Hand

Carpal Tunnel Syndrome

History

  • Numbness
  • Exacerbate when holding objects
  • Pain at night. Relieved when handing the arm
  • Dominant hand
  • Occupation and repetitive use
  • Hypothyroid features, use of thyroxin
  • Diabetic or not
  • Rheumatoid arthritis

Examination

Keep both hands over a table and examine.

Look for scars of median nerve injury on affected and other hand (might have had carpal tunnel release in the past. Look specifically for that scar)

Wasting of thenar eminenece (suggest severe disease)

Power of abductor pollicis brevis – lift thumb towards ceiling under resistance

Sensation over lateral 3 and half fingers
Ix

  • NCS
  • TSH (hypothyroidism), FBS (DM)

Mx

Carpal tunnel release under LA in a bloodless field by applying a tourniquet.

After release pain and numbness will resolve but wasting will prevail.

After release don’t apply a tight dressing as ulnar nerve can be damaged in medial side.

Keep for 4 hrs to look for ulnar claw and discharge. Suture removal in 14 days.

Radial Nerve

Direct continuation of the Posterior cord of Brachial plexus (C5-T1)

Supplies posterior compartment of arm (Triceps) and Forearm.
Injured at

Axilla – shoulder dislocation.

  • The triceps brachii and muscles in posterior compartment are affected. The patient is unable to extend at the forearm, wrist and fingers. Unopposed flexion of wrist occurs, known as wrist-drop.

Radial groove following mid shaft fracture of Humerus.

  • The triceps brachii may be weakened, but is not paralysed (branches to the long and lateral heads of the triceps arise proximal to the radial groove).
  • Muscles of the posterior forearm are affected. The patient is unable to extend at the wrist and fingers. Unopposed flexion of wrist occurs, known as wrist-drop.

Ulnar Nerve

Claw hand – Hyperextension of ulnar 2 MP joints (Ring and Small finger) and hyperflexion of MIP and PIP Joints. The lesion is at the wrist.

Ulnar Paradox – Hyperextension of ulnar 2 MP joints (Ring and Small finger) and flexion of MIP and PIP Joints. Lesion is high up (medial epicondyle). Flexor digitorum profundus also paralysed.