John Walker: A 30-Year-Old Male With Pain, Numbness, Weakness, and Paresthesias, Radiating Into the Thumb, Index and Middle Fingers

John Walker

“Call me Johnny, everyone else does. You know, Johnny Walker? What the hell were my parents thinking? I never saw either of them take a drink!” I responded, “Okay, Johnny it is.”

John Walker was a 30-year-old real estate agent with the chief complaint of “I have pain that goes from my wrist into my fingers, and my hand is weak.” John stated that over the past several months, he began noticing a deep aching sensation in his hand and wrist, especially after using his laptop computer for long periods of time. The ache was associated with electric shock–like pains into the thumb, index finger, middle finger, and radial half of the ring finger. I asked John if he had experienced any numbness or weakness, and he replied, “Doc, it’s funny that you asked. I am having trouble buttoning my top shirt button when I have to wear a tie, and lately I keep dropping my cell phone because I am having trouble holding it up to my ear. After a day at work, especially if I am using my laptop a lot, I have been noticing that my fingers, especially my thumb and index finger, have a pins-and-needles sensation.” I asked John what he thought was causing his symptoms, and he said his wife thinks he has “the carpal tunnel. But, Doc, how smart could she be? She married me!” I responded, “John, she may actually be smarter than you think! Let me ask you a few more questions, then examine you so we can figure out if your wife is indeed correct.”

I asked John what he had tried to make it better, and he said when he rested his hands and took a break from the laptop that seemed to make the pain better. After about 30 to 40 minutes the numbness got better. “Tylenol PM seems to help some, at least with the sleep,” John reported. I asked John to describe any numbness he noticed associated with the pain, and he pointed to his right thumb and index finger. “Doc, most of the thumb and index finger are numb, and so is my middle finger.” I asked John about any fever, chills, or other constitutional symptoms such as weight loss, night sweats, etc., and he shook his head no. He denied any antecedent wrist trauma, but noted that sometimes, if his hand wasn’t positioned just right, he would get an electric shock–like pain that woke him up at night.

I asked John to point with one finger to show me where it hurt the most. He pointed to the middle of the dorsal wrist. He went on to say that he could live with the pain, but the electric shocks and numbness were “really bothering.” He then asked, “Doc, could this have anything to do with diabetes?”

On physical examination, John was afebrile. His respirations were 18, his pulse was 74 and regular, and his blood pressure was 110/68. John’s head, eyes, ears, nost, throat (HEENT) exam was normal, as was his cardiopulmonary exam. His thyroid was normal. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable. Visual inspection of the right wrist was unremarkable. There was no rubor or color. There was no obvious infection or olecranon bursitis. There was a positive Tinel sign over the median nerve at the wrist ( Fig. 2.1 ). I had Johnny fully flex both wrists and hold them in that position for 1 minute to see if I could elicit a positive Phalen test ( Fig. 2.2 ). After about 45 seconds, Johnny began experiencing both pain and numbness. The left wrist examination was normal, but there was tenderness to palpation of the area over the carpal tunnel at the distal crease of the wrist. A careful neurologic examination of the upper extremities revealed decreased sensation in the distribution of the right median nerve as well as weakness of thumb opposition on the right as indicated by a positive opponens weakness test ( Fig. 2.3 ). There was some wasting of the thenar eminence noted on the right ( Fig. 2.4 ). I retorted, “Johnny, my friend, I think you have the carpal tunnel.”

Key Clinical Points—What’s Important and What’s Not

What Tests Would You Like to Order?

The following tests were ordered:

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  Ultrasound of the right wrist

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  Magnetic resonance imaging (MRI) of the right wrist

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  Electromyography (EMG) and nerve conduction velocity testing of the right upper extremity