Osmosis regularly shares an OMM-style practice question to test your medical knowledge. Can you identify the maneuver likely to reproduce the symptoms of a 47-year-old woman with bilateral tingling in her thumbs and second finger (digit) that worsens in the morning?
A 47-year-old woman presents to the clinic with two months of tingling in her hands. The tingling sensation is most prominent in her thumbs and 2nd digits and is worst when she wakes in the morning. She has unintentionally dropped a few objects over the past two months. She works at a computer for eight hours per day. Her past medical history is significant for type 2 diabetes mellitus. Her medications include insulin glargine, metformin, and pioglitazone. Her vital signs are within normal limits. On physical examination she has decreased sensation on the palmar aspect of her thumb and second digit bilaterally. When placing a sheet of paper between her thumb and second digit, you can easily pull it out from between her fingers.
Which of the following is likely to reproduce this patient’s symptoms?
A. Percussion at the medial epicondyle
B. Placing the thumb inside a closed fist and adducting the wrist
C. Having the patient flex her wrist against your resistance
D. Flexing both wrists and holding the dorsal aspect of both hands against one another
E. Nerve conduction study at the axilla
Scroll down for the correct answer!
The correct answer to today’s OMM® Question is…
D. Flexing both wrists and holding the dorsal aspect of both hands against one another
Before we get to the Main Explanation, let’s look at the incorrect answer explanations. Skip to the bottom if you want to learn more about the correct answer right away!
Incorrect Answer Explanations
A. Percussion at the medial epicondyle
Rationale: Percussing the medial epicondyle can detect ulnar nerve neuropathy. Percussion over the carpal tunnel (Tinel sign) would likely reproduce this patient’s symptoms.
B. Placing the thumb inside a closed fist and adducting the wrist
Rationale: This test (Finkelstein test) causes extra strain on the tendons running through the anatomic snuffbox and can detect deQuervain tenosynovitis.
C. Having the patient flex her wrist against your resistance
Rationale: This would cause extra strain on the flexors within the forearm and could help diagnose medial epicondylitis.
E. Nerve conduction study at the axilla
Rationale: This could detect a more proximal neuropathy; however, her symptoms indicate a more distal neuropathy (likely at the carpal tunnel).
Main Explanation
Carpal tunnel syndrome is a median nerve neuropathy that occurs due to soft tissue swelling and/or compression inside of the carpal tunnel, usually due to repetitive motions at the wrist. Diabetes mellitus is also a risk factor. Early symptoms may include numbness and tingling in the median nerve distribution of the palm (thumb to lateral half of 3rd digit). Later symptoms may include weakness in thumb opposition and eventually loss of thenar eminence muscle mass. Tinel sign (percussion over the carpal tunnel) will reproduce the patient’s symptoms. Phalen or reverse Phalen test (flexing wrists and placing dorsal aspects of hands together for 30-60 seconds) will also reproduce the patient’s symptoms.
Treatment of carpal tunnel syndrome starts conservatively and can include osteopathic manipulative treatment. Patients should try activity modification (do less of the repetitive task) and wearing splints at night that gently extend the wrist. If this fails, patients should undergo nerve conduction studies and may eventually need surgical decompression.
Major Takeaway
Carpal tunnel syndrome presents initially with numbness and tingling in the median nerve distribution of the palm. As it progresses, patients develop weakness in thumb opposition. Tinel sign and Phalen test can help confirm the diagnosis.
Want to learn more about this topic?
Watch this Osmosis video: Carpal tunnel syndrome
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