Case02

A 31yo has returned to work after maternity leave to their employment restocking an online shopping distribution warehouse. They present to the clinic with pain and swelling on the radial side of their left wrist. They have a lump approximately 1cm on the dorsal side of the left hand approximately mid-shaft on the digit 2 metacarpal that is non-painful to palpation. They indicate there has been no recent trauma and they have no history of trauma to that hand.

Incorrect. In the absence of trauma, there is unlikely to be a fracture. What the patient describes is likely an overuse injury.

Incorrect. This occurs with direct impact of a closed hand most commonly, not consistent with the overuse injury described by the patient. Pain would also occur distally on the digit 5,little finger, medial (ulnar) side and not at the anatomic snuff box on the lateral (radial) side of the hand. Also, x-ray has a high sensitivity for this type of fracture and should have shown up on the emergency room x-ray in present.

Incorrect. A fracture usually requires an impact or trauma such as all-on-outstretched-hand (FOOSH). It is unlikely to occur spontaneously at this patients age or as a consequence of an overuse injury. The scaphoid is located deep to the anatomic snuff box location on the radial side of the hand, consistent with high pain from that location, but not consistent with a non-traumatic injury.

Incorrect. Usually the result of high energy injury (e.g. motor vehicle) more than overuse in this case. The dislocation would, however, cause anterior (palmar) displacement of the lunate bone so the most sensitive/painful point should be palmar and not at the anatomic snuff box. Commonly also compromises the median nerve at that location which would have distal neurologic symptoms from the hand which are negative in this patient. The lunate bone is the most frequently dislocated carpal bone.

Correct! This is commonly an overuse injury through repetitive lifting/writing placing strain on the thumb. The patient has returned from maternity leave suggesting they are a newborn caretaker which involves repetitive lifting under the infant arms, as well as having an occupation involving lifting. Either or both could be contributing to an overuse injury of De Quervain's Tenosynovitis.

Incorrect. While the patient has what is probably a ganglion cyst along the metacarpal of digit 2, these are generally painless unless pressing on some other structure. In physical examination the patient scenario describes painless to touch. Thus, while a cyst is present, this is unlikely to be the cause of the patient pain and swelling at the wrist.

Incorrect. This is known as 'trigger finger' where repetitive trauma causes inflammation of the synovial tendon sheath and a 'locking' of the finger in position stuck in flexion or extension. Not consistent with radial side wrist inflammation and pain.