A 30-year-old woman comes to the office due to pain over the lateral side of the right wrist for the last 4 days. She is 6 weeks postpartum from her first child, and the pain is most severe when she lifts the infant from the crib. The patient has not had acute trauma to the wrist or hand. Vital signs are normal. Examination shows tenderness over the radial side of the wrist and first dorsal compartment. With the hand in a fist and the fingers closed over the thumb, passive adduction of the wrist reproduces the pain. Which of the following is the most likely diagnosis in this patient?

Question

A 30-year-old woman comes to the office due to pain over the lateral side of the right wrist for the last 4 days.  She is 6 weeks postpartum from her first child, and the pain is most severe when she lifts the infant from the crib.  The patient has not had acute trauma to the wrist or hand.  Vital signs are normal.  Examination shows tenderness over the radial side of the wrist and first dorsal compartment.  With the hand in a fist and the fingers closed over the thumb, passive adduction of the wrist reproduces the pain.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d2b7_cac9_bc81_910b90a89ce6_MD0003_00 This patient has lateral wrist pain consistent with de Quervain tendinopathy (DQT). DQT is an overuse syndrome involving the tendons of the abductor pollicis longus and extensor pollicis brevis and occurs most prominently at the point where the tendons pass under the extensor retinaculum in the first dorsal compartment. It most commonly occurs in women age 30-50 and is seen in higher frequencies 4-6 weeks postpartum, possibly because of repetitive thumb abduction and extension when lifting the infant. The diagnosis of DQT is based on clinical features. Examination typically shows tenderness at the radial side of the wrist at the base of the hand. In addition, the Finkelstein test (adduction of the wrist with the fingers closed over the thumb in a fist) causes passive stretching of the tendons over the radial styloid; reproduction of the pain in this maneuver is strongly suggestive of DQT. Conservative management with nonsteroidal anti-inflammatory drugs (eg, ibuprofen) and thumb spica splinting is usually adequate. Finkelstein test (Choice B) Flexor carpi radialis tenosynovitis is associated with excessive wrist flexion and characterized by pain and tenderness at the anterior aspect of the wrist. It is relatively uncommon; overuse of this muscle more commonly causes symptoms at the proximal origin (ie, medial epicondylitis). (Choice C) Osteoarthritis of the first metacarpophalangeal joint causes pain over that joint, not at the carpometacarpal joint. It would be uncommon in this young patient without a history of significant trauma. (Choice D) Scaphoid fractures typically occur during forceful hyperextension of the wrist (eg, fall on an outstretched hand). Pain and tenderness typically localize to the anatomic snuffbox. anatomic snuffbox (Choice E) Stenosing tenosynovitis ("trigger thumb") results in pain over the palmar aspect of the first metacarpophalangeal joint; the pain is associated with a catching sensation during movement or locking of the thumb in flexion. Educational objective: De Quervain tendinopathy presents with lateral wrist pain over the tendons of the abductor pollicis longus and extensor pollicis brevis. It is most common in women age 30-50, with an increased frequency during the postpartum period. Examination shows tenderness at the radial side of the wrist and a positive Finkelstein test (reproduction of pain on adduction of the wrist with the fingers closed over the thumb).

A 30-Year-Old Woman Comes to the Office Due to Pain