Skeletal Anatomy, Human Anatomy, USMLE Step 1 - Full Vignette with Extended Explanations

Описание: A 44-year-old woman has 3 weeks of aching pain on the thumb side of her right wrist, aggravated by lifting her child and texting, with tenderness over the first dorsal compartment and no trauma history. What clinical features and examination findings should you prioritize when distinguishing tendon disease at the wrist from an occult bone injury in a patient whose radiographs are normal?

VIDEO INFO
Category: Skeletal Anatomy, Human Anatomy, USMLE Step 1
Difficulty: Easy - Basic level - Suitable for medical students
Question Type: Differential Testing
Case Type: Typical Presentation

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QUESTION
A 44-year-old woman presents to clinic with 3 weeks of aching pain along the thumb side of her right wrist that worsens when lifting her 10-month-old child and when texting. She denies trauma. She reports intermittent tingling over the dorsal thumb but no finger numbness. Vital signs are heart rate 76 bpm, blood pressure 126/palpable approximating 126/78 mm Hg by automated cuff, respiratory rate 16 breaths per minute, temperature 36.0 degreesC, and oxygen saturation 99% on room air....

OPTIONS
A. Finkelstein maneuver reproducing sharp pain over the first dorsal compartment when the thumb is flexed across the palm and the wrist is ulnarly deviated, supporting de Quervain tenosynovitis rather than a scaphoid fracture.
B. Eichhoff maneuver performed by the patient making a fist with the thumb inside and ulnar-deviating the wrist, which is similar but less specific and can be positive with various radial-sided wrist pains.
C. Phalen test with 60-second wrist flexion to provoke median nerve paresthesias in the thumb, index, and middle fingers for carpal tunnel evaluation.
D. Anatomic snuffbox palpation for focal tenderness and pain with axial thumb compression as the only testing needed, which primarily screens for scaphoid injury rather than first dorsal compartment disease.

CORRECT ANSWER
A. Finkelstein maneuver reproducing sharp pain over the first dorsal compartment when the thumb is flexed across the palm and the wrist is ulnarly deviated, supporting de Quervain tenosynovitis rather than a scaphoid fracture.

EXPLANATION
"Finkelstein maneuver reproducing sharp pain over the first dorsal compartment when the thumb is flexed across the palm and the wrist is ulnarly deviated, supporting de Quervain tenosynovitis rather than a scaphoid fracture." The basic teaching point is that a clinician-performed Finkelstein maneuver most directly stresses the first dorsal compartment (abductor pollicis longus and extensor pollicis brevis) and helps distinguish tendon sheath disease from bony scaphoid injury when radiographs are normal. In this patient, focal radial styloid tenderness with pain on resisted radial deviation and a positive clinician-performed test localize disease to the first dorsal compartment. Lack of anatomic snuffbox tenderness and absence of pain with axial thumb compression argue against scaphoid fracture, which is consistent with the normal x-rays.

Eichhoff s test is a patient-performed variant that is more provocative but less specific, with more false positives across radial-sided wrist pain conditions. Phalen testing assesses median neuropathy at the wrist and is unrelated to first dorsal compartment pathology. Relying solely on snuffbox palpation and axial thumb loading prioritizes scaphoid screening, not tendon disease differentiation; those findings are already negative here....


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