Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 28-year-old man is evaluated for pain on the radial aspect of the right wrist that occurs with use of the thumb. The pain has been present for 2 weeks. He has never had this pain before and has not had any trauma. He works as a computer programmer and plays video games for 3 to 4 hours each night when he gets home from work.
On physical examination, vital signs are normal. Localized tenderness to palpation is present over the distal radial styloid; pain is present with resisted thumb abduction and extension, and the patient has pain on the radial side of the thumb when he is asked to make a fist over the fully flexed thumb and then to ulnar deviate the hand (positive Finkelstein test). There are no palpable masses; there is no joint pain, bogginess, or swelling; sensation is intact throughout the wrist and hand, strength is 5/5 throughout.
Which of the following is the most likely diagnosis?
A: Carpometacarpal arthritis
B: de Quervain tenosynovitis
C: Flexor carpi radialis ganglion cyst
D: Scaphoid fracture
MKSAP Answer and Critique
The correct answer is B: de Quervain tenosynovitis.
This patient’s presentation is most consistent with de Quervain tenosynovitis, which refers to swelling or stenosis of the abductor pollicis longus and extensor pollicis brevis tendon sheaths at the level of the wrist. It is most commonly caused by repetitive motion of the thumb but can also be associated with underlying conditions including pregnancy and rheumatoid arthritis. This condition commonly presents with pain and swelling located over the radial styloid. The pain occurs with use of the thumb. On examination, there is localized tenderness of the distal radial styloid. Pain is elicited with both resisted thumb abduction and extension. The Finkelstein test is frequently positive (as with this patient).
Carpometacarpal arthritis presents with pain at the base of the thumb that occurs with thumb gripping and pinching. This pain may radiate into the distal forearm. On examination, there is tenderness to palpation on both the dorsal and palmar surfaces of the joint. Compressing the joint by applying a longitudinal load frequently produces pain. In advanced cases, joint stiffness and loss of range of motion may be present. The absence of these findings, as well as the patient’s young age, argues against carpometacarpal arthritis as the cause of his pain.
A ganglion is a cyst that forms on the tendon sheath and results from inflammation, often following trauma. The anatomic location of the patient’s pain and the absence of a palpable cystic structure do not support this diagnosis.
Patients with a scaphoid fracture usually have a history of an injury that involves wrist dorsiflexion. Pain is located in the anatomic snuffbox (the radial side of the wrist between the abductor and long thumb extensor tendons just distal to the radial styloid). On examination, there is significant tenderness to palpation of the anatomic snuffbox.
- de Quervain tenosynovitis is pain that occurs with thumb use, characterized by pain and swelling over the radial styloid that is elicited with both resisted thumb abduction and extension.
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