Tingling Fingers Doug Campbell Consultant Hand Surgeon, Leeds

Contents C spine Dermatomes Peripheral nerves Examination Decisions Referrals Treatments

Functions Execution Reception Social interaction Cosmetic Thermoregulation

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

Radial Ulnar

Peripheral Nerves Radial Median Ulnar

Radial Nerve Wrist, finger and thumb extensors Dorsum 1st web space MOTOR SENSORY Posterior Interosseous Nerve Radial Sensory Nerve

Median Nerve Thenar muscles Radial half of palm MOTORSENSORY 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 SurgeryDiminished 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 MOTORSENSORY Deep BranchSuperficial 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 Examination Special tests Decisions

Summary Anatomical knowledge Thorough clinical examination Potential causes EBM approach

Thank you for your attention