Rheuma Case: 49-year-old Woman with R Proximal Thumb Pain

by Stephen Holt, MD, MS

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    00:00 Okay, having reviewed those radiographs, let's talk about the next case.

    00:05 This time we have a 49-year old woman without any significant past medical history who presents with right, proximal thumb pain for the past 3 weeks.

    00:13 Now she describes this pain as an intermittent dull ache and rates it as a 6 out of 10 in severity.

    00:19 She notices the pain most at her job where she works in construction using a power drill.

    00:24 She's managed her pain with ice and rest but now the discomfort has started to limit her ability to perform her basic functions of her occupation.

    00:31 She denies any growths, no swellings, no erythema on her hand.

    00:35 Gross inspection, similarly, no overlying skin changes.

    00:39 No warmth, no swelling, no nodules, no deformities and no evidence of atrophy.

    00:44 On palpation, you note mild tenderness at the scaphoid with more significant tenderness at the base of the thumb, the first carpometacarpal joint and there is also some mild crepitus noted at this location as well.

    00:58 Range of motion - fully intact at the wrist.

    01:00 There's some mild discomfort with abduction and opposition of the thumb.

    01:05 Strength is within normal limits at the wrist and the fingers and maneuvers, the Eichoff test is negative and the Phalen's test is negative.

    01:14 Hopefully, we'll review those again soon.

    01:17 Alright, so let's look at some key features here.

    01:19 This sounds like a subacute time course, it's been going on for a couple of weeks.

    01:24 The pattern of joint involvement, it's one joint, so it's monoarticular.

    01:29 Evidence of joint inflammation, we're not seeing any warmth or swelling so we can say that there's no joint inflammation And we don't hear anything to suggest any systemic involvement.

    01:40 So let's take a look at our list of potential diagnosis.

    01:44 First up, DeQuervains tenosynovitis.

    01:47 I'll remind you that tenosynovitis simply means inflammation of a tendon.

    01:51 In this case, DeQuervain's is tendonopathy of the abductur pollicis longus and extensor pollicis brevis tendons which help with thumb movement and it's common in patients with repeated ulnar strain injuries like from lifting babies, playing video games, occupational hazzards.

    02:08 The most useful test for this diagnosis is called the Eichoff test, though occasioanally, it's misconstrude as being called the Finkelstein test and it's the classic maneuver used to diagnose DeQuervain's.

    02:19 Well, in our patient, we had a negative Eichoff test, so we can safely take that one off the list.

    02:24 Next stop is carpal tunnel syndrome.

    02:27 Now, carpal tunnel syndrome most typically presents with paresthesias of the 1st, 2nd and 3rd fingers, remember the median nerve distribution, rather than focal pain at the 1st CMC joint.

    02:40 This shown here is the Phalen's test which is not the best test for carpal syndrome but this one of the more common ones you hear about and that test was negative.

    02:48 So, I feel comfortable taking that off the list as well.

    02:53 Next up is osteoarthritis.

    02:55 Well, it turns out that the 1st CMC joint, shown here with the green circle, is actually a common place for osteoarthritis.

    03:03 So, this is the most likely diagnosis right now.

    03:07 And lastly, a scaphoid fracture shown here is a very unlikely diagnosis in the absence of any trauma.

    03:14 So, we can very quickly take that one off of our list as well even if it's in the right location for our patient's pain.

    03:20 So, yes, I made it easy on you guys this round.

    03:23 Two diagnoses of osteoarthritis in a lecture called osteoarthritis.

    03:28 Happy birthday and you're welcome.

    About the Lecture

    The lecture Rheuma Case: 49-year-old Woman with R Proximal Thumb Pain by Stephen Holt, MD, MS is from the course Non-Autoimmune Arthritis.

    Included Quiz Questions

    1. Eichoff test
    2. Bunnell test
    3. Phalen's test
    4. Tinel sign
    5. Watson test
    1. Carpal tunnel syndrome
    2. DeQuervain's tenosynovitis
    3. Cubital tunnel syndrome
    4. Kienbock disease
    5. Scaphoid nonunion

    Author of lecture Rheuma Case: 49-year-old Woman with R Proximal Thumb Pain

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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