Wasted Hands
Unilateral vs Bilateral (think of levels!)
Unilateral
 Think of (no myopathy, got brachial plexus)
 Peripheral nerve (median, ulnar or combined)
 Mononeuropathy vs peripheral neuropathy (asymmetric involvement)
 Brachial plexus (trauma, tumor, radiation, Cx rib)
 C8-T1 root lesions (Cx spondylosis)
 Anterior Horn Cell (Poliomyelitis)
 Cervical cord
 Proceed as:
 Long case – as per protocol, check also neck and chest
 Short case
 On inspection, unilateral wasted hands noted
 Neurological hand screen
 Examine for ulnar and median nerve palsies.
 Check for sensory for nerve vs root (peripheral nerve vs brachial plexus)
and no loss (ie anterior horn cell)
 Note sensory for ulnar, median and radial
 Note sensory of peripheral neuropathy
 Note dermatomal sensory
 Feel for thickened nerves, look for hypoaesthetic macules, fasciculations
 Look for scars in the axilla and neck (neck pain, tenderness), Cx rib
 Check function
 Requests
 Palpate for cervical rib and features of Pancoast’s tumor (dullness to
percussion, Horner’s syndrome, hoarseness voice)
 Check for winging of scapula (for brachial plexus involvement)
 If brachial plexus
 Upper vs lower (wasting of muscles of hands) vs complete
 Surgical(Cx rib, Pancoast) vs medical cause(brachial neuritis)
 Test for proximal involvement
 Serratus anterior (winging of scapula on pushing against
wall) ie C5,6,7
 Supraspinatus (abduction of UL from hands by your side
position) C5
 Infraspinatus (elbow flexed and push backwards) C5
 Rhomboids (hand on hip and push backwards) C4,5,6
 Reflexes (inverted supinator jerk)
Bilateral
 Think of
 Rule out the obvious (hand screen)
 RA, gouty hands
 Dystrophia myotonica
 Levels (got myopathy, maybe brachial plexus if bilateral Cx ribs)
 Distal myopathy (reflexes normal; rare), dystrophia myotonica
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
Peripheral nerve lesions
 Combined CTS (see median nerve palsy)
 Combined ulnar and median nerve
 Leprosy (resorption, hypoaesthetic macule and thickened
nerve)
 HMSN (look at the feet for pes cavus deformities,
thickened nerves)
 Peripheral motor neuropathy
 (Not likely to be brachial plexus unless bilateral Cx ribs)
 Nerve roots
 Cervical spondylosis (inverted supinator jerk, increased jerks for
high cervical cord lesions)
 Anterior Horn cell (no sensory loss)
 MND (fasciculations)
 Poliomyelitis
 SMA
 Spinal cord lesions
 Intramedullary (Syringomyelia – dissociated sensory loss)
 Extramedullary
Request
 LL – spastic paraparesis ( if suspect Cx cord, MND)
 Lower cranial nerve (bulbar palsy – if suspect MND or syringomyelia)
Proceed as
 Long case
 Proceed as per normal
 Examine or request to examine the neck (pain tenderness and pain on neck
movements), chest, CNs and LLs accordingly
 Short case
 Neurological hand screen
 Median and ulnar nerve testing, and wrist drop( because this is also weak
in C8 root lesions)
 Sensory – peripheral nerve vs neuropathy vs root
 Check the elbows for thickened nerves
 Look for fasciculations (peripheral nerve, neuropathy, MND),
hypoaesthetic macules
 Inspect the neck
 Quick glance at the face (NG tube – bulbar palsy, LLs – HMSN)
 Check function
 Request for reflexes, percussion myotonia if deemed appropriate (if
suspect Cx cord lesion or dystrophia myotonica)
Questions
What are the levels and causes?
 Disuse atrophy (RA hands)
 Myopathy (distal myopathies or dystrophia myotonica – usually forearms more
affected)
 Peripheral neuropathy - motor (see causes in Neurology segment)
 Mononeuropathy
 Surgical, trauma or compression
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 Mononeuritis multiplex, infection, inflammatory and ischaemic
Brachial Plexus
 Surgical, trauma compression (Pancoast’s, Cx rib)
 Brachial neuritis
Nerve root (Disc prolapse)
Anterior Horn cell
 MND, poliomyelitis, SMA
Spinal cord
 Intramedullary
 Extramedullary
How would you Ix?
Blood Ix according to causes as above
Imaging – X-rays, CT or MRI of spine
NCT/EMG
What are the causes of a claw hand?
 Partial claw
 Ulnar nerve palsy (See Ulnar nerve)
 True Claw
 Non-neurological
 RA
 Severe Volkmann’s ischaemic contracture
 Neurological (5)

Combined median and ulnar nerve

Leprosy (reflexes present. Pain loss, thickened nerves)

Lower brachial plexus ( C7-T1, selective loss of reflexes, pain loss)

Poliomyelitis (reflexes selective, pain intact)

Syringomyelia (reflexes absent, pain loss)