A RARE CASE OF WRIST PAIN IN AN ADOLESCENT TENNIS PLAYER

Abstract

CLINICAL CASE -16 year old tennis athlete with dorsal wrist pain HISTORY: A 16 year old female left-handed high school tennis athlete presented with a several month history of left dorsal wrist pain. She had an episode of whole arm pain, which resolved spontaneously, prior to the wrist pain, but she continued to experience dorsal wrist pain. She described diffuse pain about the dorsal aspect of the wrist radiating into the left hand. She denied mechanical symptoms, swelling, discoloration, or paresthesias. She also denied neck pain. PHYSICAL EXAMINATION: Skin was grossly negative for erythema, breakdown, or concerning lesions in the left wrist/hand region.Neurologic exam: 5/5 strength in all forearm and hand muscles without atrophy, sensation was intact to light touch C5-T1, and tinel test was negative over the superficial radial nerve.Musculoskeletal wrist exam: no swelling or deformity. No focal tenderness or mass . Full activeand passive range of motion of the wrist. There was no pain or laxity with distal radial ulnar joint shucking. There was bo snuffbox tenderness and watson’s test was negative. DIFFERENTIAL DIAGNOSIS: 1. Ganglion cyst of the wrist joint 2. Sprain of the dorsal scaphoid-lunate ligament 3. Symptomatic extensor digitorum brevis manus 4. Dorsal Impaction syndrome 5. Extensor tendinopathy TEST AND RESULTS: Ultrasound examination revealed an extensor digitorum brevis manus accessory muscle traversing from the deep side of the 4th dorsal extensor compartment,extending across the dorsal hand, and terminating into a tendon slip that merged with the dorsal extensor hood of the 3rd digit. The muscle was notably larger on the left side than theright. . She had no evidence of tenosynovitis or other abnormalities in the dorsal wrist. MRI of the wrist revealed a tiny ganglion cyst along the volar margin of the radioscaphoid articulation and a normal variant extensor digitorum manus brevis muscle. FINAL/WORKING DIAGNOSIS: Symptomatic extensor digitorum brevis manus TREATMENT AND OUTCOMES: 1. Immobilization 2. Diclofenac Gel 3. Ultrasound guided Botox injection of the extensor digitorum manus brevis muscle. We discussed different management options and she elected to proceed with an ultrasound guided botox injection since she had minimal relief from immobilization.