Paget and hyperparathyroidism) are considered less likely. Due to the solitary nature of the lesion and lack of other systemic symptoms, metabolic bone diseases (eg. As the firm swelling arose from the distal radius and not the radio-carpal joint, the diagnoses of osteoarthritis, rheumatoid arthritis and gouty arthritis are less likely. What is the management and prognosis? Answer 1ĭifferential diagnoses include tendon sprain, rheumatoid arthritis, gouty arthritis, mal-union of fractured distal radius, osteoarthritis, metabolic bone disease, soft tissue tumours and bone tumours (benign and malignant). Plain X-ray of the patient’s left wrist Question 4 Power of the flexor muscles of the left forearm was reduced to 3/5 on a Medical Research Council (MRC) scale for muscle strength.įigure 2. Pain was elicited on hyperextension of the fingers and also on deep palpation of the volar aspect of the wrist. On examination, there was a firm swollen deformity over the distal radius, which was tender on palpation ( Figure 1a and 1b). One of his maternal aunts suffered from severe rheumatoid arthritis, and one maternal uncle had severe plaque psoriasis. His mother had a history of colon cancer. He took no regular medications and had no known allergies. Mr L exercised regularly and had never smoked cigarettes. However, the unresolved pain and increasing agony in dressing and turning the steering wheel of his vehicle, eventually alerted him to seek medical advice. He started taking analgesia 4 weeks before his visit to his family doctor. He initially used a hot pack to relieve the pain, with limited benefit. The pain started when he twisted his wrist while carrying hand luggage 3 months ago. Over the past 4 weeks, he had also noticed a swelling of the affected wrist, which felt ‘hot’ at times.
There was no anaesthesia or paraesthesia, but he had noticed increasing weakness of the lateral three fingers. He rated the wrist pain as 5/10 severity 3 months ago, and the current pain as 8/10 severity, despite regular paracetamol and ibuprofen at maximum doses. Pain was worsened by movement and only mildly relieved by rest. He described the pain as ‘dull and gnawing’, which escalated to a sharp and shooting sensation radiating to his third and fourth fingers. Mr L, an Asian man aged 48 years, presented to his family doctor with a 3 month history of pain and swelling of his left wrist.
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