Examine this patient's hands.

Ask the patient whether her hands are painful.



· Rheumatoid arthritis.

· Painful neck movements (cervical spondylosis).

· Fasciculations, weakness (motor neuron disease).

* Associated sensory loss (syringomyelia).

· Family history (Charcot-Marie-Tooth disease).

· Ascending muscle weakness (Guillain-Barr6 syndrome).

· Trauma to upper limbs (bilateral median and ulnar nerve lesions).


Wasting of thenar and hypothenar eminences and dorsal interossei.

Proceed as follows:

· Look for deformity and swelling.

· Look for fasciculations.

· Check sensation over the hand, especially index and little fingers.

· Test grip and pincer movements.

· Test for median and ulnar nerve compression.

· Ask the patient to unbutton clothes or to write.

· Palpate for cervical ribs and compare radial pulses.

· Look for Homer's syndrome.

· Examine the neck and test neck movements.


This patient has bilateral wasted hands (lesions) due to cervical myelopathy (aetiology) and is unable to button her clothes

(functional status).

Remember that the causes of bilateral wasted hands are as follows:

· Rheumatoid arthritis.

· Old age.

· Cervical spondylosis.

· Bilateral cervical ribs.

· Motor neuron disease.

· Syringomyelia.

· Guillain-Barre syndrome.

· Bilateral median and ulnar nerve lesions.

If the wasting is seen in only one hand, then in addition to the above causes consider the following:

· Brachial plexus trauma.

· Pancoast's tumour.

· Cervical cord lesions.

· Malignant infiltration of the brachial plexus.


In unilateral wasting, what is the level of the lesion?

C8, TI. These muscles are predominantly supplied by the ulnar nerve (the median nerve supplies the thenar eminence), the inner

cord of the brachial plexus, the T1 spinal root and the anterior horn cells. Thus lesions of these structures may all produce wasting of

the small muscles of the hand:

1. Lesions of the radial, median and ulnar nerves (trauma).

2. Brachial plexus (trauma, cervical lymph nodes, cervical ribs, tumour of superior sulcus of lung).

3. Anterior root (cervical spondylosis).

4. Anterior horn cell (motor neuron disease, tumours of spinal cord, syringomyelia, poliomyelitis).