Should the patient be referred for surgery? This is referred to as the Wartenberg sign. When weakness is advanced, the unopposed action of the extensor digiti minimi muscle on the little finger may result in an abducted posture of the little finger. Asking the patient to cross their fingers is a simple way to elicit weakness of the interossei. Other motor signs include subjective or objective evidence of reduced grip strength and weakness of the ulnar nerve–innervated interossei. When asked to grip a sheet of paper between thumb and radial border of the index finger, the patient compensates by flexing the thumb at the interphalangeal joint and recruiting the median nerve–innervated flexor pollicis longus muscle ( Figure 1).
The Froment sign may be abnormal and results from weakness of the adductor pollicis muscle. Tapping a finger over the cubital tunnel may produce an abnormal Tinel sign, with altered sensation in the distribution of the ulnar nerve. Taking the elbow through a range of movement may unmask any instability or “snapping” of the nerve. The ulnar nerve may be palpated behind the medial epicondyle. Sensation should be tested throughout the hand, with reduced or altered sensation expected in the little finger and the ulnar half of the ring finger. What tests for nerve function should be included in the examination?Įxamination should include inspection for wasting of the hypothenar muscles and the interossei. 1 Bilateral symptoms, atypical patterns of weakness or altered sensation, and cervical symptoms should be specifically sought and should prompt consideration of alternative diagnoses ( Box 1). Patients may report a range of motor symptoms, including weakness or clumsiness when performing tasks involving fine motor skills. In severe cases, sensory symptoms may be permanent, and patients may have signs of muscle atrophy and clawing in the hand.
Intermittent symptoms, worse at night or with elbow flexion, are suggestive of cubital tunnel syndrome. These symptoms are usually confined to the ring and little fingers, but may be accompanied by pain localized to the medial aspect of the elbow or radiating into the ring or little fingers. Numbness and paresthesia are the predominant presenting features early in cubital tunnel syndrome. A comprehensive systemic enquiry, including any family history of neurologic conditions, should be completed. In evaluating the cause of numbness in the hand, the handedness and occupation of the patient should be elicited, as well as any history of trauma or surgery to the elbow. Less frequent causes include systemic conditions such as Guillain–Barré syndrome, motor neuron disease or polyneuropathyīilateral symptoms or unusual patterns of neurologic signs on examination Substantial smoking history chest pain, breathlessness hemoptysis constitutional symptoms of malignancy Horner syndrome Widespread neurologic symptoms and examination findings cape-like loss of pain and temperature sensation Pain is a predominant feature discoloration of the hand symptoms related to strenuous exercise History of trauma, more widespread neurologic symptoms and signs Sparing of sensation on the dorsum of the hand Neck pain, reduced range of movement in the neck, sensory changes proximal to the wrist crease Sparing of ring and little fingers, thenar muscle wasting, lack of interossei wasting, positive Phalen test and Durkan compression test
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