A patient case was posted in November 2019 to the Healthcasts peer-to-peer community. More than 100 unique opinions were contributed by Healthcasts members practicing Internal or Family Medicine, Rheumatology and other specialties. The following is a synopsis of their consensus treatment plan and recommendations.
A 23-year-old recently-delivered mother is 6 weeks postpartum. She has developed pain on the radial side of both her wrists and hands. Her right side is more involved than her left (she is right-handed). Gripping recreates the pain which radiates into her forearm. Pain is also evoked from palpation of her distal radius (styloid). There are no ganglia noted. Is this process most likely hormonal, neurological or mechanical in nature? Is the most prudent remedy surgery, injection with steroids or splinting?
HEALTHCASTS COMMUNITY RESPONSE
Provided diagnosis: de Quervain tenosynovitis
Total respondents: 110
Case assessed: November 2019
PROCESS: HORMONAL, NEUROLOGICAL OR MECHANICAL?
Most respondents concluded that the patient’s symptoms were mechanical (42%) or hormonal (35%), but many (18%) felt it was likely a combination of the processes that is causing the patient’s pain.
Community opinions provided these common scenarios by which each process could lead to pain or discomfort:
Mechanical. Repetitive motions of holding, carrying and lifting a newborn may put a strain on the tendons of the patient’s wrist
Hormonal. Postpartum fluctuation in hormone levels may lead to increased inflammation and fluid retention
Neurological. Increased fluid retention may cause compression of the median nerve
DIAGNOSIS: DE QUERVAIN’S OR CARPAL TUNNEL?
The case contributor cited de Quervain tenosynovitis as the official diagnosis for this patient. Nearly half of the respondents (44%) chose to include a diagnosis in their opinion. Of those, half supported the case contributor’s opinion, and half submitted carpal tunnel syndrome. Symptoms of both conditions are similar, but there are a few distinct differences.
De Quervain’s is often seen in patients after pregnancy due to edema of the tendons in the wrist. This can cause pain, tenderness and fluid retention on the thumb side of the wrist. With carpal tunnel syndrome, patients typically experience numbness and tingling in the hand and arm resulting from compression of the median nerve caused by inflammation. Typically, de Quervain’s results from repeating sideways motions, while carpal tunnel results from repeated or prolonged flexing of the fingers or wrist.
Some respondents suggested screening for postpartum hypothyroidism and undiagnosed rheumatoid arthritis.
In addition to resting, icing and bracing the wrist, three main therapies were suggested by the physician community.
66% recommended splinting the wrist. Immobilization will provide the support needed to recover from overuse, and reduce the pain, swelling, inflammation and nerve pressure/compression throughout the healing process.
23% recommended prescribing NSAIDs. If the patient is not nursing, a nonsteroidal anti-inflammatory drug regimen will reduce pain, inflammation and swelling.
30% said that If the patient is not feeling better after these treatments, a steroid injection to the area may be effective in alleviating remaining symptoms.
Surgical intervention may be considered as a final treatment plan if previous therapies, and occupational therapy, fail to resolve the patient’s complaints.