AJR 2004; 182:719-724
© American Roentgen Ray Society
"Baby Wrist": MRI of an Overuse Syndrome in Mothers
Suzanne E. Anderson1,
Lynne S. Steinbach2,
Damir De Monaco3,
Harald M. Bonel1,
Yvonne Hurtienne4 and
Esther Voegelin5
1 Department of Diagnostic Radiology, University Hospital of Bern, Inselspital,
Freiburgstrasse, Bern CH-3010, Switzerland.
2 Department of Radiology, University of California, San Francisco, CA.
3 Department of Plastic, Reconstructive, and Hand Surgery, Kantonsspital Aarau,
Aarau, Switzerland.
4 Department of Orthopedic Surgery, Kantonsspital Aarau, Aarau,
Switzerland.
5 Department of Orthopedics, Subsection: Hand Surgery, University Hospital of
Bern, Inselspital, Bern, Switzerland.
Received July 28, 2003;
accepted after revision September 5, 2003.
Address correspondence to S. E. Anderson
(suzanne.anderson{at}bluewin.ch).
Abstract
OBJECTIVE. The purpose of our study was to describe the MRI findings
and interesting clinical aspects of a postpartum overuse syndrome of the wrist
and thumb, de Quervain's tenosynovitis, or "baby wrist."
CONCLUSION. Mothers may experience a wrist and thumb overuse
syndrome, which can be diagnosed by MRI with an increase in size and low
signal intensity on both T1- and T2-weighting, in and around the first dorsal
tendon sheath compartment of the wrist.
Introduction
Tennis elbow, "washerwoman's sprain" of the wrist,
"oarsman's wrist," and "golfer's hand"
[1] have been described, but,
to our knowledge, no descriptions to date of "baby wrist," an
overuse syndrome common in new mothers, have been offered. We review the MRI
findings of baby wrist in the wrist and thumb, occurring approximately 8
months postpartum in four wrists in three patients. Repetitive low-grade
trauma to the wrist and thumb is a result of prolonged carrying of large heavy
babies with the wrist held in flexion and ulnar deviation and the thumb in
extension. This leads to the development of de Quervain's tenosynovitis.
Subjects and Methods
Clinical
Written informed consent was obtained before MRI, and all three patients
gave consent to participate in this study. Three primiparous patients, ages
34–41 years, with four painful wrists presented for clinical examination
and MRI. The dominant hand was involved in two patients, both hands in the
third. All three patients had clinical histories of protracted wrist pain
occurring around 8 months postpartum localized to the radial side of the
wrist, increasing with movement of the thumb. There was no history of
pregnancy- or lactation-related wrist pain or trauma in any patient.
Imaging
MRI was performed using a 1.5-T machine (Sonata Maestro Class, Siemens,
Erlangen, Germany). The imaging protocol was T1-weighting (TR range/TE range,
453–585/13–19), T2-weighting (TR range/TE, 3,200–3,500/80),
and turbo STIR (TR/TE range, 4,100/21–28; inversion time, 160 msec) in
the axial plane and STIR additionally in the coronal plane. All sequences were
acquired with 3-mm slice thickness and 1-mm gap. IV contrast material was
administered in one patient with fat-saturated T1-weighting performed in the
axial and coronal planes. A dedicated four-channel phased array wrist coil was
used in all cases. One patient had an additional high-resolution 3D
time-of-flight MR angiography sequence (TR/TE, 40/5; flip angle,
25°; field of view, 125 x 200; matrix, 160 x 512) to
exclude pseudoaneurysm formation. MR images were prospectively reviewed by two
musculoskeletal radiologists by consensus. MR images were analyzed for signal
intensities, tendon sheath thickening and tendon size and location of
abnormalities, presence of normal variants, tenosynovitis, and wrist joint
abnormalities.
Results
Clinical
The study group comprised three women (ages, 41, 35, and 34 years; average
age, 36.6 years). All patients showed wrist swelling and complained of marked
pain especially provoked by carrying their infants, who had a tendency to lean
heavily against the mother's dominant (right) hand in all three patients
(bilateral in one), with the wrist in flexion and ulnar deviation and the
thumb in excessive extension supporting the baby's head. The onset of wrist
pain and swelling occurred at 7, 8, and 10 months postpartum, with an average
of 8 months. The duration of symptoms was 3, 3, and 5 months (average, 3.6
months). All patients complained of wrist and thumb pain coinciding with
increased carrying of the infants who were all large and long babies, with two
being over the 97th percentile for weight and height for age and one being
over the 95th percentile. All mothers were professional individuals who were
primiparous and lived distant from family, necessitating longer periods of
infant carrying. Two mothers had breast-fed until 6 months and the third until
9 months. All three were otherwise healthy with uneventful pregnancies and had
not experienced previous wrist pain.
All patients had histories of repetitive and sustained thumb abduction and
extension in combination with radial and ulnar wrist movements in the dominant
right hand. Soft-tissue swelling in two wrists and masslike lesions in two
wrists 1–2 cm proximal to the radial styloid process were present.
Finkelstein's and Brunelli's tests were performed by the senior author, an
experienced hand surgeon, with positive results for de Quervain's
tenosynovitis in four wrists in all three patients (Fig.
1A,
1B).
View larger version (19K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —Line drawings of clinical tests for "baby wrist."
These tests provoke pain of tenosynovitis of first dorsal wrist compartment.
Arrows show direction of movement. Drawing illustrates Finkelstein's test.
|
|
View larger version (23K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —Line drawings of clinical tests for "baby wrist."
These tests provoke pain of tenosynovitis of first dorsal wrist compartment.
Arrows show direction of movement. Drawing illustrates Brunelli's test. This
is performed during wrist extension and flexion.
|
|
Imaging
MRI showed findings of de Quervain's tenosynovitis of the first extensor
compartment in four wrists in three patients (Figs.
2A,
2B,
2C,
2D,
2E,
3A,
3B,
3C,
4A,
4B,
4C). The clinical soft-tissue
mass corresponded to tendon sheath thickening of the first extensor
compartment with tenosynovitis of the extensor pollicis brevis and the
abductor pollicis longus, the classic localization of de Quervain's disease,
at the level of the distal dorsolateral aspect of the radial styloid process
in all cases. Signal intensity was decreased on both T1- and T2-weighting
within and around the region of the first extensor compartment of the wrist.
In all four wrists in the three patients, evidence of some increased signal
intensity was seen on turbo STIR imaging, and in one patient who received
contrast material, evidence of contrast material enhancement around the first
compartment was also seen. The tendon sheath was thickened in all three
patients, and there was no evidence of fluid within the tendon sheath. Two
patients had common normal variants with double slips of the abductor pollicis
longus tendon within the first compartment (Figs.
3A,
3B,
3C and
4A,
4B,
4C). This is clinically
relevant because it may be associated with prolonged pain and poor response to
conservative treatment. It is important to document these normal variants
because both subcompartments may need to have surgical release or steroid
injections [2]. Subtle evidence
of bone spurring was noted at the attachment of the extensor retinaculum at
the edges of the bone groove for the first compartment tendons. No other
significant soft-tissue, bone, or joint disorder was present.
View larger version (99K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A. —41-year-old woman presented with focal right-sided painful
mass, first web space pain, and a clinical provisional diagnosis of
soft-tissue mass, either ganglionic cyst or pseudoaneurysm. Baby had colic and
rapidly grew over 97th percentile for weight and length. Photograph of dorsal
surface of wrist and forearm shows soft-tissue mass (arrows) slightly
on dorsolateral aspect of radial side of wrist.
|
|
View larger version (112K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B. —41-year-old woman presented with focal right-sided painful
mass, first web space pain, and a clinical provisional diagnosis of
soft-tissue mass, either ganglionic cyst or pseudoaneurysm. Baby had colic and
rapidly grew over 97th percentile for weight and length. Axial T1-weighted
image (TR/TE, 520/13) shows thickening of tendon sheath of first extensor
compartment with diffuse irregular signal intensity in adjacent subcutaneous
fat (arrows). Terminal divisions of radial sensory nerve lie
immediately superficial to first compartment, which was presumably involved in
this case, accounting for first web space referred pain.
|
|
View larger version (116K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2C. —41-year-old woman presented with focal right-sided painful
mass, first web space pain, and a clinical provisional diagnosis of
soft-tissue mass, either ganglionic cyst or pseudoaneurysm. Baby had colic and
rapidly grew over 97th percentile for weight and length. Corresponding axial
T2-weighted image (3,500/80) again shows thickening of first extensor
compartment tendon sheath, with decreased signal intensity in this region
compared with muscle, and irregularity of adjacent subcutaneous fat
(arrows). No evidence of fluid within tendon sheath is present. Fluid
is noted in volar recess (arrowhead).
|
|
View larger version (106K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2D. —41-year-old woman presented with focal right-sided painful
mass, first web space pain, and a clinical provisional diagnosis of
soft-tissue mass, either ganglionic cyst or pseudoaneurysm. Baby had colic and
rapidly grew over 97th percentile for weight and length. Source image without
subtraction in axial plane from 3D time-of-flight MR angiogram (40/5;
inversion time, 25 msec; field of view, 125 x 200) shows displacement of
superficial branch of radial artery (arrow) caused by masslike effect
of de Quervain's tenosynovitis.
|
|
View larger version (121K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2E. —41-year-old woman presented with focal right-sided painful
mass, first web space pain, and a clinical provisional diagnosis of
soft-tissue mass, either ganglionic cyst or pseudoaneurysm. Baby had colic and
rapidly grew over 97th percentile for weight and length. Oblique coronal
maximal-intensity-projection image shows displaced superficial branch of
radial artery (arrow).
|
|
View larger version (119K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3A. —34-year-old women with bilateral wrist pain (marked in
dominant right hand) who had clinical diagnosis of probable de Quervain's
tenosynovitis. MRI was performed to confirm diagnosis and to determine any
possible underlying anatomic variants that may have accounted for persistent
pain and failed initial conservative treatment. Baby was over 97th percentile
for weight and length. Axial T1-weighted image (TR/TE, 453/19) shows masslike
effect of first extensor compartment with thickening of tendon sheath
(solid arrows) and evidence of double slips of abductor pollicis
longus tendons (asterisks). Subtle bone spur formation at insertion
site of extensor retinaculum of first compartment, "double groove"
sign [1], of distal dorsal
radius (open arrow) is noted.
|
|
View larger version (131K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3B. —34-year-old women with bilateral wrist pain (marked in
dominant right hand) who had clinical diagnosis of probable de Quervain's
tenosynovitis. MRI was performed to confirm diagnosis and to determine any
possible underlying anatomic variants that may have accounted for persistent
pain and failed initial conservative treatment. Baby was over 97th percentile
for weight and length. Corresponding axial T2-weighted image (3,200/80) again
shows duplication of abductor pollicis longus tendon (asterisks) and
thickening of tendon sheath with decreased signal intensity in this region.
Abductor pollicis longus tendon often contains two tendinous separate slips,
which may be frequently separated from extensor pollicis brevis tendon by
fibrouslike septum. This variant may have contributed to persistent pain with
conservative casting. No evidence of fluid within tendon sheath was found.
|
|
View larger version (115K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3C. —34-year-old women with bilateral wrist pain (marked in
dominant right hand) who had clinical diagnosis of probable de Quervain's
tenosynovitis. MRI was performed to confirm diagnosis and to determine any
possible underlying anatomic variants that may have accounted for persistent
pain and failed initial conservative treatment. Baby was over 97th percentile
for weight and length. Corresponding coronal STIR image (4,100/21; inversion
time, 160 msec) shows increased signal intensity in and around thickened
tendon sheath of first extensor compartment and adjacent subcutaneous fat
(arrows).
|
|
View larger version (154K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4A. —35-year-old woman with marked wrist pain who had diagnosis of
mercury excess and had been instructed to wear wrist cast for 2 months. She
referred herself for MRI to confirm original diagnosis, concerned by
persistent pain and swelling. Her baby was over 95th percentile for weight and
length. Axial T1-weighted image (TR/TE, 585/19) shows thickening of first
extensor compartment tendon sheath (arrows) and evidence of double
tendon slips of abductor pollicis longus (asterisks).
|
|
View larger version (157K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4B. —35-year-old woman with marked wrist pain who had diagnosis of
mercury excess and had been instructed to wear wrist cast for 2 months. She
referred herself for MRI to confirm original diagnosis, concerned by
persistent pain and swelling. Her baby was over 95th percentile for weight and
length. Corresponding T2-weighted image (3,200/80) again shows thickening of
tendon sheath with decreased signal intensity and irregular margins with
adjacent subcutaneous fat (arrows). No fluid is seen within tendon
sheath.
|
|
View larger version (133K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4C. —35-year-old woman with marked wrist pain who had diagnosis of
mercury excess and had been instructed to wear wrist cast for 2 months. She
referred herself for MRI to confirm original diagnosis, concerned by
persistent pain and swelling. Her baby was over 95th percentile for weight and
length. Coronal STIR image (4,000/21) shows masslike effect of first extensor
compartment with subtle increase in signal intensity (arrows) of
adjacent soft tissues.
|
|
Discussion
The relationship between pregnancy and de Quervain's tenosynovitis in
lactating mothers within the first 3 months of delivery has been reported
[3–6].
The cause is presumed to be endocrine in origin and similar to the carpal
tunnel syndrome described during pregnancy and the lactating postpartum
period. Endocrine causes and influence on fluid retention are thought to be
primary [7], although the role
of mechanical stress on the thumb from holding the baby may be contributory
[4]. Overuse as a result of
diaper wringing in the washing process was also proposed in the early 1960s,
though patients presented during pregnancy, preceding infant care, and the
condition continues despite modern washing appliances and disposable diapers
[8]. The postulated mechanism
for the development of de Quervain's disease in our patients is an overuse of
the abductor pollicis longus and extensor pollicis brevis tendons in the first
extensor compartment. By forced, repetitive extension or flexion of the wrist
with abduction of the thumb against resistance (holding of the baby's head),
inflammation of the synovial sheaths of the tendons in the narrow fibroosseous
tunnel can occur. In addition, normal variations of the first compartment may
contribute to irritation and inflammation of the tendons within the narrow
fibroosseous tunnel. This was presumed to be the case in two of our patients.
Either one or both subdivisions of the first dorsal compartment may be
stenotic. The various slips of the abductor pollicis longus may insert into
the base of the first metacarpal, trapezium, volar carpal ligament, opponens
pollicis, or abductor pollicis brevis
[1]. Wolfe
[1] reported a large variation
of normal anatomy, with fewer than 20% having the so-called normal anatomic
arrangement.
To our knowledge, no imaging study combined with clinical description of an
overuse syndrome of the wrist and thumb associated with de Quervain's
tenosynovitis around the eighth month postpartum has been conducted. In our
series, overuse of the dominant wrist and thumb caused by prolonged periods of
carrying heavy large babies who were over the 95th and 97th percentiles for
weight and height was prevalent. All three mothers had a lack of local
extended family who could have shared in carrying the baby. All mothers
reported that their babies excessively leaned on their thumbs as if they were
sofas. No mothers were lactating at the time of severe pain.
The MRI findings reported in our series are typical for those of de
Quervain's tenosynovitis, with soft-tissue enlargement in the region of the
first compartment of the wrist, thickening of the tendon sheath, and decreased
signal intensity on both T1- and T2-weighting. Bone spurring at the site of
attachment of the overlying extensor retinaculum is subtly evident in our
series, as described in classic de Quervain's tenosynovitis
[1].
Typically, classic de Quervain's tenosynovitis includes chronic
inflammation scar formation with stenosis of the approximately 1-cm-long
fibroosseous tunnel of the first dorsal compartment (the groove along the
radial styloid process covered by the overlying extensor retinaculum through
which the abductor pollicis longus and extensor pollicis brevis tendons run)
[1]. Histologic examination of
the disease, unrelated to pregnancy, reveals myxoid degeneration within the
tendon sheath wall with ultrastructural studies supporting degeneration as the
primary process rather than inflammation within the tendon sheath
[8]. The histologic appearances
of de Quervain's disease occurring during pregnancy or related to lactation
within 12 months of childbirth have findings the same as those described in
patients with de Quervain's disease unrelated to pregnancy. Myxoid
degeneration responsible for the thickening is observed in the sheath and
intramural deposits of mucopolysaccharides predominantly within the
subsynovial regions. This would account for the nonsharp margins of the tendon
sheath and altered signal intensity within the adjacent subcutaneous fat on
MRI.
The radiologic differential diagnoses for these MRI findings include
atypical infections, scaphoid fracture or nonunions or radioscaphoid
arthritis, and trapeziometacarpal joint arthritis. However, with careful
review of the wrist joint compartment anatomy with findings centered in and
around the first extensor compartment, especially in the axial plane, and with
exclusion of other osseous disorders in the coronal plane images, other
diagnoses should be excluded. Clinically, flexor carpi radialis tenosynovitis
entrapment of the branches of the superficial radial nerve can mimic de
Quervain's disease. Another rare differential diagnosis, both clinically and
radiologically, is the intersection syndrome
[1]. Pain and swelling of the
muscle bellies of abductor pollicis longus and extensor pollicis brevis 4 cm
proximal to the wrist joint and the disorder location are probably caused by
tenosynovitis of the second dorsal compartment of the wrist. Rheumatoid
arthritis can be another cause of stenosing tenosynovitis of the wrist.
Awareness of the baby wrist overuse syndrome and MRI findings is important,
because this entity is probably more common than recognized. Early diagnosis
allows insight about the cause and potential altered behavior.
Current treatment for pregnancy- and early endocrine-related lactational
postpartum de Quervain's tenosynovitis is conservative therapy with rest and
immobilization and pain relief because the disease is largely self-limiting,
usually resolving after cessation of breast feeding
[9]. If conservative measures
fail after 4–6 months, surgery is recommended. Steroid injections have
also been reported as being useful
[7,
9]. Nonpregnancy-related de
Quervain's disease is currently best treated with surgery by unroofing or
reconstruction of the fibroosseous tunnel after failed conservative treatment
[7]. At 1-year follow-up, all
three patients in our study had pain relief with wrist splinting. With
increasing age of the baby, increasing head control, development of crawling,
and cessation of overuse of the wrist, the pain, swelling, and mass associated
with the tenosynovitis resolved.
Unfortunately, our study included only three patients; however, increasing
awareness of this syndrome may prompt further reviews, and the syndrome may
prove more common than is currently known. Another limitation is the absence
of histologic correlation; however, MRI confirmed the inflammatory component
even without the use of contrast material. Although there was a normal
variation (Figs. 3A,
3B,
3C and
4A,
4B,
4C) within the first dorsal
compartment as described, which may be associated with more severe disease
[1] necessitating surgical
intervention after a failed trial of immobilization, surgical intervention was
not required in any of the three patients.
Acknowledgments
We thank J. L. Anderson for suggesting the title of this entity and S. A.
J. Anderson-Sembach, M. Sembach, and S. Furrer for their involvement and
support.
References
- Wolfe SW. Tenosynovitis. In: Green DP, ed. Green's
operative hand surgery. New York, NY: Churchill Livingstone,1999
: 2022–2044
- Leslie BM, Ericson WB, Morehead JR. Incidence of a septum within
the first dorsal compartment of the wrist. J Hand Surg
Am 1990;15:88
–91[Medline]
- Nygaard IE, Saltzman CL, Whitehouse MB, Hankin FM. Hand problems in
pregnancy. Am Fam Physician1989; 39:123
–126
- Schned ES. De Quervain tenosynovitis in pregnant and postpartum
women. Obstet Gynecol1986; 68:411
–414[Abstract]
- Johnson CA. Occurrence of de Quervain's disease in postpartum
women. J Fam Pract1991; 32:325
–327[Medline]
- Wand JS. Carpal tunnel syndrome in pregnancy and lactation.
J Hand Surg Br1990; 15:93
–95[Medline]
- Capasso G, Vittorino T, Maffulli N, Turco G, Piluso G. Surgical
release of de Quervain's stenosing tenosynovitis postpartum: can it wait?
Int Orthop2002; 26:23
–25[Medline]
- Read HS, Hooper G, Davie R. Histological appearances in post-partum
de Quervain's disease. J Hand Surg Br2000; 25:70
–72[Medline]
- Avci S, Yilmaz C, Sayli U. Comparison of nonsurgical treatment
measures for de Quervain's disease of pregnancy and lactation. J
Hand Surg Am 2002;27:322
–324[Medline]
- Brunelli G. Finkelstein's versus Brunelli's test in De Quervain
tenosynovitis [in French]. Chir Main2003; 22:43
–45[Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
B. P. Wood
Baby Wrist: A Maternal Overuse Syndrome
AAP Grand Rounds,
October 1, 2004;
12(4):
50 - 51.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
