What can you do about my floppy fingers doc?

I’ll start by sharing a little mistake I made…

I saw a 72 year old lady who attended the ED 36 hours after sudden onset right 4th and 5th finger motor weakness, flexion 2/5  extension 3/5.  Coordination in the rest of the hand was normal, her radial and median nerve had no sensory or motor deficits.  Apart from the weakness, of the 4th and 5th digit, she had no other symptoms.

No history of trauma, carpal tunnel, or diabetes.  Past medical history was high blood pressure, which she was on Enalapril for.

I wasn’t really sure what was going on here so along with the consultant we sent this lady to the plastic surgeons for ?ulnar nerve entrapment.  She was reviewed the next day by the plastic surgery team, who referred her to the Neurology department, the neurology registrar diagnosed her with a “hand knob” stroke, a rare but well documented stroke syndrome.

So yes, I sent a lady with a stroke to plastics.

On reflection:

  • Nerve entrapment was unlikely because the symptoms came on suddenly, and were at their most severe immediately.
  • There was no involvement of any modality other than power, if this was a peripheral nerve lesion, sensation should also be affected.