Tingling Fingers

Doug Campbell

Consultant Hand Surgeon,

Leeds

www.handandwristclinic.com

Contents

• C spine• Dermatomes• Peripheral nerves• Examination• Decisions• Referrals• Treatments

Functions

• Execution• Reception• Social

interaction• Cosmetic• Thermoregulati

on

Composition

• 19 bones• 17 joints• 19 muscles

Composition

• 19 bones• 17 joints• 19 muscles• 1 wrist• 1 elbow• 1 shoulder

Composition

• 19 bones• 17 joints• 19 muscles• 1 wrist• 1 elbow• 1 shoulder• 1 BRAIN !!!!

The Homunculus

C6

C7 C8

Dermatomes

Same front & back

Acute disc prolapse

• Sudden onset severe pain

• Lancinating• Brachalgia• Scoliosis• Torticollis• Uncontrollable

NOT ‘tingly fingers’!

Cervical spondylosis• Some neck pain• Trapezial spasm• Brachalgia• Posturally dependent• Altered motor power• ?altered reflexes

‘Tingly fingers’

Thoracic Outlet Syndrome (TOS)

• Posture or activity dependent

• Intermittent• Significant brachalgia• Ache• Poorly localised

Rarely ‘tingly fingers’

Cervical spondylosis

• Neurological examination

• Neural tension tests• History based

diagnosis

Thoracic Outlet Syndrome (TOS)

Adson’s Test

Thoracic Outlet Syndrome (TOS)

Roos’s Test

C6

C7 C8

Dermatomes

Same front & back

Median Ulnar

Peripheral nerves

Same front & back

NOT

Dorsal sensation

Dorsal sensation

Radial

Ulnar

Peripheral Nerves

• Radial• Median• Ulnar

Radial Nerve

• Wrist, finger and thumb extensors

• Dorsum 1st web space

MOTOR SENSORYPosterior Interosseous Nerve Radial Sensory Nerve

Median Nerve

• Thenar muscles • Radial half of palm

MOTOR SENSORY

Recurrent Motor Branch

Main Trunk

Palmar cutaneous branch

Median Nerve

• Tinel’s test• Phalen’s Test

Carpal tunnel syndrome

• Spontaneous improvement in up to 34%

• NSAIDs as effective as splints & PT• Unusual to find a cause• No workplace association

Carpal tunnel syndrome

• Benefits are early (1-3 months)• Effectiveness beyond 1 month

uncertain• Multiple injections may be reqd• Similar results with simple splinting

Steroid injections

Carpal tunnel syndrome

• Only when diagnosis uncertain

• Less useful in elderly• 15% false negative rate

Do I need nerve conduction studies?

BSSH guidelines

• Intermittent paraesthesia

• Nocturnal wakening

• +/- pain

MILD

BSSH guidelines

• Exclude a cause• Nocturnal splint• Activity

modification• Consider steroid

injection if trained

• Intermittent paraesthesia

• Nocturnal wakening

• +/- pain

MILD

BSSH guidelines

• Permanent paraesthesia

• ADL interference• Reversible

numbness or pain• Weakness or

clumsiness

MODERATE

BSSH guidelines

• Exclude a cause• Nocturnal splint• Activity

modification• Consider steroid

injection if trained

• Permanent paraesthesia

• ADL interference• Reversible

numbness or pain• Weakness or

clumsiness

MODERATE

BSSH guidelines

• Diminished sensation

• Disabling pain• Thenar wasting• Weakness of

APB/OP

SEVERE

BSSH guidelines

• Surgery• Diminished sensation

• Disabling pain• Thenar wasting• Weakness of

APB/OP

SEVERE

MILD

MODERATE

SEVERE

MILD

MODERATE

SEVERE

• Night splints

• Steroid injctn

• Hand therapy

TFTs, BlGl

MILD

MODERATE

SEVERE

• Night splints

• Steroid injctn

• Hand therapy

TFTs, BlGl

Max 3 mths

MILD

MODERATE

SEVERE

• Night splints

• Steroid injctn

• Hand therapy

TFTs, BlGl

RESOLVED

Max 3 mths

Improvement

MILD

MODERATE

SEVERE

• Night splints

• Steroid injctn

• Hand therapy

TFTs, BlGl

RESOLVED

Max 3 mths

Improvement

Deterioration

SURGERY

MILD

MODERATE

SEVERE

• Night splints

• Steroid injctn

• Hand therapy

TFTs, BlGl

RESOLVED

Max 3 mths

Improvement

Deterioration

SURGERY

MILD

MODERATE

SEVERE

• Night splints

• Steroid injctn

• Hand therapy

TFTs, BlGl

RESOLVED

Max 3 mths

Improvement

Deterioration

SURGERY

• Elderly

• Neck pain

• Bilateral

• Phalen/Tinel -ve

MILD

MODERATE

SEVERE

• Night splints

• Steroid injctn

• Hand therapy

TFTs, BlGl

RESOLVED

Max 3 mths

Improvement

Deterioration

SURGERY

• Elderly

• Neck pain

• Bilateral

• Phalen/Tinel -ve

NCS

MILD

MODERATE

SEVERE

• Night splints

• Steroid injctn

• Hand therapy

TFTs, BlGl

RESOLVED

Max 3 mths

Improvement

Deterioration

SURGERY

• Elderly

• Neck pain

• Bilateral

• Phalen/Tinel -ve

NCS

MILD

MODERATE

SEVERE

• Night splints

• Steroid injctn

• Hand therapy

TFTs, BlGl

RESOLVED

Max 3 mths

Improvement

Deterioration

SURGERY

• Elderly

• Neck pain

• Bilateral

• Phalen/Tinel -ve

NCS

Ulnar Nerve

• Hypothenar muscles• Interossei• Ulnar 2 lumbricals• Adductor Pollicis

• Ulnar half of palm

MOTOR SENSORY

Deep Branch

Superficial Branch

Ulnar nerve

• Froment’s test• Interosseous weakness• FDO weakness• Tinel’s

Wartenburg’s abnormality

Intrinsic Tightness

Flex the MCP

Extend the IP’s

Intrinsic minus

Cubital tunnel syndrome

• Elbow splint at night• Drawing pin• Monitor grip & stamina• Greater use of NCS• Consider surgery

Neural Control of the Thumb

15 minutes with a patient

with ‘tingly fingers’

• History• Examinatio

n• Special

tests• Decisions

Summary

• Anatomical knowledge• Thorough clinical examination• Potential causes• EBM approach

Thank you for your attention

www.handandwristclinic.com