Thursday, May 10, 2012

Differential diagnosis of Anatomic (Radial) snuffbox pain: It is not always DeQuervain’s tenosynovitis.

Tendon, Bone & Ligament causes:
1. DeQuervain’s tenosynovitis:
Swelling of tendon of APL (Abductor pollicis longus) & extensor pollicis brevis at lateral wrist near anatomic snuff box.  The primary complaint is radial sided wrist pain that radiates up the forearm with grasping or extension of the thumb. The pain has been described as a “constant aching, burning, pulling sensation." Pain is often aggravated by repetitive lifting, gripping, or twisting motions of the hand. Swelling in the anatomical snuff box, tenderness at the radial styloid process, decreased CMC abduction ROM of the 1st digit, palpable thickening of the extensor sheaths of the 1st dorsal compartment and crepitus of the tendons moving from the extensor sheath may be found upon examination. Other possible findings include weakness and paresthesia in the hand. Finkelstein’s diagnostic test will present positive provoking the patient’s symptoms.

If left untreated, the inflammation and progressive narrowing (stenosis) can cause scarring that further limits thumb motion.

 2. Carpal Instabilities:
Altered biomechanics of the wrist may produce pain. Scapholunate disassociation, scapho-trapezio-trapezoidal joint degeneratioin, and lunatotriquetral dissociation could all present with radial sided wrist pain.

3. Scaphoid Fracture
A scaphoid fracture commonly present with radial sided wrist pain, tenderness and possible swelling in the anatomical snuff box, and limited ROM with pain especially at end ranges.

4. Osteoarthritis of the 1st CMC
Osteoarthritis of the 1st CMC typically occurs in individuals greater than 50 years old, and will most frequently present with morning stiffness of the 1st CMC joint, a general decrease in ROM of the joint, tenderness along the joint line, and a positive grind test.

Neural Causes:

1. Cheiralgia paresthetica:
Cheiralgia paresthetica is commonly referred to as handcuff neuropathy. It is a neuropathy of the hand generally caused by compression or trauma to the superficial branch of the radial nerve.

The area affected is typically on the back or side of the hand at the base of the thumb, near the anatomical snuffbox, but may extend up the back of the thumb and index finger and across the back of the hand. /S includesnumbness, tingling, burning or pain. Since the nerve branch is sensory there is no motor impairment.

Differentiating point: It may be distinguished from de Quervain syndrome because it is not dependent on motion of the hand or fingers.

2. C6 Cervical Radiculopahy:
Compression on a spinal nerve root can cause sensory disturbances, myotomal weakness, and diminished reflexes throughout the root's distribution. The dermatomal key point for the C6 nerve root is the radial aspect of the 2nd metacarpal and index finger which is close to the area of pain experienced with De Quervain’s. Since a radiculopathy can present much like De Quervain’s a thorough screen of the cervical spine is necessary.

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