[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

“This patient has complained of a loss of manual dexterity.  Please examine their arms and present your findings to the examiners.”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/138191683″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station Time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”6″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”4″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has a claw hand caused by an ulnar nerve palsy.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]Entrapment of the ulnar nerve or an injury to it causing denervation and paralysis of the muscles to which it supplies is known as ulnar nerve palsy. The nerve runs close to the medial side of the body and controls almost all the muscles responsible for fine movements of hand.  The underlying causes of palsy may include:

  • Elbow fractures or dislocations
  • Palsy associated with medial epicondylitis
  • Nerve entrapment
  • Artery aneurysm
  • Thrombosis
  • Repeated trauma
  • Deformities (rheumatoid arthritis)
  • Metabolic derangements (diabetes mellitus)
  • Malnutrition causing atrophy and loss of fatty protection around joints making nerve more vulnerable to injury
  • Tumours
  • Ganglionic cysts (ulnar tunnel, Guyon’s canal)
  • Blunt injuries (mountain bikers are particularly vulnerable)
  • idiopathic

While entrapment and injury can occur anywhere along nerve’s course, the most common site of entrapment is the cubital tunnel of elbow (cubital tunnel syndrome), followed by wrist in the canal of Guyon. A damaged ulnar nerve is characterized by:

  • A) Symptoms
    • Unusual sensations in little and ring (medial border) fingers (burning, tingling and numbness)
    • Loss of coordination in fingers
    • Pain in arm and elbow more common than pain in hand
    • Weakness (difficulty in opening bottles or jars)
    • Weakness worsening on physical activity
    • Occasionally there is severe pain in elbow or wrist radiating to hand and shoulders and neck.
    • A weak grip
  • B) Signs on physical examination
    • Claw-like deformity (low ulnar lesion – occurring at the wrist)
    • Wasting of muscles along medial side of forearm and hand muscles with sparing of the thenar eminence
    • Dorsal guttering (first dorsal interosseus initially noticeable)
    • Flexor digitorum profundus paralysed (high ulnar lesion, with less pronounced clawing)
    • Discomfort and paraesthesia within 60 seconds on elbow flexion test
    • Positive shoulder internal rotation test
    • Wartenberg sign (paralysis of the abducting palmar interosseous muscle causing a somewhat increased abduction of the fifth digit and therefore unopposed action of the radial innervated extensor muscles)
    • Froment sign (inability to grip a piece of paper between the index finger and thumb without distal interphalangeal joint flexion due to weak thumb adduction)

High ulnar lesions are classified as occurring at the elbow. The nerve roots supplying the ulnar nerve are C8 and T1.

Apart from physical examination, routine investigations carried out to rule out other causes and diagnose the condition include:

  • Baseline blood tests including full blood count, renal function liver function, ESR and clotting along with ANA (for vasculitides)
  • Urinalysis
  • HbA1c testing (diabetic cheiropathy is a complication of long term Type 1 Diabetes featuring skin tightening which leads to restriction of the joint and tendon sheath sclerosis)
  • Imaging tests (X-ray, MRI of neck, ultrasound, nerve conduction tests)

Pharmacotherapy is aimed at reducing morbidity, improving life quality and preventing complications involves administering:

  • Over-the-counter pain relievers
  • Corticosteroid injections (to reduce swelling)
  • Tricyclic antidepressants (to reduce stabbing pains)
  • Anticonvulsants

Splints may be used to support hand and reduce pain and physical therapy helps in strengthening muscle and function. A failed conservative treatment may require surgical intervention, the indications are:

  • Progressive palsy
  • No improvement in symptoms (despite 6-12 weeks of treatment)
  • Long-standing lesion evident clinically

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has a claw hand caused by an ulnar nerve palsy.  I would like to confirm this with nerve conduction studies.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]