CASE 146
By: Dr. Nizar Al-Nakshabandi MD, FRCPC
HISTORY: 27-year-old female complaining of wrist pain, she is 1 week postpartum.
What are your findings?
What is the differential diagnosis?
What are the causes?
FINDINGS:
Coronal T2 fat sat weighted images [A and B] through the rest demonstrate tenosynovitis of the extensor pollicis brevis tendon and abductor pollicis longus tendon sheath. Transaxial short axis view at the level of the wrist demonstrate tenosynovitis involving extensor compartment #1.
DIFFERENTIAL DIAGNOSIS:
· De Quervain’s tenosynovitis.
· Osteoarthritis of the first carpometacarpal joint.
· Intersection syndrome.
· Wartenberg’s syndrome.
DIAGNOSIS:
De Quervain’s tenosynovitis.
PEARLS AND DISCUSSION:
De Quervain’s tenosynovitis is a clinical diagnosis based on history and physical examination. The role of imaging is to rule out fractures, arthritis, or atypical history and presentation.
Finklelstein’s test is the physical examination that is used to diagnosis.
De Quervain’s syndrome is inflammation of the tendon sheaths surrounding the extensor pollicis brevis, and abductor pollicis longus muscles and tendons is caused by a non-inflammatory thickening of the tendons in the synovial sheath.
Other names for it is iPhone thumb, Nintendinitis from excessive use of the thumb. Condition was originally described in mothers and child care workers due to lifting of infants.
Plain films will and can demonstrate soft tissue swelling over the radial styloid and rarely cortical erosions of the radial styloid. Ultrasound has become golden standard to demonstrate fluid surrounding the extensor tendon compartment #1. Peritendinous inflammation and thickening along with hyperemia on Doppler imaging could be seen. MRI is extremely sensitive and specific for detecting this disease by identifying tenosynovitis, tendinitis, and rarely longitudinal tear of the tendon.
Treatment is by conservative measures with nonsteroidal anti-inflammatory drugs, rest and splinting. Fluoroscopic or US guided tendon sheath injection can be effective in up to 50% of the cases. Surgical decompression is a rare approach for treatment of such cases.
FURTHER READING:
1. Stoller DW, Tirman PF, Bredella MA. Diagnostic imaging, Orthopaedics. Amirsys Inc. (2004) ISBN:0721629202.
2. Anderson SE, Steinbach LS, De Monaco D et-al. "Baby wrist": MRI of an overuse syndrome in mothers. AJR Am J Roentgenol. 2004;182 (3): 719-24.
3. Chien AJ, Jacobson JA, Martel W et-al. Focal radial styloid abnormality as a manifestation of de Quervain tenosynovitis. AJR Am J Roentgenol. 2001;177 (6):
