Inspection
o Myotonic facies
o Symmetry
o Fasciculations
o Distribution
o Clawing of the hand (C8/T1 lesion or combined median / ulnar nerve palsy)
Tone
Reflexes
Power
o Point your thumb to the ceiling flexor pollicis brevis, median nerve
o Make an OK sign, then touch each finger with your thumb) opponens pollicis,
median nerve
o Hold this piece of paper between your fingers palmar interossei, ulnar nerve
o Hold this piece of paper between your thumb and index finger if the thumb
flexes to compensate, this is a positive Froments sign and indicates ulnar nerve palsy
o Check flexion of the DIPJ of the 5th finger in ulnar nerve palsy if preserved, lesion is
distal to elbow
Sensation
o Check for sensory loss in distribution of median, ulnar and radial nerves
Myotonic dystrophy
Differential diagnosis
Cervical myelopathy
C8/T1 radiculopathy
o Pancoasts syndrome
Mononeuropathy
Charcot-Marie-Tooth disease
Myotonic dystrophy
Disuse atrophy
Investigations
Nerve conduction studies: to look for slowing of conduction across affected nerves
Chest radiograph
o Cervical rib
o Pancoast tumour
Magnetic resonance imaging of the cervical spine to look for cervical myelopathy
Management
Patient education
Compression neuropathies may require decompressive surgery (e.g. carpal tunnel release)
Summary
Sir, this patient has asymmetric wasting of the small muscles of the right hand. On examination,
there is weakness of muscles supplied by the median nerve, such as abductor pollicis brevis and
flexor pollicis brevis, as well as those supplied by the ulnar nerve, such as the palmar interossei. Wrist
extension and finger flexion are relatively spared, implying that this is a C8/T1 lesion. Sensation is
also lost to pinprick in those dermatomes. The possibilities for this include a C8/T1 radiculopathy or a
lower brachial plexopathy. This may be caused by low cervical spondylosis, although it usually affects
the middle cervical cord, an apical lung tumour, although I did not see any overt ipsilateral Horners
syndrome, a cervical rib, or traumatic avulsion of the brachial plexus.
In summary, this patient has a C8/T1 lesion, causing unilateral wasting of the small muscles of the
hand.