A 32-year-old right-hand-dominant woman living in New Hampshire comes to the physician complaining of right wrist pain for the past 3 months. She has no history of tick bites, recent travel, or illness in the family. Review of systems is negative for fever, pain or swelling in any other joints, skin rash, or recent gastrointestinal or genitourinary infections. The patient is sexually active in a monogamous relationship. She delivered her first child 4 months ago. She smokes marijuana occasionally.
Her temperature is 37.2° C (99° F), blood pressure is 110/78 mm Hg, pulse is 78/min, and respirations are 12/min. She weighs 80 kg (176 lb). There is a sharp tenderness on palpation of the radial styloid at the wrist. The pain is aggravated on ulnar deviation of the wrist after she is asked to make a fist over the thumb. There is no synovitis or tenderness noted on any other joints. The right hand x-ray is shown below.

Which of the following is the most likely diagnosis?

Question

A 32-year-old right-hand-dominant woman living in New Hampshire comes to the physician complaining of right wrist pain for the past 3 months.  She has no history of tick bites, recent travel, or illness in the family.  Review of systems is negative for fever, pain or swelling in any other joints, skin rash, or recent gastrointestinal or genitourinary infections.  The patient is sexually active in a monogamous relationship.  She delivered her first child 4 months ago.  She smokes marijuana occasionally.
Her temperature is 37.2° C (99° F), blood pressure is 110/78 mm Hg, pulse is 78/min, and respirations are 12/min.  She weighs 80 kg (176 lb).  There is a sharp tenderness on palpation of the radial styloid at the wrist.  The pain is aggravated on ulnar deviation of the wrist after she is asked to make a fist over the thumb.  There is no synovitis or tenderness noted on any other joints.  The right hand x-ray is shown below.

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_9933_0d2c_853d_c1d6dc818469_MD0002_00 This patient's wrist pain, history of caring for an infant, positive Finkelstein's maneuver, and normal hand x-ray suggest de Quervain's tenosynovitis. Chronic overuse of the wrist, trauma, or repetitive activity may entrap the abductor pollicis longus and extensor pollicis brevis tendons at the radial styloid process. The resultant tendinitis/tenosynovitis causes pain. The tenosynovitis occurs most commonly in women ages 30-50 with infants and daycare workers. Patients usually present with pain at the radial side of the wrist; pain can radiate to the thumb or volar aspect of the wrist with movement. Examination may show painful swelling or enlargement of the first extensor (dorsal) compartment. Tenderness and thickening at the radial styloid can be present in many patients. Finkelstein's maneuver involves grasping the patient's clenched hands (with fingers over the thumb) and rotating the wrist toward the ulnar aspect. Pain with movement is a positive sign and suggests the diagnosis. Complete painless thumb movement with active hand opening and closing usually rules out de Quervain's tenosynovitis. Finkelstein's maneuver Acute treatment of de Quervain's tenosynovitis involves activity modification, thumb splints, and anti-inflammatory agents. Local steroid injections are reserved for persistent pain despite these measures. Surgery is considered for recurrent or persistent symptoms after 2 steroid injections within 1 year. Finkelstein's maneuver may also be positive in osteoarthritis of the carpometacarpal (CMC) joint. X-ray is usually normal in de Quervain's tenosynovitis; CMC osteoarthritis may have CMC joint subluxation, diminished CMC space, osteophytes, and joint surface sclerosis. However, some patients require local anesthetic block directly over the radial styloid to differentiate de Quervain's tenosynovitis (pain relief with injection) from CMC arthritic flare (no response). This patient is unlikely to have osteoarthritis at her age (Choice E). (Choice A) Carpal tunnel syndrome presents with pain or paresthesia (usually worse at night) in the distribution of the median nerve (involvement of the first 3 and 1/2 digits) with a positive Tinel's sign on examination. (Choice C) Gonococcal arthritis usually presents with tenosynovitis, migratory polyarthritis, and pustular skin lesions. (Choice D) Lyme arthritis typically presents with intermittent or persistent monoarthritis affecting larger joints (eg, knee or ankle) and more swelling than pain. Educational objective: de Quervain's tenosynovitis is due to thickening and stenosis of the synovial sheath from chronic overuse of the wrist or hand, trauma, or repetitive activity. Patients usually present with pain at the radial side of the wrist and positive Finkelstein's maneuver. Acute treatment involves activity modification, thumb splints, and anti-inflammatory agents. __________ References: De Quervain tenosynovitis of the wrist. (http://www.ncbi.nlm.nih.gov/pubmed/18063716)

A 32-Year-Old Right-Hand-Dominant Woman Living in New Hampshire Comes to the Physician