Review Question - QID 219438

This 33-year-old male presents with volar-radial wrist pain and an MRI demonstrating fluid around the flexor carpi radialis (FCR) tendon, suggestive of FCR tendinitis. He has failed nonoperative interventions to include physical therapy and activity modifications, and as such, would benefit from FCR sheath injection.

Flexor carpi radialis tendinitis is an uncommon source of palmar wrist pain but is most commonly seen in patients engaging in activities necessitating repetitive wrist flexion, like golfing or tennis. Clinical presentation can often be vague, and obtaining an MRI is often necessary to ascertain the diagnosis. Initial management involves activity modification with physical therapy (PT) to reduce the amount of trauma subjected to the tendon. If symptoms prove to be recalcitrant to PT and activity modification, FCR sheath injections can be attempted, being careful not to inject the tendon itself to reduce the risk of spontaneous rupture. If injections do not quell the symptoms, FCR sheath debridement with possible tendon release can be performed.

Patrick and Hammert review hand and wrist tendinopathies, including De Quervain’s tenosynovitis, intersection syndrome, extensor carpi ulnaris tendinitis, flexor carpi ulnaris tendinitis, and flexor carpi radialis tendinitis. They emphasize the importance of physical therapy and activity cessation as the mainstay of treatment and conclude corticosteroid injections and surgical intervention should be reserved when the aforementioned nonoperative modalities fail to improve symptoms.

Harris et al. report on a case of acute calcific tendinitis, a process well-known in the shoulder but more rare in the hand, that occurred within the carpal tunnel surrounding the flexor pollicis longus (FPL) and manifested as acute hand pain and swelling amid a chronic carpal tunnel syndrome-like presentation. Calcification of the FPL was identified on plain films, and the patient subsequently underwent carpal tunnel decompression with calcification removal and her symptoms significantly improved in the ensuing weeks.

Nikci and Doumas review calcium deposition within the hand and wrist, noting the most common sites being the flexor carpi ulnaris and flexor/extensor tendons of the fingers. Patients commonly experience an acute onset of severe pain, swelling, and warmth in the setting of a normal white blood cell count and inflammatory markers. Plain radiographs are typically diagnostic and the mainstay of treatment is nonoperative with NSAIDs and a short course of immobilization.

Figures 1 & 2 represent axial and sagittal T2-weighted MRI images that demonstrate increased fluid within the FCR tendon sheath.

Answer 1: as the patient has failed to respond to activity modification/PT, continued treatment would not be the most appropriate answer.
Answer 2: while carpal tunnel syndrome can present with palmar wrist pain, typically it also involves neurological symptoms seen in the hand.
Answer 3: the patient reports neither radial-sided wrist pain nor nerve symptoms within the hand, therefore nerve decompression is not indicated.
Answer 5: this would be indicated if the patient demonstrated continued pain over the flexor carpi ulnaris unresponsive to nonoperative means.