1. Tingling Fingers Doug Campbell Consultant Hand Surgeon, Leeds www.handandwristclinic.com

2. Contents C spine Dermatomes Peripheral nerves Examination Decisions Referrals Treatments

3. Functions Execution Reception Social interaction Cosmetic Thermoregulation

4. Composition 19 bones 17 joints 19 muscles

5. Composition 19 bones 17 joints 19 muscles 1 wrist 1 elbow 1 shoulder

6. Composition 19 bones 17 joints 19 muscles 1 wrist 1 elbow 1 shoulder 1 BRAIN !!!!

7. The Homunculus

12. C6 C7 C8 Dermatomes Same front & back

15. Acute disc prolapse Sudden onset severe pain Lancinating Brachalgia Scoliosis Torticollis Uncontrollable NOT ‘tingly fingers’!

16. Cervical spondylosis Some neck pain Trapezial spasm Brachalgia Posturally dependent Altered motor power ?altered reflexes ‘Tingly fingers’

18. Thoracic Outlet Syndrome (TOS) Posture or activity dependent Intermittent Significant brachalgia Ache Poorly localised Rarely ‘tingly fingers’

19. Cervical spondylosis Neurological examination Neural tension tests History based diagnosis

20. Thoracic Outlet Syndrome (TOS) Adson’s Test

21. Thoracic Outlet Syndrome (TOS) Roos’s Test

22. C6 C7 C8 Dermatomes Same front & back

23. Median Ulnar Peripheral nerves Same front & back NOT

24. Dorsal sensation

25. Radial Ulnar

26. Peripheral Nerves Radial Median Ulnar

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

28. Median Nerve Thenar muscles Radial half of palm MOTORSENSORY Recurrent Motor Branch Main Trunk Palmar cutaneous branch

30. Median Nerve Tinel’s test Phalen’s Test

31. Carpal tunnel syndrome Spontaneous improvement in up to 34% NSAIDs as effective as splints & PT Unusual to find a cause No workplace association

32. 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

33. Carpal tunnel syndrome Only when diagnosis uncertain Less useful in elderly 15% false negative rate Do I need nerve conduction studies?

34. BSSH guidelines Intermittent paraesthesia Nocturnal wakening +/- pain MILD

35. BSSH guidelines Exclude a cause Nocturnal splint Activity modification Consider steroid injection if trained Intermittent paraesthesia Nocturnal wakening +/- pain MILD

36. BSSH guidelines Permanent paraesthesia ADL interference Reversible numbness or pain Weakness or clumsiness MODERATE

37. 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

38. BSSH guidelines Diminished sensation Disabling pain Thenar wasting Weakness of APB/OP SEVERE

39. BSSH guidelines SurgeryDiminished sensation Disabling pain Thenar wasting Weakness of APB/OP SEVERE

40. MILD MODERATE SEVERE

41. MILD MODERATE SEVERE Night splints Steroid injctn Hand therapy TFTs, BlGl

42. MILD MODERATE SEVERE Night splints Steroid injctn Hand therapy TFTs, BlGl Max 3 mths

43. MILD MODERATE SEVERE Night splints Steroid injctn Hand therapy TFTs, BlGl RESOLVED Max 3 mths Improvement

44. MILD MODERATE SEVERE Night splints Steroid injctn Hand therapy TFTs, BlGl RESOLVED Max 3 mths Improvement Deterioration SURGERY

45. MILD MODERATE SEVERE Night splints Steroid injctn Hand therapy TFTs, BlGl RESOLVED Max 3 mths Improvement Deterioration SURGERY

46. 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

47. 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

48. 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

49. 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

50. Ulnar Nerve Hypothenar muscles Interossei Ulnar 2 lumbricals Adductor Pollicis Ulnar half of palm MOTORSENSORY Deep BranchSuperficial Branch

52. Ulnar nerve Froment’s test Interosseous weakness FDO weakness Tinel’s

53. Wartenburg’s abnormality

54. Intrinsic Tightness Flex the MCP Extend the IP’s

55. Intrinsic minus

56. Cubital tunnel syndrome Elbow splint at night Drawing pin Monitor grip & stamina Greater use of NCS Consider surgery

57. Neural Control of the Thumb

58. 15 minutes with a patient with ‘tingly fingers’

59. History Examination Special tests Decisions

60. Summary Anatomical knowledge Thorough clinical examination Potential causes EBM approach

61. Thank you for your attention www.handandwristclinic.com