323 - From the Kitchen to the Clinic: A Rare Case of La Main Du Cuisinier (Chef's Hand Neuropathy)

Case Diagnosis: La Main Du Cuisinier; a rare occupationally-linked hand neuropathy.

Case Description: 53 year-old right-hand dominant female presented to an outpatient FM clinic with a one year history of arthralgias and paresthesias in the hands; limited to digits 2-5 bilaterally. Patient has been a chef for 29 years, with no reported history of trauma. Patient experienced an insidious onset of decreased sensation resulting in work-related burns, and decreased grip strength. Physical exam exhibited 2/5 strength of intrinsic hand muscles, 5/5 strength in the thumb/wrist/forearm bilaterally, and decreased sensation to light touch/pain/temperature in the palm and digits 2-5, distal to the wrist joint, sparing the thenar eminence and thumb, worse on the right. Decreased active and passive ROM of the wrist, DIPs, and PIPs. Provocative testing revealed positive Phalen's and Tinel's tests bilaterally. Point-of-care ultrasound demonstrated entrapment of both median and ulnar nerves at the palmar crease.

Discussions: La main du cuisinier is a peripheral neuropathy seen predominantly in the culinary industry, due to repetitive motion of using kitchen equipment. The unique distribution of motor and sensory weakness, is hypothesized to result from compression of the median and ulnar nerves at the proximal palmar crease, distal to the branchpoint of the median nerve supplying the thumb. The two reported cases of "Chef's Hand neuropathy" align with our patient's presentation, with worsening symptoms in the dominant hand providing evidence for an occupational linkage. This rare constellation of symptoms is believed to be due to repetitive pressure from the knife handle compressing the nerves at the proximal palmar crease.

Conclusions: This occupationally-linked hand neuropathy should be considered in the correct patient population with this unique array of symptoms, representative of distal median and ulnar neuropathy. Treatment modalities include overnight bracing and additionally, the usage of ergonomic knives and kitchen equipment to reduce pressure at the proximal palmar crease.