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Case #5: Wrist Pain and the Safety of Corticosteroid
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complain of pain when picking up their children or with any movement of the wrist toward the small finger. There may be a sensation of clicking, snapping, or locking of the tendons as they pass over the distal radius. Diagnosis is confirmed by a posi- tive Finkelstein’s test in which the patient makes a fist over the thumb and ulnar deviates the wrist, while the practitioner places an ulnar-directed stress over the second metacarpal [47]. Pain is reproduced at the radial styloid and often into the thumb, where patients may also exhibit pain and weakness with resisted extension and abduction. This pain should be differentiated from osteoarthritis of the first carpometacarpal (CMC) joint by performing a careful first CMC grind test [50] and looking at x-rays, which are also important to rule out a fracture.
Though compression of the median nerve at the wrist – carpal tunnel syndrome – is also prevalent in pregnant women [51], it differs from de Quervain’s in the location and nature of pain and peresthesias. Whereas de Quervain’s pain is usually isolated to the wrist and thumb, pain with carpal tunnel syndrome extends into the first radial three-and-a-half digits and is usually accompanied by numbness and tingling in the same distribution. Pain often wakes patients up at night and is related to overuse, though in pregnancy, increased peripheral edema is thought to compress the nerve [51]. Manual compression of the median nerve at the carpal tunnel reproduces pain, numbness, and tingling throughout the nerve’s distribution in the hand and fingers.
Reproduction of paresthesias into the radial three-and-a-half digits when tapping the median nerve over the carpal tunnel, weakness of the thumb abductors, and loss of sensation in the median nerve distribution – tested over the palmar tip of the index finger – also suggest the presence of carpal tunnel syndrome. Electromyography and nerve conduction studies are used to confirm the diagnosis in preoperative patients, though these invasive tests are usually unnecessary during pregnancy.
Both de Quervain’s tenosynovitis and carpal tunnel syndrome in pregnancy are self-limited [49, 51], but given the intense pain and functional deficits that can occur, conservative treatment in warranted. Initial management of de Quervain’s is use of a thumb spica splint to stabilize the APL and EPB and limit snapping and friction of the tendons during ulnar deviation [52]. It has been suggested, however, that symptoms resolve most effectively with a corticosteroid injection to the tendon sheath of the first dorsal compartment, and practitioners may use this as first-line treatment [49]. Splints to limit wrist flexion in those with carpal tunnel syndrome may improve symptoms at night, though injections have also proven useful in this population. Corticosteroid injections during pregnancy have been shown to be safe with no ill effects to the fetus or the mother, as long as no medical contraindications exist [49]. While any injection carries the risk of infec- tion, bleeding and hematoma, pain, and nerve injury, with a wrist injection, the most common side effect is hypopigmentation and fat atrophy [53], the risk of which should be clearly discussed with the woman prior to injection. Discoloration and atrophy of subcutaneous fat occur when a portion of the steroid is injected just beneath the dermis rather than into the sheath. Direct visualization of the tendons or nerve with musculoskeletal ultrasound may help decrease the inci- dence of these complications. Regardless, hypopigmentation and fat atrophy resolve spontaneously by around 6–12 months postinjection [53].
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C. Bernstein, T.C. Takoudes (eds.), Medical Problems During Pregnancy, DOI 10.1007/978-3-319-39328-5_9