In an adult with a month‑long history of progressive right wrist pain and swelling at the base of the thumb, limited flexion, marginally positive De Quervain’s test, normal X‑ray and laboratory studies, and no red‑flag findings, what is the appropriate disposition and outpatient management plan?

Disposition and Outpatient Management for Occupational Wrist Tenosynovitis

This patient should be discharged from the ER with a diagnosis of occupational overuse tenosynovitis (likely intersection syndrome or extensor tendinopathy given the diffuse dorsal wrist involvement), prescribed NSAIDs, referred urgently to hand surgery or occupational medicine within 1–2 weeks, and counseled on strict work modification or temporary work cessation, as continued exposure will prevent healing and lead to chronic disability.

Clinical Reasoning

The presentation strongly suggests occupational overuse tenosynovitis rather than isolated De Quervain's disease, based on:

• Diffuse circumferential wrist swelling and pain extending beyond the first dorsal compartment 1
• Marginally positive Finkelstein test that is no more positive than other ROM testing, making De Quervain's less likely 2
• Clear occupational causation with symptom onset correlating to increased welding workload and prior resolution when leaving similar work 3
• Dorsal wrist pain with flexion suggesting extensor tendon involvement 2

The normal X-ray and laboratory studies effectively rule out fracture, arthritis, gout, and infection 1, 3.

Immediate ER Disposition

Pharmacologic Management

• Prescribe naproxen 500 mg twice daily for 2–4 weeks, as NSAIDs have demonstrated efficacy in reducing inflammatory tenosynovitis 4
• Consider a short course of oral corticosteroids (prednisone 40 mg daily for 5–7 days) for severe inflammation, though this is off-guideline and based on clinical judgment

Splinting

• Replace the current wrist splint with a thumb spica splint that immobilizes the wrist in neutral and the thumb in slight extension, as proper immobilization is critical for tendon rest 5, 6
• The patient's current splint has failed because it likely does not adequately immobilize the involved tendons 5

Work Modification

• Provide a work restriction note mandating no welding or repetitive wrist motion for at least 2–4 weeks 5, 7
• Emphasize that continued occupational exposure will cause treatment failure and potential permanent disability, as evidenced by his prior symptom resolution only after job cessation 3

Outpatient Follow-Up Plan

Urgent Referrals

• Refer to hand surgery or sports medicine within 1–2 weeks for definitive diagnosis and consideration of corticosteroid injection 8, 9, 7
• Refer to occupational medicine to assess workplace ergonomics and determine if job modification or permanent work restrictions are needed 5

Advanced Imaging if Symptoms Persist

• Order ultrasound of the wrist as the next diagnostic study if symptoms do not improve within 2 weeks, as ultrasound can identify tenosynovitis, tendinopathy, synovitis, and guide therapeutic injections 2
• Ultrasound is preferred over MRI initially because it is cost-effective, readily available, and can identify the specific tendons involved (abductor pollicis longus, extensor pollicis brevis, extensor carpi radialis, extensor carpi ulnaris) 2
• If ultrasound is inconclusive, order MRI without IV contrast to evaluate for occult bone stress injury, ligament pathology, or intersection syndrome 2, 1, 3

Corticosteroid Injection Considerations

• Ultrasound-guided corticosteroid injection into the affected tendon sheath(s) is highly effective, with 97% of patients achieving at least partial symptom resolution at 6 weeks 9
• Ultrasound guidance is superior to blind injection because it identifies subcompartments in 52% of cases and ensures accurate delivery 9
• Two to three injections may be required for complete symptom resolution, with 98.75% of patients symptom-free by 12 weeks 8
• If injections fail after 2–3 attempts, surgical release should be considered 5, 6, 7

Common Pitfalls to Avoid

• Do not allow the patient to return to full welding duties without documented symptom resolution, as this will cause recurrence and chronic tendinopathy 3, 5
• Do not assume this is isolated De Quervain's disease based on thumb base pain alone; the diffuse wrist involvement suggests a broader tendinopathy 2
• Do not delay hand surgery referral beyond 2 weeks, as chronic tenosynovitis becomes progressively harder to treat conservatively 5, 7
• Do not order MRI from the ER unless there is concern for occult fracture or infection; ultrasound is the appropriate next imaging study 2

Prognosis and Return-to-Work Counseling

• Conservative management (NSAIDs, splinting, injection) succeeds in 85–95% of cases when combined with adequate work modification 8, 9, 7
• Surgical release provides excellent outcomes if conservative measures fail, with most patients returning to work pain-free 5, 7
• The patient must understand that continued welding without treatment will lead to permanent disability, as evidenced by his prior experience requiring job cessation 3