Presenting Complaints:
A 42-year-old right-handed female presents with pain and swelling at the base of her right thumb. The pain has been gradually worsening over the past six weeks. She noticed it after performing repetitive grasping and pinching activities at work, particularly when lifting heavy objects and using tools. The patient reports that the pain is interfering with her ability to perform daily activities and work-related tasks. She denies any recent trauma or injury to the hand.
History of Presenting Complaints:
The patient reports experiencing discomfort and tenderness along the tendons at the base of her thumb. The pain radiates up the thumb and forearm, especially during thumb and wrist movement. She also noticed swelling and a slight difficulty in moving her thumb without pain.
Chief Complaints:
- Pain and swelling at the base of the right thumb
- Difficulty performing daily activities and work-related tasks
Past Medical and Surgical History:
The patient has no significant past medical or surgical history, and she is not currently taking any medications.
Family History:
There is no family history of musculoskeletal disorders or chronic inflammatory conditions.
Socioeconomic Status:
The patient is employed full-time in a physically demanding job and has a middle-class socioeconomic status.
Present and Pre-Morbid Functional Status:
Prior to the onset of symptoms, the patient had no limitations in hand function and was able to perform all daily activities and work tasks without any difficulty.
General Health Status:
The patient’s overall health is good, and there are no other significant health issues.
Vitals:
- Blood pressure: 120/80 mmHg
- Heart rate: 70 beats per minute
- Respiratory rate: 16 breaths per minute
- Temperature: 98.6°F (37°C)
- Oxygen saturation: 98%
Aggravating Factors:
- Repetitive thumb and wrist movements
- Grasping and pinching activities
- Lifting heavy objects
- Using tools at work
Easing Factors:
- Resting the affected hand
- Avoiding repetitive movements
Examination:
Physical examination reveals swelling and tenderness over the radial aspect of the wrist, at the base of the thumb. Finkelstein’s test is positive, eliciting sharp pain when the patient’s thumb is flexed and the wrist is ulnarly deviated. There is no evidence of warmth or redness in the area.
Sleep and 24-hour Pattern:
The patient reportsdifficulty falling asleep due to pain in the affected hand. Pain also wakes her up during the night, disrupting her sleep pattern.
Duration of Current Symptoms:
The patient has been experiencing symptoms for approximately six weeks.
Mechanism of Injury/Current Symptoms:
The patient’s symptoms are consistent with overuse and repetitive strain injury due to her work-related activities that involve constant grasping, pinching, and lifting.
Progression Since the Current Episode:
The symptoms have gradually worsened over the past six weeks, affecting the patient’s ability to perform daily tasks and work duties.
Significant Prior History:
There is no significant prior history of hand or wrist injuries.
Previous Treatment:
The patient has not sought any medical treatment for her symptoms before the current visit.
Diagnostic Test/Imaging:
X-rays of the hand and wrist are ordered to rule out any other potential underlying conditions, such as fractures or arthritis.
Differential Diagnosis:
- De Quervain’s Tenosynovitis
- Basal joint arthritis
- Intersection syndrome
- Carpal tunnel syndrome
Postural Observation:
The patient’s hand and wrist appear to be in a neutral resting position, without any obvious deformities or abnormalities.
Precautions and Contraindications:
The patient should avoid activities that exacerbate her symptoms, such as repetitive thumb and wrist movements and heavy lifting.
Functional Movement Analysis (Sign):
The patient demonstrates limited range of motion and pain during thumb and wrist movements, especially with ulnar deviation.
Quick Screening Tests/Clearing of Additional Joint Structures:
The patient’s quick screening tests for other joint structures, such as the metacarpophalangeal and interphalangeal joints, are within normal limits.
Range of Motion (ROM):
The range of motion of the thumb and wrist is limited due to pain and swelling.
Special Tests:
- Finkelstein’s test: Positive, with reproduction of pain when the thumb is flexed and the wrist is ulnarly deviated.
- Phalen’s test and Tinel’s sign at the carpal tunnel: Negative.
Assessment:
Based on the patient’s history, physical examination, and positive Finkelstein’s test, the provisional diagnosis is De Quervain’s tenosynovitis.
Problem List/Complaints:
- Pain and swelling at the base of the right thumb
- Difficulty performing daily activities and work-related tasks
Treatment:
- Activity modification: The patient is advised to avoid activities that exacerbate her symptoms, especially repetitive thumb and wrist movements and heavy lifting.
- Thumb and wrist immobilization: A thumb spica splint is recommended to immobilize the thumb and wrist, allowing for rest and reducing inflammation.
- Pain management: Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed to alleviate pain and reduce inflammation.
- Physical therapy: Referral to a hand therapist for therapeutic exercises and modalities to improve range of motion and strength.
- Corticosteroid injection: If symptoms persist despite conservative measures, a corticosteroid injection may be considered to reduce inflammation.
Prognosis:
With appropriate treatment and activity modification, the prognosis for De Quervain’s tenosynovitis is generally favorable. Most patients experience significant improvement within a few weeks to a few months.
Goals:
- Reduce pain and swelling
- Restore normal thumb and wrist function
- Enable the patient to resume daily activities and work-related tasks without limitations
Interventions:
Education on activity modification and ergonomic principles
- Immobilization with a thumb spica splint
- Medication management with NSAIDs
- Referral for physical therapy
- Consideration of corticosteroid injection if needed
Patient Education:
- The patient will be educated on the following:
- Importance of activity modification to prevent further aggravation of symptoms
- Proper use of thumb spica splint and duration of immobilization
- Appropriate techniques for performing daily activities with reduced strain on the thumb and wrist
- Potential side effects and precautions related to NSAIDs
Patient/Family Education:
The patient’s family will be educated on ways to provide support and assistance during the recovery process, including minimizing household chores that require excessive use of the thumb and wrist.
Discharge Plan:
The patient will be discharged with a thumb spica splint and a prescription for NSAIDs. A referral to a hand therapist will be provided for further management, and a follow-up appointment will be scheduled to monitor progress and determine the need for additional interventions.