Carpal tunnel syndrome and ulnar nerve palsy

Question 1

What is carpal tunnel syndrome?

Answer 1

Compression of median n in the carpal tunnel

Question 2

Presentation of carpal tunnel syndrome?

Answer 2

Pain/pins and needles in the thumb, index and middle finger
Patient shakes hand to obtain relief, classically at night
Unusually the symptoms may ascend proximally

Question 3

What would you find on examination in CTS?

Answer 3

Weakness of thumb abduction (abductor pollicis brevis)
Wasting of thenar eminence
Tinel’s sign
Phalen’s sign

Question 4

What is Tinel’s sign?

Answer 4

Tapping causes paraesthesia

Question 5

What is Phalen’s sign?

Answer 5

Flexion of wrist causes symptoms

Question 6

What muscle is responsible for thumb abduction?

Answer 6

Abductor pollicis brevis

Question 7

Cause of CTS?

Answer 7

Idiopathic
Pregnancy
Oedema e.g. HF
Lunate fracture
Rheumatoid arthritis
Repetitive wrist flexion or hand elevation
Obesity
Hypothyroidism
Ganglion cysts
DM

Question 8

DDx of CTS?

Answer 8

Cubital tunnel syndrome
Cervical nerve root entrapment (radiculopathy at C6/7 level–> neck pain with radiation of pain and numbness)
De Quervains tenosynovitis
OA
Trigger thumb

Question 9

Electrophysiology findings in CTS?

Answer 9

Motor + sensory prolongation of the AP

Question 10

Management of CTS?

Answer 10

6 week trial of conservative treatments if symptoms are mild/moderate: Corticosteroid injection and wrist splints at night

Severe symptoms or symptoms that persist despite conservative treatment:
Surgical decompression

Question 11

What is cubital tunnel syndrome?

Answer 11

Compression of ulnar nerve as it passed through cubital tunnel

Question 12

Clinical features of cubital tunnel syndrome?

Answer 12

Tingling and numbness of the 4th and 5th finger which starts off intermittent and then becomes constant.
Over time patients may also develop weakness and muscle wasting
Pain worse on leaning on the affected elbow
Often a history of osteoarthritis or prior trauma to the area.

Question 13

Investigations of cubital tunnel syndrome?

Answer 13

Usually clinical diagnosis
Sometimes nerve conduction studies used

Question 14

Management of cubital tunnel syndrome?

Answer 14

Avoid aggravating activity
Physiotherapy
Steroid injections
Surgery in resistant cases

Question 15

Presentation of damage to ulnar nerve at the wrist?

Answer 15

‘Claw hand’- hyperextension of metacarpophalangeal joints and flexion at the distal and proximal interphalengeal joints of 4th and 5th digits

Wasting and paralysis or intrinsic hand muscles (except lateral 2 lumbricals)
Wasting and paralysis of hypothenar muscles
Sensory loss to the medial 1.5 fingers (palmar and dorsal aspect)

Question 16

Presentation of damage to ulnar nerve at wrist?

Answer 16

‘claw hand’ - more severe than at the elbow
wasting and paralysis of intrinsic hand muscles (except lateral two lumbricals)
wasting and paralysis of hypothenar muscles
sensory loss to the medial 1 1/2 fingers (palmar and dorsal aspects)

Radial deviation of the wrist