The examination of hand for neuropathies is commonly encountered at OSCE stations. One of the most common scenarios would be carpal tunnel syndrome.
Firstly, introduce yourself and get consent before you proceed to examine the patient.
Usually, the command is to examine the hands of the patient, but sometimes you might be given a clue like “This lady presented with tingling sensation in her hands”. The disease is often bilateral.
This patient who presented with tingling sensation of hands has bilateral thenar muscle wasting but there is no wasting of hypothenar eminence or dorsal guttering. There are no visible surgical scars, suggestive of previous carpal tunnel decompression surgery. Her opposition of the thumbs is weak and the pen touch test is positive, but there is no weakness in finger adduction or extension. There is an area of sensory loss over the palmar aspect of the lateral three and a half fingers and no other areas of sensory loss. Tinel’s test and Phalen’s test are positive. So my tentative diagnosis is bilateral Carpal Tunnel Syndrome (CTS) and I would like to assess her functional disability and probable aetiology.
It is the symptomatic compression of the median nerve at the carpal tunnel where it runs deep to the flexor retinaculum (Commonest entrapment neuropathy).
Roof – Flexor retinaculum. Medial (Ulnar) – Pisiform & Hook of Hamate. Lateral (Radial) – Scaphoid and Trapezius. Palmar aspect – Transverse carpal ligament.
1. Median nerve.
2. Four tendons of Flexor Digitorum Superficialis.
3. Four tendons of Flexor Digitorum Profundus.
4. Tendon of Flexor Pollicis Longus.
5. Tendon of Flexor Carpi Ulnaris (in a separate compartment).
1. Palmar cutaneous branch of the Median nerve.
2. Ulnar nerve.
3. Ulnar artery.
4. Tendon of Palmaris Longus.
Because the palmar cutaneous branch of the Median nerve is given away proximal to the flexor retinaculum and which passes over it.
1. All thenar muscles except Adductor Pollicis.
2. Radial two Lumbricals.
Nerve conduction studies (NCS).
4. Diabetes Mellitus.
5. Rheumatoid Arthritis.
1. Cervical rib.
2. Cervical spondylosis.
3. Pancoast’s syndrome.
Carpal tunnel decompression by longitudinally dividing the flexor retinaculum in full length in a bloodless field under local anesthesia.
1. Local steroid injection.
2. Splinting of the wrist at night.
3. Treating the underlying cause.