Thursday, 21 February 2008 (19 pages)

Information Sheet for Candidates

A 45 year old waiter, John, comes to you for a flu injection and he mentions that he
has increasing difficulties with his job, carrying heavy trays, his right hand does not
seem to be strong enough anymore specifically because he feels numbness in his hand
with tingling in his little and ring finger and generally he seems to have a decreased
strength when gripping a tray.
Your task is:
To take a brief focused history
To explain the possible causes and the most likely diagnosis to the patient
To explain treatment options

-2HISTORY:
PHx of NIDDM, well controlled, nil else
Recently he severely bumped his elbow when he fell of a motor bike with bruising
around the elbow and he rested his arm for a few weeks, started to mobilise and then
realized the problems:
Tingling and numbness in little and ring finger (especially at night)
Numbness in the hand when the elbow is bent
Difficulty using hand for day to day activities
Decreased grip and pinch strength and muscle weakness
Tenderness along the inside of the elbow

Froments sign is illustrated and is positive on the left side. A positive sign indicates
that there is paralysis of the adductor pollicis which is supplied by the ulnar nerve.
The thumb on the left side is being flexed at the interphalangeal joint by the flexor
pollicis longus. This is to compensate for the adductor paralysis and to allow for the
cloth to be held and not pulled away from the thumb.

-3DIAGNOSIS:
ULNAR NERVE ENTRAPMENT / ULNAR NERVE PALSY / CUBITAL
TUNNEL
SYNDROME
INVESTIGATIONS:
1. X-ray to exclude a fracture around the elbow
2. electromyography (EMG)
CAUSES:
Diabetes
Arthritis
Alcoholism
Thyroid problems
TREATMENT OPTIONS:
In the early stages of the nerve compression if there is no muscle wasting it is feasible
to treat the condition without operation and conservative treatment:
Keep elbow as straight as possible because it puts less pressure on the ulnar nerve
Avoid crossing your arms
Use headsets attachment for the telephone to avoid bending the elbow
Wear a splint at night
Adjust your work environment so you dont have to bend your elbow
If muscle wasting is present or the conservative treatment fails then surgery is
indicated. The most frequently used surgery movers the ulnar nerve from behind the
bone to the front of the elbow. After the surgery, treatment must focus on maximizing
the use of the hand and arm through physio. This can take months.