Okay, having reviewed those radiographs,
let's talk about the next case.
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.
Now she describes this pain as an intermittent dull
ache and rates it as a 6 out of 10 in severity.
She notices the pain most at her job where she
works in construction using a power drill.
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.
She denies any growths, no
swellings, no erythema on her hand.
Gross inspection, similarly,
no overlying skin changes.
No warmth, no swelling, no nodules, no
deformities and no evidence of atrophy.
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.
Range of motion - fully
intact at the wrist.
There's some mild discomfort with
abduction and opposition of the thumb.
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.
Hopefully, we'll review
those again soon.
Alright, so let's look at
some key features here.
This sounds like a subacute time course,
it's been going on for a couple of weeks.
The pattern of joint involvement, it's
one joint, so it's monoarticular.
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.
So let's take a look at our
list of potential diagnosis.
First up, DeQuervains
I'll remind you that tenosynovitis
simply means inflammation of a tendon.
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.
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.
Well, in our patient, we had a negative Eichoff
test, so we can safely take that one off the list.
Next stop is carpal
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.
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.
So, I feel comfortable taking
that off the list as well.
Next up is osteoarthritis.
Well, it turns out that the 1st CMC joint, shown here with the
green circle, is actually a common place for osteoarthritis.
So, this is the most likely
diagnosis right now.
And lastly, a scaphoid fracture shown here is a very
unlikely diagnosis in the absence of any trauma.
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.
So, yes, I made it easy
on you guys this round.
Two diagnoses of osteoarthritis in
a lecture called osteoarthritis.
Happy birthday and