1. An Unusual contributor to dequervain’s tenosynovitis: a case study
T. Daniel Smith, MD, MS

2. History
HPI:
20 yo caucasian male presented with chief complaint of radial-sided wrist pain x1 year.
History of closed-hand punching a car 15 months ago
Immediate pain/swelling to radial aspect of wrist
Subsequently convalesced and pain was replaced by dull & persistent ache
Improved with rest, worsened by work as a manual laborer also worsened by recreation, crossfit
Has tried ibuprofen before workouts and work with modest efficacy
The patient, an otherwise healthy 20-year- old caucasian male, presented to our outpatient family medicine clinic complaining of radial sided right wrist pain for over a year.  The patient reports that the pain began after he close-hand punched a vehicle while intoxicated 15 months ago.  He experienced sharp pain and immediate swelling, primarily to the radial side of his wrist, which lasted for several weeks and slowly regressed. The pain since changed its character, becoming dull and chronic and subsequently affecting his work as a manual laborer and his recreational activities in Olympic-style lifting. The patient had used ibuprofen regularly for pain control.

3. History PMH: Bipolar type 2 Meds: Lithium Allergies: None
FH: Essential hypertension, “heart problems” in father
Social: Baptist, former recreational marijuana, drinks occasionally
ROS: Notably negative for paresthesias, weakness, numbness, pallor, cool extremities

4. Physical Examination General: Right forearm, wrist, and hand:
WDWN male in NAD
Right forearm, wrist, and hand:
No deformity, sensation intact to light touch
Motor function intact to AIN, PIN, and Ulnar Nerve
Notably, some discomfort with “thumbs up”
Allen’s test positive for collateral circulation
+TTP over radial aspect of distal wrist, ~ TTP over snuffbox, - TTP over carpus or scaphoid in particular
- TTP at intersection of 1st and 2nd dorsal compartments
+ Finkelstein test, - CMC grind, - Watson’s
- Phalen’s, - Tinel, - Pain on resisted wrist extension

5. Differential Diagnosis List
DeQuervain’s Tenosynovitis
Scaphoid Fracture
Intersection Syndrome
Scapholunate Ligament Injury
Kienbock’s Disease

6. Questions?

7. Data-Plain Films
Figure 1. PA of R wrist with ulnar deviation. Osteophyte over lateral aspect of distal radius – arrow. Old facture line of radial styloid – arrow heads.

8. Data-Plain Films
Figure 2. Oblique of R wrist. Redemonstration of osteophyte (arrow) and fracture callus (arrowheads)

9. Data-Plain Films
Figure 3. Lateral of the R wrist. No acute or chronic osseous abnormality seen.)

10. Data - Ultrasound Images
Figure 4.
Lateral surface of radius with prominent osteophyte. Superficially, the APL and EPB tendons exhibiting tendinopathy.

11. Data – Ultrasound Images

12. Final Working Diagnosis
DeQuervain’s Tenosynovitis
Positive Finkelstein’s
Fitting symptomatology
Largely negative exam otherwise
Contributing factor of underlying osteophyte
Demonstrated to lie under1st dorsal compartment
History and radiographs consistent with likely radial styloid fracture

13. Treatment Thumb spica splint 1st dorsal compartment steroid injection
Relative rest
NSAIDS eschewed given chronicity and prior usage
Discussed surgical removal of osteophyte
This was declined however
Patient moving shortly to join the military

14. Outcome Seen briefly in the community 3 days later
Ostensibly an unofficial visit
Symptomatology improved
Less pain with work and recreation
Reported no change to intensity level of physical activity
Reported to armed services 1 week later without further follow-up

15. References
Hoppenfeld, S. (1976). Physical Examination of the Spine and Extremities. Physical Examination of the Wrist and Hand. pp  
Drake, R. Vogle A. Mitchell, A. (2010). Gray’s Anatomy for Students, 2nd ed. Upper Limb. pp
Cleland, J. Koppenhaver, S. (2011). Netter’s Orthopaedic Clinical Examination: An Evidence-Based Approach - 2nd ed. Wrist and Hand. pp
Wolf, J. Sturdivant, R. Owens, B. (2009). Incidence of de Quervain’s Tenosynovitis in a Young, Active Population.  Journal of Hand Surgery-American Volume, Jan;34(1),
Clarke, M. Lyall, H. Grant, J. Matthewson, M. The Histopathology of de Quervain’s disease. Journal of Hand Surgery: British and European Volume Dec;23(6):
Finkelstein, H. Stenosing Tenovaginitis at the Radial Styloid Process.  Journal of Bone and Joint Surgery. 1930; 12:9-540.
Alexander, R. Catalano, L. Barron, O. Glickel, S. The Extensor Pollicis Brevis Entrapment Test in teh Treatment of de Quervain’s Disease.  
DeQuervain F: Ueber eine Form von chronischer Tendovaginitis. Corresp Blatt Schweizer Arzte 1895; 25:
Rettig AC Athletic Injuries of the Wrist and Hand, Part II: Overuse Injuries of the Wrist and Hand and Traumatic Injuries to the Hand. The American Journal of Sports Medicine;32:

16. Thank you