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Numb fingers that wake her at night
A 34-year-old woman, 30 weeks pregnant, wakes most nights with tingling and numbness in her right thumb, index and middle fingers. Shaking her hand makes it better.
Step 1 of 4
Where is the nerve most likely compressed?
Correct answer: E
Nocturnal paresthesias of the lateral 3½ digits relieved by shaking the hand ("flick sign") is carpal tunnel syndrome, the most common entrapment neuropathy. Pregnancy is a classic association (fluid), along with hypothyroidism, diabetes and rheumatoid arthritis (see median nerve).
Show answer
E
Nocturnal paresthesias of the lateral 3½ digits relieved by shaking the hand ("flick sign") is carpal tunnel syndrome, the most common entrapment neuropathy. Pregnancy is a classic association (fluid), along with hypothyroidism, diabetes and rheumatoid arthritis (see median nerve).
Step 2 of 4
Sensation over the thenar eminence is normal.
Why is the skin over the thenar eminence spared?
Correct answer: A
The palmar cutaneous branch of the median nerve leaves before the wrist and runs superficial to the flexor retinaculum, outside the carpal tunnel. In pronator syndrome (compression at the elbow) thenar sensation is reduced.
Show answer
A
The palmar cutaneous branch of the median nerve leaves before the wrist and runs superficial to the flexor retinaculum, outside the carpal tunnel. In pronator syndrome (compression at the elbow) thenar sensation is reduced.
Step 3 of 4
Which test confirms the diagnosis and grades its severity?
Correct answer: A
The diagnosis is clinical (Tinel, Phalen and carpal compression tests); nerve conduction studies/EMG confirm and grade it.
Show answer
A
The diagnosis is clinical (Tinel, Phalen and carpal compression tests); nerve conduction studies/EMG confirm and grade it.
Step 4 of 4
Her symptoms are mild and she has no weakness. What is the most appropriate initial management?
Correct answer: D
Mild to moderate carpal tunnel syndrome is commonly managed first with a wrist splint in neutral, especially at night. Thenar atrophy or a severe or progressive deficit prompts surgical referral.
Show answer
D
Mild to moderate carpal tunnel syndrome is commonly managed first with a wrist splint in neutral, especially at night. Thenar atrophy or a severe or progressive deficit prompts surgical referral.
Key points
- Night-time paresthesias of the lateral 3½ digits + flick sign → carpal tunnel syndrome.
- Thenar sensation spared in CTS (palmar cutaneous branch); reduced in pronator syndrome.
- Confirm with nerve conduction studies; start with a night splint; refer for atrophy.
Study: Carpal tunnel, Median nerve, Wrist joint