Emily:
Diff Dx:
autoimmune pathology
sepsis - any cat scratches?
I would immediately refer for further w/u - hand surgeon or neurologist.
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Douglas M. White, PT, OCS
191 Blue Hills Parkway
Milton, MA 02186
Ph: 617.696.1974
Dear all
Would be glad of your thoughts on my last patient this evening:
13 year old boy, 8 day history of sudden (ie, over a few hours) onset left
hand weakness in the 4th and 5th fingers. Also notes reduced sensation in
these fingers only. No pain or discomfort of any sort in neck, arm, wrist,
hand. No other symptoms anywhere else. No recollection of sleeping
awkwardly, prolonged use of power tools, contusion, fall, etc etc etc.
On o/e: Claw deformity 4th and 5th at rest, deviated into adduction at
MCPs
Unable to correct hyperextension at 4th and 5th mcps and
flexion at IPs
Slight wasting (already!) 4th and 5th web spaces dorsally
Decreased sensation dorsal and medial 4th and 5th fingers,
less so palmar surface
1/5 strength 4th and 5th lumbricals and interossei
2/5 strength remaining interossei and 3/5 remaining
lumbricals
3/5 strength flexion DIPs 4th and 5th
Slight decrease only in wirist flexion and ulnar deviation -
no hand radial deviation at rest
All shoulder and scapular strength testing NAD
No Tinel's response anywhere along entire arm/hand
No pain on palpation anywhere arm/hand.
No sympathetic changes apparent
Spinal reflexes NAD
Cervical spine - ROM and PPIVMs and PAIVMs all NAD and
painfree
Neuropathodynamic tests - no difference R vs L and no
positive signs or symptoms
It seems to me that this lad has a peripheral ulnar nerve lesion, but
how????? My main questions are as follows:
- Forearm or wrist origin of lesion? I would have expected both flexor dig.
profundis and flexor carpi ulnaris to be equally affected if the lesion was
in the forearm, but, as you can seen, one is moderately affected, the other
not significantly
- How did this happen - any ideas?
- Should I refer on immediately for further tests - is there a chance of
nasty pathology?
I have adopted a policy of watch and wait for the next 5 days and have sent
him off with a tape/splint arrangement for the 4th and 5th fingers.
Any ideas gratefully accepted!!
Emilie McGrath
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