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CASE DISCUSSION Dr Rizwan Arshad PGR Orthopedic Surgery DHQ Hospital Sargodha


Patient Name: Eman Gender: Female Age: 6 years Address: 99 PRESENTING COMPLAINT:- Deformity of Right Hand with Associated Paresthesia for 8 months.


History of Presenting Complaint:- Gradual onset and progressive deformity with weakness of right hand 8 months back, not associated with joint pain. Associated paresthesia , initially involving 4 th & 5 th digits but now 2 nd , 3 rd , 4 th & 5 th digits. No history of trauma to the right limb.


Systemic Inquiry: Multiple Superficial Lumps on different body parts, otherwise Unremarkable. Past Surgical History: Unremarkable. Family History: Unremarkable. Social & Personal History: Plays cricket as a hobby with dominant right arm.


EXAMINATION Inspection :- Hyperextension of MP joint with flexion of PIP & DIP joints of 2 nd to 4 th digits (not a typical ulnar claw) Increased space between 4 th & 5 th Digits. Sensory Examination :- Decreased Touch sensation along the ulnar border of hand, dorsum (ulnar division) & 2 nd , 3 rd , 4 th , 5 th Digits (least in 4 th & 5 th ) . Touch Sensation also decreased along the medial forearm.

Motor Examination:-:

Motor Examination :- Bulk: Only Mildly Decreased in the Right Forearm. Prominent wasting of Hypothenar Muscles and inter-metacarpal spaces. Tone: Normal in Right Upper Limb. Power Grades:- Dorsal Interossei : 0/5 Lumbricals : 3 rd & 4 th – 3/5 1 st & 2 nd – 5/5 Hypothenar Compartment: Adductor digiti minimi , Flexor Digiti minimi & Opponens digiti – All 3/5 Adductor Pollicis Brevis : 2/5 Flexor Carpi Ulnaris : 3/5 Flexor Digitorum Profundus : 5/5


Deep Tendon Reflexes: Biceps – Normal & Intact Triceps – Normal & Intact Brachioradialis – Normal & Intact Carrying Angle: Increased in both limbs. Tinel’s Sign Positive. Positive froment sign. Unable to abd -add middle finger and unable to abd little Investigations :- Complete Blood Profile. X-Ray Forearm, Elbow & Hand (AP & Lateral). Electromyography. Nerve Conduction Studies.


Provisional Diagnosis: Cubital Tunnel Syndrome. Differential Diagnosis :- 1- Guyon Canal Syndrome:- Most commoly caused by ganglion, also by trauma or congenital anomaly. Characteristic Ulnar Claw present. Sensory loss most prominent on 5 th digit & Ulnar side of 4 th Digit but not on the ulnar dorsum of hand. Motor symptoms more pronounced than other associated symptoms.


2- Thoracic Outlet Syndrome:- Caused by Cervical Rib, Fibrous or Tendinous Bands, Swellings or Clavicle Trauma. Pain (major complaint). Burning or cutting in nature, radiates down the forearm, worst at night. Vascular Complications prominent. Thromboembolic complications & poststenotic aneurysms. Raynaud’s Phenomenon. Colour & Temperature – Blue & Cold. Palsy of thenar muscles often accompany paralysis of ulner innervated muscles.


Sensory Disturbances in Upper arm (medial cutaneous nerve of arm) along with forearm & hand. Symptoms Exagerated on lateral flexion away from the affected side ( Spurling Sign). Diminished Pulse & Low B.P. Adson’s Test positive. Wright Test positive. Claudication .


3- Cervical Root Compression:- Most commonly caused by cervical root tumor & disc herniation . Pain (major complaint), Aching in nature, radiating toward the occipital region. Tenderness over cervical vertebra. Sensory symptoms less evident. Motor weakness in specific nerve root distribution. C5-C6 Disc: Biceps & Biceps Jerk weakness C6-C7 Disc: Triceps & Triceps Jerk Weakness Symptoms exaggerated on lateral flexion toward the affected side.


Treatment :- Neurolysis with division of the aponeurosis . Anterior Transposition.

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