Assessment of upper extremity mononeuropathy

insidious onset of numbness and/or tingling in digits 1 to 4 ± palm of hand; often worse at night or on awakening; symptoms commonly reported to be worse when holding a phone/newspaper/book; flexion/extension activities of the wrist aggravate symptoms (e.g., knitting, many types of manual labour, strong evidence of BMI and high hand/wrist repetition rate increases risk of CTS); complaints of dropping things; pain if present often radiates from wrist into the hand and up into forearm, occasionally into shoulder

decreased sensation over palmar aspect of thumb, index finger, and middle finger, and over radial aspect of ring finger; atrophy of thenar eminence strongly supports a diagnosis and weakness of abductor pollicis brevis (thumb abduction)

insidious onset of numbness and/or tingling in digit 5 ± digit 4 ± medial aspect of hand; symptoms aggravated by leaning on the elbow and by periods of prolonged elbow flexion (e.g., talking on the phone, sleep); difficulty with fine motor activities in more severe cases (e.g., using a fingernail clipper, doing up zippers or buttons); pain if present usually radiates from elbow into hand; increased incidence postoperatively; leprosy

decreased sensation over finger 5, ulnar side of finger 4, and medial hand; atrophy of interossei leading to scalloping of first web space and prominence of extensor tendons in hand; weakness of finger abductors and adductors; weakness extending proximal interphalangeal joints of 4th and 5th fingers can lead to 'claw hand deformity' in severe cases; focal tenderness at the elbow may be present

pain and/or tingling radiating from the neck into the arm and/or hand; exacerbation of the pain or sensory symptoms with neck movement, cough, or sneeze; pain tends to be persistent; paraesthesiae intermittent

decreased triceps reflex in C7 radiculopathies; decreased biceps and/or brachioradialis reflexes in C5 or C6 radiculopathies (reflex judged to be decreased based on comparison with same reflex in unaffected arm); weakness and altered sensation in the distribution of the affected nerve root in severe cases

sensory loss/paraesthesiae over the medial aspect of the hand, the medial aspect of finger 4, and the entire finger 5, and/or weakness affecting fine motor activities (buttons, zippers, using a fingernail clipper); history of activity involving chronic pressure on the wrist or palm (e.g., tools, bicycle riding, paddling); when the lesion is distal to the sensory branch of the ulnar nerve, patients will complain of weakness (difficulty with fine motor activities) but no sensory loss

sensory loss over the palm in an ulnar nerve distribution; no sensory loss over dorsum of hand; weakness and atrophy of all ulnar-innervated hand muscles (hypothenar eminence, all dorsal interossei, and hypothenar to 4th and 5th digits); weakness of all ulnar-innervated hand muscles except those in the hypothenar eminence; occasionally, a ganglion cyst is palpable in the hand or in the region of Guyon canal at the wrist; if the lesion is distal to the sensory branch of the ulnar nerve, there will be weakness of ulnar-innervated hand muscles but no sensory loss; a midpalmar lesion may result in weakness in the first dorsal interosseus with sparing of the adductor digiti minimi and sensation in the 4th and 5th fingers

awakening with complete or partial wrist drop, often described by patient as 'my entire arm is numb and/or weak'; painless; alcohol and/or drug intoxication on night symptoms developed

marked weakness of thumb, finger, and wrist extension; weakness of brachioradialis (tested by having patient flex elbow against resistance with thumb facing the ceiling); patients may appear to have weakness of the finger abductors because of the inability to stabilise the fingers in extension (required to abduct fingers) unless tested with hand placed flat on table; sensory loss is usually identified over dorsum of hand between thumb and index finger

insidious-onset atrophy of all hand muscles resulting in weakness primarily affecting fine motor activities; numbness in 4th and 5th digits; medial hand and medial forearm (sensory symptoms tend to be less prominent than weakness)

prominent weakness and atrophy of the thenar eminence; sensory loss involving the 4th and 5th digits, medial hand, and medial forearm

pain or dull ache in forearm distal to radial head; no sensory loss

weakness of thumb and finger extension and weakness of ulnar wrist extension resulting in radial deviation on extension of wrist; normal strength in brachioradialis muscle (tested by having patient flex elbow against resistance with thumb facing the ceiling); normal sensation

isolated weakness of pinch and inability to flex distal phalanx of thumb; transient forearm pain occasionally reported

unable to flex distal phalanx of thumb; occasionally will also have weakness of flexion of the distal phalanx of digits 2 and 3; no numbness or paraesthesiae

acute-onset, relatively severe pain in shoulder region; pain typically lasts from a few days to 2 weeks, although may last longer; acute onset of weakness and atrophy of various muscles in the ipsilateral arm, typically 2 to 3 days after pain starts

usually marked atrophy and weakness of affected muscles; scapular winging, atrophy of deltoid muscle, atrophy of supraspinatus and infraspinatus, weakness of flexor pollicis longus (anterior interosseus nerve involvement) most commonly found; minimal, if any, sensory abnormalities

insidious onset of painless weakness; in the upper extremity, weakness usually starts in the dominant hand;[14]Masrori P, Van Damme P. Amyotrophic lateral sclerosis: a clinical review. Eur J Neurol. 2020 Oct;27(10):1918-29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7540334 http://www.ncbi.nlm.nih.gov/pubmed/32526057?tool=bestpractice.com ​ no sensory symptoms

fasciculations in proximal limbs; atrophy of affected muscles; usually hyperreflexia, particularly in affected limb (i.e., combination of upper and lower motor neuron signs); may have evidence of more diffuse involvement (i.e., dysarthria, lower extremity spasticity, and/or weakness)

shoulder pain, subacute onset; known cancer with possibility of primary or metastatic lesions to brachial plexus region (e.g., breast cancer, lung cancer, lymphoma);[20]Rubin DI. Brachial and lumbosacral plexopathies: a review. Clin Neurophysiol Pract. 2020;5:173-93. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7484503 http://www.ncbi.nlm.nih.gov/pubmed/32954064?tool=bestpractice.com ​ systemic symptoms to suggest malignancy (e.g., unexplained weight loss, night sweats)

Horner syndrome (ipsilateral pupil miosis and mild ptosis); weakness and atrophy of thenar + hypothenar eminence with sensory loss limited to medial aspect of hand and/or arm (i.e., no median nerve sensory loss); weakness and/or atrophy of shoulder girdle or upper arm muscles; depressed reflexes in affected limb compared with non-affected limb (may or may not be present depending on region of brachial plexus that is affected)

does not typically present with an isolated or multiple mononeuropathy, but should be considered in patients with carpal tunnel syndrome and a length-dependent polyneuropathy if no other explanation is found (e.g., diabetes mellitus, thyroid disease); insidious onset of severe, symmetrical painful paraesthesiae/burning sensation in feet; objective sensory loss and weakness in feet and calves and later in hands; early upper extremity symptoms are those of carpal tunnel syndrome; autonomic symptoms, particularly orthostatic hypotension, early satiety, and diarrhoea or constipation, may also occur; may have associated renal failure (nephrotic syndrome) and cardiomyopathy; positive family history in those with familial amyloid (rare)

orthostatic hypotension; decreased sensation, first to small fibre modalities (pinprick, temperature, vibration) and later to large fibre modalities (increased vibratory loss and proprioceptive loss) in a stocking distribution; decreased sensation in a median nerve distribution (if advanced, sensory loss will be in a complete glove-and-stocking distribution); with advanced disease, patient will have a distal muscle weakness and atrophy along with the stocking-glove sensory loss

subacute onset of arm/hand weakness in a patient with a history of irradiation to the upper chest (most commonly seen in patients treated for breast cancer); may occur anywhere from 3 months to 26 years after treatment (mean is 5 years); may start with proximal weakness (upper trunk of brachial plexus) and progress distally or with distal weakness (lower trunk of the brachial plexus) and progress proximally; may or may not be painful clinically; can be very hard to differentiate from tumour recurrence​[23]Fathers E, Thrush D, Huson SM, et al. Radiation-induced brachial plexopathy in women treated for carcinoma of the breast. Clin Rehabil. 2002 Mar;16(2):160-5. http://www.ncbi.nlm.nih.gov/pubmed/11911514?tool=bestpractice.com [24]Stubblefield MD. Neuromuscular complications of radiation therapy. Muscle Nerve. 2017 Dec;56(6):1031-40. http://www.ncbi.nlm.nih.gov/pubmed/28833264?tool=bestpractice.com

weakness and atrophy of thenar + hypothenar eminence with sensory loss limited to medial aspect of hand and/or arm (i.e., no median nerve sensory loss); weakness and/or atrophy of shoulder girdle or upper arm muscles; weakness/atrophy and sensory loss affecting entire arm (depends on degree of progression at time of presentation); depressed reflexes in affected limb compared with non-affected limb (may or may not be present depending on region of brachial plexus that is affected)

sudden onset of symptoms; severe constant pain; systemic symptoms (fever, weight loss, rash); associated connective tissue disorder predisposing to vasculitis (e.g., rheumatoid arthritis, systemic lupus erythematosus, granulomatosis with polyangiitis [formerly known as Wegener’s granulomatosis])

usually have more complete sensory loss and weakness than is seen in compression neuropathies at the time of initial presentation; deficits in >1 nerve distribution[25]Gwathmey KG, Burns TM, Collins MP, et al. Vasculitic neuropathies. Lancet Neurol. 2014 Jan;13(1):67-82. http://www.ncbi.nlm.nih.gov/pubmed/24331794?tool=bestpractice.com

numbness and weakness in the distribution of multiple nerves; cranial neuropathies frequent; may also complain of sensory loss in thoracic nerve distribution (over trunk); multisystem disease, so patients may have symptoms of other organ involvement (e.g., cough, dyspnoea)

sensory loss and weakness corresponding to the distribution of multiple peripheral nerves

insidious onset of weakness and numbness/paraesthesiae in multiple nerve distribution; onset is typically in the upper extremity, although it can start in the leg; pain can occur but is usually not prominent

weakness and sensory loss corresponding to multiple nerve distributions; decreased or absent reflexes (in a symmetrical or multifocal pattern)

present with isolated mononeuropathy with history of multiple prior mononeuropathies; typically painless; usually no other predisposing factors (e.g., diabetes mellitus); autosomal dominant so similar symptoms in family members may be reported; resolves spontaneously within 6 to 12 weeks

weakness and sensory loss in distribution of a peripheral nerve

patient has lived in an endemic region; severe pain in distribution of affected nerves; multiple nerves affected; may or may not report anaesthetic patches elsewhere

weakness and sensory loss corresponding to multiple nerve distributions (ulnar nerve frequently involved); affected nerves may be thickened and palpable; hypopigmented, hypoaesthetic (or anaesthetic) skin lesions

Associated with HIV-positive with CD4 count <50 cells/mm³; multiple mononeuropathies (weakness and sensory loss in multiple nerve distributions)

multiple mononeuropathies

multiple mononeuropathies (weakness and sensory loss in multiple nerve distributions); HIV-associated mononeuritis multiplex can present at time of seroconversion before HIV antibodies develop; exposure to blood/body fluids (e.g., history of drug abuse, blood transfusion, unprotected intercourse); weight loss >10%; fever and diarrhoea for at least 1 month; CD4 count <50 cells/mm³

multiple mononeuropathies; lymphadenopathy; fever; oropharyngeal and anogenital ulceration

usually 4 to 6 weeks after exposure; painful cranial neuropathies and/or radiculopathies are the most frequent manifestation of Lyme disease affecting the peripheral nervous system;[27]Garcia-Monco JC, Benach JL. Lyme neuroborreliosis: clinical outcomes, controversy, pathogenesis, and polymicrobial infections. Ann Neurol. 2019 Jan;85(1):21-31. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7025284 http://www.ncbi.nlm.nih.gov/pubmed/30536421?tool=bestpractice.com ​ patients present with pain, weakness, and sensory loss in the distribution of affected nerve roots that is often associated with a meningitis resulting in severe headache; it is not clear whether Lyme disease is a cause of true mononeuropathies; however, some patients complain of numbness and paraesthesiae associated with mild abnormalities on nerve conduction studies, both of which resolve with antibiotics[28]Halperin J, Luft BJ, Volkman DJ, et al. Lyme neuroborreliosis. Peripheral nervous system manifestations. Brain. 1990 Aug;113(Pt 4):1207-21. http://www.ncbi.nlm.nih.gov/pubmed/2168778?tool=bestpractice.com

weakness and sensory loss corresponding to multiple nerve root distributions; hyporeflexia in distribution of affected nerve roots; facial weakness from involvement of facial nerve; nuchal rigidity if concurrent meningitis; in patients presenting only with non-specific sensory symptoms, neurological examination is typically normal with the exception of mildly altered sensation in affected region