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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
