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WASTED HANDS

Relevant physical signs

Inspection

o Myotonic facies

o Ipsilateral Horners syndrome (Pancoasts tumour)

o Tongue fasciculations (motor neurone disease)

o Symmetry

o Fasciculations

o Distribution

Muscles innervated by median nerve (thenar eminence)

Muscles innervated by ulnar nerve (hypothenar eminence)

Generalized wasting (C8/T1 anterior horn cell disease / plexopathy)

o Involvement of the lower limbs

Foot drop (myotonic dystrophy, inclusion body myositis)

Pes cavus (Charcot-Marie-Tooth disease)

o Clawing of the hand (C8/T1 lesion or combined median / ulnar nerve palsy)

o Deforming polyarthropathy (disuse atrophy from rheumatoid arthritis)

o Clubbing (Pancoats tumour, especially if unilateral)

Tone

o Flaccid as wasting is a sign of lower motor neurone disease

o Spastic lower limbs if cervical myelopathy

Reflexes

o Normal biceps, supinator, triceps if C8-T1 cord lesion

o May be depressed if cord lesion is multi-level / peripheral neuropathy

Power

o Point your thumb to the ceiling flexor pollicis brevis, median nerve

o Push your thumb inwards abductor pollicis brevis, median nerve


o Make a fist hand of Benediction in median nerve palsy

o Make an OK sign, then touch each finger with your thumb) opponens pollicis,
median nerve

o Hold this piece of paper between your fingers palmar interossei, ulnar nerve

o Hold this piece of paper between your thumb and index finger if the thumb
flexes to compensate, this is a positive Froments sign and indicates ulnar nerve palsy

o Check flexion of the DIPJ of the 5th finger in ulnar nerve palsy if preserved, lesion is
distal to elbow

o Wrist extension radial nerve, C7/8

Coordination usually normal

Sensation

o Check for sensory loss in distribution of median, ulnar and radial nerves

o If glove and stocking loss: peripheral neuropathy such as Charcot-Marie-Tooth

o If dissociated sensory loss to pain and temperature only: syringomyelia

o If proprioception affected more: cervical myelopathy

o If sensation completely preserved

Anterior horn cell disease e.g. old poliomyelitis

Motor neurone disease

Myotonic dystrophy

Inclusion body myositis

Distal spinal muscular atrophy

Differential diagnosis

Cervical myelopathy

Anterior horn cell disease

Motor neurone disease

C8/T1 radiculopathy

o Pancoasts syndrome

Lower brachial plexopathy


o Cervical rib

Mononeuropathy

Charcot-Marie-Tooth disease

Myotonic dystrophy

Inclusion body myositis

Distal spinal muscular atrophy

Disuse atrophy

Investigations

Nerve conduction studies: to look for slowing of conduction across affected nerves

Chest radiograph

o Cervical rib

o Pancoast tumour

Magnetic resonance imaging of the cervical spine to look for cervical myelopathy

EMG to look for electrical myotonia if myotonic dystrophy suspected

Muscle biopsy if inclusion body myositis

Management

Patient education

PT/OT to maximize and preserve function

Compression neuropathies may require decompressive surgery (e.g. carpal tunnel release)

Treat the underlying cause

Summary

Sir, this patient has asymmetric wasting of the small muscles of the right hand. On examination,
there is weakness of muscles supplied by the median nerve, such as abductor pollicis brevis and
flexor pollicis brevis, as well as those supplied by the ulnar nerve, such as the palmar interossei. Wrist
extension and finger flexion are relatively spared, implying that this is a C8/T1 lesion. Sensation is
also lost to pinprick in those dermatomes. The possibilities for this include a C8/T1 radiculopathy or a
lower brachial plexopathy. This may be caused by low cervical spondylosis, although it usually affects
the middle cervical cord, an apical lung tumour, although I did not see any overt ipsilateral Horners
syndrome, a cervical rib, or traumatic avulsion of the brachial plexus.

In summary, this patient has a C8/T1 lesion, causing unilateral wasting of the small muscles of the
hand.