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Radiography of the wrist
22%
9/40
Thumb spica cast
20%
8/40
Wrist guard to be worn during work and at night
18%
7/40
Repositioning of the wrist while cycling
2%
1/40
Rest and ibuprofen
35%
14/40
Select Answer to see Preferred Response
This patient is a new mother presenting with wrist pain that is exacerbated by ulnar deviation of the wrist with a flexed thumb suggestive of a diagnosis of De Quervain's tenosynovitis. The best initial step in management is conservative therapy such as rest and ibuprofen as needed. De Quervain's tenosynovitis is classically seen in new mothers because they hold their newborn babies in the classic "football" position, and occurs due to injury to the abductor pollicis longus and extensor pollicis brevis tendons in the first extensor compartment at the styloid process of the radius. A highly specific exam maneuver to make the diagnosis of De Quervain's tenosynovitis is recapitulation of pain with ulnar deviation of the wrist with a flexed thumb. Conservative therapy with rest and NSAIDs is the standard therapy for most cases though severe cases refractory to conservative therapy can be treated with steroid injections. Incorrect Answers: Answer 1: Radiography of the wrist would be indicated if the diagnosis was a scaphoid fracture. A scaphoid fracture would present with pain over the anatomic snuffbox. This diagnosis is possible given the patient's recent trauma, but it is less likely given the physical exam findings. Answer 2: A thumb spica cast is indicated in the treatment of a scaphoid fracture after radiography of the wrist has been performed. Even in the absence of positive radiography, a strong clinical suspicion of a scaphoid fracture should prompt placement of a spica cast and repeat radiology several weeks later. Answer 3: A wrist guard worn during work and at night would be the treatment of choice for carpal tunnel syndrome. This diagnosis is possible given the patient's occupation, recent pregnancy, and hypothyroidism. However, she does not complain of any symptoms of carpal tunnel syndrome such as numbness in the distribution of the median nerve distal to the wrist. Answer 4: Repositioning of the wrist while cycling could be indicated if the diagnosis was compression of the ulnar nerve as it traverses Guyon's canal. Compression of the ulnar nerve would present with a loss of sensation and strength in the medial two digits as well as weakness of abduction and adduction of the digits. Bullet Summary: De Quervain's tenosynovitis is initially treated with conservative measures such as rest and NSAIDs.
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