Background
The patient is 50 years old and works as a cleaner. Previously healthy. Seeks the GP due to increasing problems with paresthesia and pain (VAS 5) in the right hand, localized to the 1st–3rd fingers and the radial half of the 4th finger. It is particularly bad at night, when the patient has to shake the hand to get rid of the numbness.
The symptoms have lasted for about a year. In the last two months, the patient has also been troubled with pain and numbness during the day. Paracetamol has little effect on the pain.
Consultation video
Medical history
- Doctor
What can I help you with?
- Patient
I have gotten more and more problems with my right hand. It tingles and hurts.
- Doctor
Where in the hand do you feel it?
- Patient
Mostly in the thumb, index finger, and middle finger... and a little in the ring finger as well, on this side.
- Doctor
How long have you had it like this?
- Patient
About a year, I think. But it has gotten much worse in the last two months.
- Doctor
When is it worst?
- Patient
At night. Then I wake up because my hand is numb and painful.
- Doctor
What do you do then?
- Patient
I have to shake my hand to make it release a little.
- Doctor
Do you also have trouble during the day?
- Patient
Yes, now I feel it during the day too. More both pain and numbness.
- Doctor
Have you tried anything for it?
- Patient
I have taken Paracetamol, but it hardly helps.
- Doctor
Do you notice that your hand is weaker than before?
- Patient
Yes… I think I am weaker, especially when I have to grip properly.
Standard examination
Perform standard examination:
- 1 Inspection
- 2 Active movements
- 3 Passive movements
- 4 Isometric movements
- 5 Palpation
Tentative diagnosis
based on medical history and standard examination- Carpal tunnel syndrome.
Examination
Special tests to strengthen or weaken the likelihood of the tentative diagnosis.
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1. Sensation in the median nerve area
Doctor
I will examine the sense of touch in the hand. Let me know if it feels the same on both sides.
Patient
Indicates a clear difference in the right hand, particularly at the fingertips of the 2nd and 3rd fingers and the radial side of the 4th finger.
There is less sensation there.
It feels more numb.
Findings
- Reduced sensation in the median nerve area of the right hand.
- Especially on the palmar side of the finger pads of the 2nd and 3rd fingers.
- Also reduced sensation on the radial side of the 4th finger.
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2. Tinel's test
Doctor
Now I am going to tap lightly here at the wrist. Tell me what you feel.
Patient
When the doctor taps over the carpal ligament, it shoots out into the fingers.
Yes, it tingles into the fingers.
Thumb, index finger, and middle finger.
Findings
- Positive Tinel with tingling in the 1st–3rd fingers.
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3. Phalen's test
Doctor
Keep your wrists bent like this for a little while, and let me know if the symptoms appear.
Patient
After a short time, the numbness increases.
Now it comes again.
It goes numb in the same fingers.
Findings
- Positive Phalen with numbness in the median area, 1st–3rd finger and the radial side of the 4th finger.
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4. Compression test over the carpal tunnel
Doctor
I press a little here over the wrist. Let me know if it triggers the symptoms.
Patient
Known numbness is quickly reproduced.
Yes, it's the same feeling.
It tingles and becomes numb again.
Findings
- Positive compression test with numbness in the median area.
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5. Strength in opposition grip
Doctor
Try to press your thumb against your little finger and hold back when I try to pull them apart.
Patient
Tries, but is noticeably weaker in the right hand. There is reduced strength and control without dramatic pain reaction.
It is weaker than before.
I can't resist as well.
Findings
- Reduced strength in opposition grip.
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6. Assessment of thenar musculature
Doctor
Have you yourself noticed any change here at the base of the thumb?
Patient
Yes… I think that muscle part has become smaller than before.
Findings
- The patient experiences that the thenar musculature is smaller than before.
Learning points
- 1 Classic symptom distribution in median nerve involvement in the hand with nocturnal symptoms, paresthesia, numbness, positive Tinel and Phalen, reduced thenar function, and strength loss in opposition grip.
- 2 The case shows the difference between peripheral nerve compression in the wrist, more proximal neurological causes, and non-neurological hand pain.