1. Upper Limb Case #1 Table 36 Farah Abbas Jeremy Jacobs Brian McQuillan
David Smith

2. Chief Complaint and HPI
35 yr/o female, computer software executive
Burning/tingling sensation in left hand
Symptoms progressing over past 3 months
Localized to thumb, index, middle, and lateral side of left ring finger
Difficulty grasping objects
Frequently drops things

3. Vitals Normal Vital signs: Blood Pressure: 130/80 Pulse: 75
Rhythm: Regular
Temperature: 99.0oF
Respiratory rate: 17
Height: 5’10”
Weight: 150 lbs.
HEENT Examination: Normal
All other systems: Normal

4. Musculoskeletal Exam Thenar eminence of left hand flattened
Minor loss of touch sensation on thumb, index, middle, and lateral side of left ring finger
Positive Tinel’s Sign (tapping over the median nerve on flexor retinaculum caused pain to shoot from wrist to hand)
Loss of strength of certain movements of left thumb

5. WHAT’S IN THE FOREARM AND HAND?

6. Anatomy of the Forearm and Hand

7. Anatomy of the Forearm and Hand

8. Anatomy of Forearm and Hand
Muscle
Innervation
Origin
Insertion
Action
Flexor Pollicis Brevis
(Thenar)
Median n.
Flexor Retinaculum
Trapezium
Proximal Phalanx of 1st digit
Flexes the Carpometacarpal &
Metacarpophalangeal joints of Thumb
Opponens Pollicis
Flexor Retinaculum Trapezium
Shaft of 1st Metacarpal
Opposes the Thumb
Abductor Pollicis Brevis
Scaphoid
Abducts the Thumb,
Grasping

9. WHAT’S THE DIAGNOSIS?

10. Diagnosis Weakness of thumb muscles (thenar) Loss of touch sensation
Positive Tinel’s sign
Compression of the median nerve
Carpal Tunnel Syndrome

11. Treatment Splint the affected wrist, 2-6 weeks
NSAIDs (aspirin or ibuprofen)
See a specialist if there is atrophy of thenar muscles or continued weakness for an injection of corticosteroids
Surgery (cut the transverse carpal ligament to relieve swelling)

12. References
Hellman, David B., Current Medical Diagnosis & Treatment 2008, Forty-Seventh Edition, "Musculoskeletal Disorders- Carpal Tunnel Syndrome." 2008.
Netter, F.H. Atlas of Human Anatomy (4th ed.)
Deune, E. Gene. Current Rheumatology Diagnosis & Treatment, Second Edition "CH 6: The Patient with Hand, Wrist, or Elbow Pain"

13. References
Harris: Kelley’s Tesxbook of Rheumatology, 7th ed “Common Etiologies for Hand and Wrist Pain.”