Strumming Through Wrist Pain: A Guitarist’s Unexpected Challenge

HISTORY:34 year old classical guitarist with a history of bilateral De Quervain’s Tenosynovitis who presented with new onset pain in the right lateral forearm which worsened with ulnar deviation. She presented with a similar complaint 1 year ago where she underwent ultrasound-guided corticosteroid injection on the right side which resolved the pain at that time. Of note, she recently increased her level of activity for an upcoming performance, started using bell weights, and had to carry her 30 pound newborn son. She initially tried a thumb spica splint and brace, topical NSAIDs, and physical therapy with mild benefit. After failing 3 weeks of physical therapy, she returned for a steroid injection. Earlier that week, she felt a sharp pain along radial styloid as if something "popped". Limited diagnostic US showed hypoechoic fluid surrounding the 1st compartment and a small hyperechoic disruption along tendon sheath. Patient decided to forgo steroid injection until further MRI imaging given the risk of tearing or worsening of the acute disruption. PHYSICAL EXAMINATION: No gross deformity, upper and lower extremity strength and range of motion grossly intact. Tenderness to palpation along the right lateral wrist. Positive finkelstein test. DIFFERENTIAL DIAGNOSIS: 1) Osteoarthritis of the first carpometacarpal joint 2) De Quervain's Tenosynovitis 3) Intersection Syndrome TEST AND RESULTS: X-ray Right Wrist: Mild bony changes and chronic traction at the radial styloid. No fracture or dislocation. Joint spaces, articular surfaces, and carpal alignment are normal. MRI Right Wrist: Tenosynovitis in the first dorsal compartment. Enlarged abductor pollicis longus tendon at the radial styloid. Other tendons intact. Flexor tendons and carpal tunnel normal. FINAL WORKING DIAGNOSIS: De Quervain’s Tenosynovitis TREATMENT AND OUTCOMES: Following the MRI, the patient was referred to orthopedic surgery for possible surgical intervention, as she had previously tried corticosteroid injections, occupational therapy, and other conservative treatments. She underwent a debridement and release of the right wrist’s first dorsal extensor compartment tendon sheath. Since the procedure, her pain and activity levels have significantly improved, and she has returned to her normal health.