior muscle. Other investigated muscles
and upper limb nerve conduction tests were normal. With these findings, subacute partial
axonal degeneration of the long thoracic nerve was reported. A rehabilitation program
consisting of shoulder joint range of motion and serratus anterior strengthening exercises
were given to the patient. The patient was being followed up.
CONCLUSIONS: Finding out the causes of this clinical pathology which can be missed or confused
with other diagnosis has critical importance to avoid complications.
Keywords: Winged scapula, long thoracic nerve, peripheric nerve injury