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Clinical Case

Mr. HB is 35 year old man who presented to the clinic because of inability to move his hand since the morning. There is no pain or numbness in the whole arm. No neck pain. No other neurologic deficit. No joint pain. No trauma. No fall. No previous similar episode.

PMH: Rheumatoid arthritis controlled off medication for the past few years.

Medications: None

PSH: None

Social history: married with 3 kids; works in a hotel as a janitor who cleans windows; non smoker

Allergies: None

Physical Exam: BP 120/80 Pulse 80 regular
Physical examination of the Right Upper arm: wrist drop; no sensory loss; nl DTR; good motor power of the fingers; he just can not extend his wrist; no tenderness; no swelling Rest of exam negative

Questions: What is the differential diagnosis? What to do next?

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On 5/29/2009 6:27:39 AM, Sani Hlais (Family Medicine) wrote

The differential diagnosis includes radial nerve palsy (but it is not probable due to the absence of sensory symptoms), cervical radiculitis (but no neck pain, and pure motor). I think the first diagnosis to rule out would be a CVA (motor deficit unilateral with no pain in a high risk patient; RA puts the patient at a high cardiovascular risk). I would begin with a cerebral MRI.

On 6/3/2009 4:16:46 AM, Jumana (Antoun) wrote

Where would be the lesion in the brain to just give a wrist drop; if you are considering CVA you would refer to ER immediately for MRI or just go through the regular channels of taking appointments and perfomring MRI

On 6/12/2009 9:54:51 AM, joumana zeineddine (family medicine) wrote

i think that this a case of "posterior interosseus nerve palsy" which is secondary to the compression of the motor branch of the radial nerve at the elbow level.the treatment should be surgical and urgent to prevent permanent damage to the nerve

On 6/12/2009 10:09:58 AM, joumana zeineddine (family medicine) wrote

we should do MRI to eliminate a compression secondary to tumor. in this case a synovitis seconadry to rheumatoid arthritis may be a cause. the surgery is needed only if there is a tumor

On 7/20/2009 1:28:01 PM, Charbel Bou Yazbek (Family Medicine) wrote

Hi, could it be a rupture of the extensor digitorum communis caused by occupational overuse giving that he cleans windows ? I suppose he is a right-handed man.

On 7/22/2009 8:02:35 AM, Raafat ammar (ICU) wrote

I woudld suggest mononeuropathy of the radial nerve Is he diabetic? then post interosseous nerve palsy

On 7/23/2009 6:01:44 AM, Charbel Bou Yazbek (Family Medicine) wrote

This patiant has an isolated wrist drop with no sensory or motor signs except the inability to extend his wrist with a conserved motor power of the fingers. No motor nerve palsy can explain this presentation. I would suggest a rupture of the wrist extensor tendons as it is a known complication of Rhumatoid Arthritis wrists facilitated by occupational overuse. an MRI or an ultrasound of the wrist would confirm the diagnosis.

On 7/24/2009 10:13:16 AM, Marouan Zoghbi (FM) wrote

The posterior interosseous nerve controls finger extension, and to a small degree, wrist extension.since fingers motricity is not affected , and knowing that this patient has RA, I think tendon rupture is the most likely diagnosis.

On 7/24/2009 10:14:33 AM, Marouan Zoghbi (MF) wrote

Musculoskelettal ultrasound of both wrists would be helpful in establishing the diagnosis

On 7/29/2009 6:24:50 AM, Dr Wassim Abdel Khalek (Family Medicine) wrote

Most probably this patiente suffer from Radial Nerve Palsy.Acording to his social history and abscence of trauma,most probably his work cleaning windows daily can cause radial nerve injury. First thing to do es EMG to see nerve conduction velocity and eventuallly MRI to rule out other causes.Splinting and rest of the arn may help recovery should there is no other surgical treatment. Dr Wassim Abdel Khalek Spain

On 9/13/2009 9:22:25 PM, Louna Mohammad () wrote

The differential diagnosis includes: -1-Carpal Tunnel syndromedue (due to a narrowing in the path of the median nerve. or another nerve compression at the level of the wrist like the radial nerve palsy typical of repetitive movements) -2-Guillain-Barré syndrome -3-or Myasthenia Gravis(associated with rheumatoid arthritis). The workup might be nerve conduction velocity studies to isolate and confirm the radial nerve as the source of the problem. -Plain films can help identify bone spurs and fractures that may have injured the nerve. -An MRI imaging can be required to differentiate subtle causes. -and serologic tests to investigate for the presence of autoantibodies.

On 9/25/2009 10:48:23 PM, Asma Tarabah () wrote

-1-If the pt had Posterior Interosseous Nerve Palsy he would have a weakness in his finger and thumb extension, and this is not the case. -2-Guillain-Barré syndrome is also not a differential diagnosis since in this syndrome the weakness starts in the legs then progresses upward. -3-If the pt had Myasthenia gravis then he would have atleast dysphagia, diplopia or dysarthria, which is not the case. -4-Carpal Tunnel syndrome is not likely to fall under this case since the patient's fingers are not affected. The differential diagnosis is most probably radial nerve palsy. Tests may include EMG, nerve conduction velocity study(to determine the location of the nerve injury). Initial management includes splinting of the wrist for support.

On 9/14/2010 12:58:08 PM, Wasl Al-Adsani, DO, PhD (Family Medicine/Geriatrics/Internal Medicine) wrote

"Saturday night" radial nerve palsy. Treatment is primarily supportie. Splinting of wrist, PT and home exercises to mininize muscle atrophy. Prognosis is good for regain full function.

On 12/31/2010 6:51:16 AM, Jihad Nassar (Family Medicine) wrote

From the history and the physical examination ,the patient has deep(post.interosseus nerve)branch of the radial nerve i.e interosseus syndrome syndrome ,because the patient has only periphral motor loss,and intact sensory branch which is the superfacial branch,imaging and electrdiagnostic test is indicated if diagnosis is unclear or recovery not following expected clinical course,next step is treatment which consist of cock-up splint to assist weakend wrist muscule,avoid provocative activity and consider elbow emmobilization,duration of 3-6 months

On 12/31/2010 7:58:17 AM, JIHAD NASSAR (FAMILY MEDICINE) wrote

for interosseus nerve syndrome if the patient would have late presentation with atrophy of the muscules, progressive weakness,or failed conservetive treatment then referal and surgery sould be considered .NOTE:Because the patient has RA ,and normal finguer motor power ,the rupture of extensor tendon, is also in the DD.

On 12/31/2010 7:59:43 AM, JIHAD NASSAR (FAMILY MEDICINE) wrote

for interosseus nerve syndrome if the patient would have late presentation with atrophy of the muscules, progressive weakness,or failed conservetive treatment then referal and surgery sould be considered .NOTE:Because the patient has RA ,and normal fingers motor power ,the rupture of extensor tendon, is also in the DD.

On 10/6/2011 6:38:44 AM, seham abdel hamid (family physcian) wrote

because his normal neurological exam. most propably he suffers from hestrical attack due to pSYCOsomatic disorder

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