Question

A 55 year-old male presents with progressive history of weakness of both arms and forearms, as well as tingling along the 4^th and 5^th fingers of the hands, and loss of sensitivity on the medial side of the forearms and back of the hands. There is no history of trauma. There is no diabetes, infection, rheumatism, or alcoholism. The patient cannot hold a card between the thumb and the index finger. Picture of the right hand (on the left) shows the following features, which are actually seen on both hands.

Patient Normal hand

1. Which nerve has been affected in this patient?                                                                                                                                                                                                                                                                                                                                          

2. Discuss the potential sites of compression of this nerve and how to distinguish between them?                                                                                                             

Examination finds that the radial pulse is lost during abduction and external rotation of the shoulder.

3. What could be the hypothesis concerning the site of compression?          

An X-ray shows the following abnormalities (arrows):

4. What is the name of this syndrome? Describe it (origin and symptoms) and discuss the tests that can be useful for diagnosis and evaluation.                                                                                                                                                                                     

5. Discuss the treatment that could be indicated in the present case?            

Answer 1

1. Compression of ulnar nerve are responsible for this symptom

2.occurs mainly 2 sites elbow ( cubital tunnel syndrome)and wrist (Guyon's canal syndrome )

Symptoms

Cubital tunnel syndrome	Guyon's canal syndrome
Tingling of 4th and 5th finger Hypothesis and paresthesia Pain Weak grip strength Muscle atrophy	Weakness in finger abduction Paresthesia Sensory loss and pain on fourth digit medial aspect Muscular atrophy

3. Compression of bronchial plexus, sites: cervical rib

4.Thoracic outlet syndrome

• Tests- history collection about symptoms and onset, chest X ray, palpitation of ribcage, MRI and CT. Nerve compression studies

5.Treatment

• Anticoagulants- warfarin
• Compression of blood vessels.
• Surgery removal of cervical rib that are affected
• Physiotherapy eg. Stretching exercises
• Drugs : Non steroid Antinflammatory drugs, for relieving symptoms and calcium channel blockers.