Clinical approach to wasting of the small muscles of the hand

The small muscles of the hand are supplied by C8 and T1 spinal segments wasting of
these muscles may be due to:
1. A.H.C. lesions:
Anterior spinal Motor
Trasverse
poliomyelitis artery neurone syringomyelia
myelitis
occlusion disease
Onset Acute acute acute gradual Gradual
Regressive or Regressive or
Course Regressive Progressive Progressive
stationary stationary
Middle & old
Age 6m – 2y Any age any age 15 – 35 y
age
- Asymmetrical - At the level - Both U.L show - U.L. tonic - U.L show flaccid
- L.L. More of lesion flaccid atrophy - L.L. show spastic
than U.L. (C8-T1) - Both L.L. show - L.L. spastic - Fasciculation
- fasciculation flaccid spastic - Fasciculation
Motor
- Below the
level of
lesion
spastic
No Sensory level Sensory level of No Jacket sensory loss of
C8-T1 dissociative in dissociative nature
Sensory nature (touch & (touch & deep sensation
deep sensation are are intact) with sacral
intact) spare.

2. Anterior root and spinal nerve lesions:

a. Cervical Spondylosis: usually old age with gradual onset and progressive course due to
degeneration of the intervertebral discs and osteophytes formation affecting mainly C8 and T1.
Resulting in a localized LMN weakness or paralysis in the flexor of the wrist and small muscles
of the hand (Motor). Pain and paraesthesia at the onset referred to medial aspect of forearm,
hypothenar eminence, little finger and medial aspect of arm.
b. Cervical Pott’s disease (tuberculous spondylitis): Pott disease is usually secondary to an
extraspinal source of infection. The basic lesion involved in Pott disease is a combination of
osteomyelitis and arthritis that usually involves more than one vertebra. The anterior aspect of
the vertebral body adjacent to the subchondral plate is area usually affected. Tuberculosis may
spread from that area to adjacent intervertebral disks. In adults, disk disease is secondary to the
 spread of infection from the vertebral body. In children, because the disk is vascularized, it can
be a primary site.
c. Primary and metastatic tumours of cervical vertebrae.
d. Freacture and dislocation of the cervical vertebrae.
e. Cervical neurofibromatosis: s a multisystem genetic disorder associated with bilateral
vestibular schwannomas, spinal cord schwannomas, meningiomas, gliomas, and juvenile
cataracts with a paucity of cutaneous features. Resulting from mutations in (or rarely deletion
of) the NF gene located on the long arm of chromosome 22. The gene product known as merlin
serves as a tumor suppressor; decreased function or production of this protein results in a
predisposition to develop a variety of tumors of the central and peripheral nervous systems. It is
inherited as an autosomal dominant condition.

3. LOWER BRACHIAL PLEXUS LESIONS:

a. Dejerine-Klumpke's paralysis 2ry to birth injury which affecting small muscles of the hand
resulting in claw hand.
b. Thoracic outlet syndrome:
i. Cervical rib:
 Only 10% of cases symptomatise.
 The wasting of the muscles is associated with paraesthesias over the ulnar side of
the forearm and hand.
 The radial pulse is diminished or lost on the affected side when the arm is
dragged downwards while the neck is stretched to the opposite side (Adson's
test).
 X-ray may show a complete or incomplete rib.
ii. Pancoast tumor: affecting the lungs
iii. Enlarged cervical lymph nodes.
iv. Aneurysm of the subclavian artery.

4. PERIPHERAL NERVE LESIONS:

a. All causes of mono, mono multiplex and polyneuropathy (as ulnar and median nerve
entrapment, diabetic polyneuropathy and charcot- marie-tooth disease)
b. Carpal tunnel syndrome:
 Due to compression of the median nerve in the tunnel.
 Mainly in middle-aged women and in pregnancy; it may also be 2ry to myxoedema and
acromegaly.
 The thenar muscles are mainly affected, with wasting and weakness.
 Pain and paraesthesias especially at night associated with sensory loss over the palmar
surface of the fingers.
5. MUSCLE LESIONS:
1) Distal type of Gower myopathy affecting mainly distal muscles of the hand
with gradual onset and regressive course and no sensory affection, on
fasciculation and no sphinctric distubance
2) Myotonia atrophica: 3rd and 4th decades, males are more affected than
females, atrophy specially of (facial muscles, mastication muscles,
sternomastoid and distal muscles of the hand). Dystrophic changes are
present in the form of (cataract, frontal baldness and testicular atrophy)
6. Other Causes:
a. Arthritis of the joints of the hand (rheumatoid).
b. Scleroderma & dermatomyositis.
c. Sudek's atrophy (shoulder hand syndrome): affection in the shoulder resulting in hand wasting
and vasomotor manifestations
d. Volkman's ischaemic contractions (elbow supracondylar fracture affectngthe ulnar and median
nerve and the brachial artery)
e. Disuse atrophy in long standing U.M.N.L.