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A 23-year-old female patient complained of left thumb pain following a home do-it-yourself project that involved a lot of hammering of nails. The patient described a gradual onset of pain about 2 months ago, and described the pain as burning located at the base of the left thumb. The patient also reported some swelling at the wrist. The patient attributed the pain to the hammering of nails as subsequent attempts to use the hammer reproduced the pain. Over time, the pain had worsened to the point where it hurt all of the time, even at night. The NSAIDs prescribed by the physician 2 weeks ago appeared to be helping. The patient reported no past history of elbow, forearm or wrist pain, although she underwent surgery to remove ganglion cysts from her right wrist/hand about 1 year ago. The patient’s goals were to decrease pain with activities of daily living.

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What are some of the more common diagnoses characterized by thumb pain?

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Diagnoses to consider in this case would include scaphoid fracture (unlikely in this case), radial nerve neuritis, referral from the cervical spine, shoulder, or elbow, and basal joint arthritis.

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What does the history of the gradual onset and of repetitive activity tell the clinician?

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A history of a gradual onset and repetitive activity typically indicates an overuse injury.

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What additional questions would you ask to help rule out referral of pain from the cervical spine, shoulder or elbow?

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Question should be asked as to whether the symptoms are affected by movement or positions of the cervical spine, shoulder, or elbow. Given the clear mechanism of injury in this case, referrals from these joints are unlikely, but the clinician must always consider the possibility.

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List the tests you would use to rule out the other diagnoses that you listed in question 1.

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A scaphoid fracture is indicated when there is tenderness in the anatomical snuff box and a history of trauma such as falling forward on an outstretched hand. Radial nerve neuritis, involving the superficial radial nerve, if typically accompanied with complaints of dysthesia, numbness, and tingling in the radial nerve distribution (the posteroradial aspect of the thumb and thenar eminence as well as the posterior aspect of the index, long, and ring fingers as far as the proximal interphalangeal joints. Basal joint arthritis can be assessed using axial compression of the carpometacarpal joint (passive grinding and rotation of the metacarpal against the trapezium). A positive finding is pain and tenderness with this maneuver.

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Does this presentation/history warrant an upper quarter scanning examination? Why or why not?

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This patient does not warrant an upper ...

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