What is the best course of action for a patient with a history of right carpal tunnel and cubital tunnel surgery, now experiencing frequent dropping of objects from their left hand?

Immediate Diagnostic Workup for Left Hand Weakness with Dropping Objects

Obtain plain radiographs of the left hand, wrist, and forearm immediately as the first-line imaging study to exclude occult fracture or bony pathology, followed urgently by MRI without IV contrast if radiographs are negative, to evaluate for nerve compression, soft tissue masses, or nerve injury. 1, 2

Initial Clinical Assessment

The patient's symptom of frequently dropping objects from the left hand, combined with a history of contralateral (right) carpal and cubital tunnel surgery, raises immediate concern for:

• Carpal tunnel syndrome affecting the left median nerve, which would impair grip strength and fine motor control through weakness of the abductor pollicis brevis and thenar muscles 3, 4
• Cubital tunnel syndrome affecting the left ulnar nerve, causing intrinsic hand muscle weakness and impaired grip 5, 4
• Radial nerve pathology (including posterior interosseous nerve compression), which would cause weakness of finger and thumb extension 2, 6
• Occult fracture or bone lesion compressing peripheral nerves, even without recalled trauma 2

Diagnostic Imaging Algorithm

Step 1: Plain Radiographs (Immediate)

• Obtain 3-view radiographs of the left hand (posteroanterior, lateral, and oblique projections) to detect metacarpal and phalangeal fractures 1
• Obtain 3-view radiographs of the left wrist (posteroanterior, lateral, and 45-degree semipronated oblique) to identify distal radius fractures or carpal bone abnormalities 1
• Include forearm radiographs to rule out occult fractures, bone lesions, or other bony abnormalities that could compress nerves along their course 2

Step 2: MRI Without IV Contrast (If Radiographs Negative or Equivocal)

• MRI is the preferred advanced imaging modality for evaluating nerve compression, soft tissue masses (lipomas, ganglion cysts), inflammatory changes, or nerve injury when radiographs are normal 1, 2, 7
• MRI with dedicated neurography sequences provides superior visualization of injured nerves and can identify the exact site and cause of nerve compromise 1, 2, 7
• MRI detects concomitant ligament injuries and soft tissue pathology that may contribute to functional impairment 1

Step 3: Electrodiagnostic Studies

• Nerve conduction studies are the gold standard for confirming carpal tunnel syndrome and cubital tunnel syndrome, though they have false positive and false negative rates 3
• Diagnosis should integrate history, physical examination findings, and electrophysiological results rather than relying on any single test 3, 4

Critical Physical Examination Findings to Document

• Median nerve distribution: Test abductor pollicis brevis strength (5/5 scale), assess for thenar atrophy, check static two-point discrimination in thumb/index/middle fingers, and evaluate for nocturnal pain with tingling in median nerve distribution 3, 5
• Ulnar nerve distribution: Test intrinsic hand muscle strength and flexor digitorum profundus strength, assess for hypothenar atrophy, check two-point discrimination in ring/small fingers 5, 6
• Radial nerve distribution: Test wrist and finger extension strength, assess for wrist drop, check sensation over first dorsal web space 2, 6
• Grip and pinch strength measurements: Document baseline chuck pinch and key pinch strength for comparison 5

Urgent Referral Indications

Refer immediately to hand surgery or neurology if:

• MRI reveals a compressive mass, nerve discontinuity, or other surgical pathology requiring intervention 2
• Progressive motor weakness develops despite conservative management 4
• Electrodiagnostic studies confirm moderate to severe nerve compression 3, 4

Common Pitfalls to Avoid

• Do not assume "no trauma history" excludes fracture: Occult fractures can present without recalled trauma, and progressive neurologic symptoms mandate imaging 2
• Do not skip radiographs and proceed directly to MRI: Bony pathology must be excluded first per ACR guidelines, as radiographs may immediately reveal the diagnosis 1, 2
• Do not delay imaging pending specialist consultation: Obtain radiographs immediately and MRI urgently if radiographs are normal, as early diagnosis significantly impacts outcomes 2
• Do not attribute symptoms solely to bilateral disease: While the patient has a history of right-sided surgery, each side requires independent diagnostic evaluation 5, 4
• Do not rely on physical examination tests alone: No single physical examination maneuver is diagnostic for carpal or cubital tunnel syndrome; electrodiagnostic confirmation is essential 3

Treatment Considerations After Diagnosis

• Mild carpal tunnel syndrome can be managed with conservative treatment, particularly local steroid injection 3
• Moderate to severe cases require surgical decompression as the only curative treatment 3, 4
• Concomitant carpal and cubital tunnel syndromes can be safely treated with dual endoscopic release if both are confirmed, with success rates comparable to isolated procedures 5
• Surgical decompression for carpal tunnel syndrome has success rates of 91.6-93.4% regardless of technique (open vs. endoscopic), with complication rates below 1% when performed by experienced surgeons 4