Differential Diagnoses for Dorothy

Taking the information which you have gathered from Dorothy, consider the following differential diagnoses and document what you think her problem is. Using the link in materials, plan and document your management for Dorothy in the workbook.

Differential Diagnoses and typical symptoms.

The table below is a resource to help you understand the symptoms where nerves are compromised.

Adapted from Differential Diagnosis for the Painful Tingling Arm (Smith, Sarah M. MBBS; McMullen, Christopher W. MD; Herring, Stanley A. MD, FACSM)

Table 1 – Neurologic injuries.

DiagnosisPeripheral NerveEntrapment SiteSensory DistributionMuscles AffectedCommon Physical Examination Findings
Cervical radiculopathyN/ANerve rootCorresponds with affected dermatome based on nerve root levelCorresponds with affected myotome based on nerve root levelWeakness and sensory impairments; absent deep tendon reflexes associated with affected nerve root
Carpal tunnel syndromeMedian nerveCarpal tunnel (wrist)Palmar portion of the first three digits and radial half of the fourth digit as well as the distal dorsal aspects of these digitsAbductor pollicis brevis, opponens pollicis, superficial head of flexor pollicis brevis, lumbricals I/IIWeakness and sensory impairments
Pronator teres syndromeMedian nerveVarious locations at the elbow or proximal forearm, most commonly between the two heads of pronator teresThe same as in carpal tunnel syndrome, with the addition of the thenar eminenceThe same as in carpal tunnel syndrome with the possible addition of pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and the anterior interosseous nerve innervated musclesWeakness and sensory impairments; Reproduction of symptoms with resisted forearm pronation
Anterior interosseous nerve syndromeAnterior interosseous nerveSame as in pronator teres syndromeNone, this is a pure motor palsyFlexor pollicis longus, flexor digitorum profundus, pronator quadratusWeakness; Difficulty making an “OK” sign with the thumb and the forefinger
Ulnar neuropathy at the elbowUlnar nerveElbow, most commonly within the cubital tunnelUlnar half of digit 4, entire digit 5Frequently spares the ulnar innervated forearm muscles (flexor carpi ulnaris and flexor digitorum profundus to digits 4/5), while commonly affecting the ulnar innervated hand muscles, particularly the first dorsal interosseous muscleWeakness and sensory impairments
Posterior interosseous neuropathyPIN (branch of radial nerve)Forearm, most commonly within the Arcade of FrohseNo cutaneous sensory loss although pain may be presentThe same as in radial neuropathy at the spiral groove except for sparing of brachioradialis, long and short heads of the extensor carpi radialisWeakness
Radial nerve compression at the wristSuperficial branch of the radial nerveWristThe same as in radial neuropathy at the spiral grooveNone, pure sensory palsySensory impairments, tenderness at compression site
Lateral antebrachial cutaneous nerve entrapmentLateral antebrachial cutaneous nerveBetween biceps tendon/aponeurosis and the brachialisLateral forearmNone, pure sensory palsy (compression of the musculocutaneous nerve more proximally could have motor findings)Sensory impairments, tenderness at compression site

 

Due to the many differential diagnoses and because she relies on her job as hairdresser you decide to call her in this afternoon for a clinical examination.