Anteroposterior radiograph of the hand of a 57-year-old woman with a 3-week history of thumb pain
Lateral radiograph of the patient’s hand
Oblique radiograph of the patient’s hand
A 57-year-old woman presents with a 3-week history of thumb pain. She started babysitting her 1-year-old granddaughter a month previously and lifting the toddler seems to aggravate the pain. The woman has tried oral nonsteroidal anti-inflammatory drugs, with minimal relief. Examination reveals negative first carpometacarpal grind test, no active triggering at the A1 pulley, and positive Finkelstein maneuver. Anteroposterior, oblique, and lateral radiographs of the hand are taken.
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The key physical examination finding in this patient was positive Finkelstein maneuver. Finkelstein maneuver is accomplished by having the patient clench the flexed thumb in a fist and perform ulnar deviation of the wrist. Pain with ulnar deviation of the wrist constitutes positive Finkelstein maneuver and indicates De Quervain tenosynovitis as the most likely diagnosis. De Quervain occurs most commonly in women aged between 30 and 50 years and occurs more often in the dominant hand. De Quervain is common among new mothers and other caregivers who use the thumb frequently to lift.
The condition is caused by irritation of the abductor pollicis longus and extensor pollicis brevis tendons as they repeatedly traverse through the tendon sheath of the first dorsal compartment. Initial treatment of De Quervain tenosynovitis includes rest and use of a thumb spica splint, administration of nonsteroidal anti-inflammatory drugs, and/or corticosteroid injections into the tendon sheath.
Stenosing tenosynovitis, also known as trigger finger, occurs when the flexor tendon becomes inflamed and swollen, making it harder for it to travel through the A1 pulley in the hand. The tendon can become so swollen that it gets stuck, or triggers, at the A1 pulley located anterior to the metacarpal head. Basal joint arthritis is arthritis of the first carpometacarpal joint (base of thumb) and pain is generally produced with a carpometacarpal grind test. Flexor tenosynovitis, or pyogenic flexor tenosynovitis, is an infection of the synovial sheath that surrounds the flexor tendon and is often caused by penetrating trauma.
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- American Academy of Orthopaedic Surgeons. De Quervain’s tendinosis. OrthoInfo website. http://orthoinfo.aaos.org/topic.cfm?topic=A00007. December 2013. Accessed November 8, 2016.
- Watts E. De Quervain’s tenosynovitis. OrthoBullets website. http://www.orthobullets.com/hand/6026/de-quervains-tenosynovitis. Accessed November 8, 2016.