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with the condition. The history is notable for the acute onset of severe pain, limited wrist motion, and swelling, but no systemic complaints suggesting infection. There is no history of penetrating injury and usually no recent trauma. The physical findings include swelling, loss of motion, and exquisite tenderness of the flexor carpi ulnaris tendon, often just proximal to the pisiform. There may be erythema-tous streaking extending into the forearm. The physical findings may mimic a septic joint or cellulitis with ascending lymphangitis, but there is no lymphadenopathy or fever. The radiographic findings are often pathognomonic. Often, there is a large fluffy calcific deposit in the region of the flexor carpi ulnaris tendon just proximal to the pisiform. The calcification may be subtle and visualized only on oblique radiographs as in this case. White count, differential, and sedimentation rate are almost always normal.

The pathogenesis of calcium deposition in the soft tissues is unknown. It has been postulated that trauma induces an area of necrosis into which calcium is deposited. Symptoms are unrelated to the size of the calcium deposit. The actual deposit may be small and visible only with oblique radiographs. The calcium is released and causes a significant inflammatory response. The clinical picture is so much like an infectious process that many patients have been treated with antibiotics. Once the diagnosis is made, the treatment is straightforward. On follow-up radiographs, the calcium deposits have usually been resorbed within a few weeks.

Surgical Management

Most patients respond to conservative measures. In patients who are refractory to conservative treatment, the calcific deposit may be surgically excised. This is accomplished by making a longitudinal incision in the flexor carpi ulnaris tendon, excising the offending material, and repairing the tendon. Use of intraoperative fluoroscopy or radiographs is recommended to ensure complete removal.

Postoperative Management

A bulky compressive dressing is initially applied with a short arm splint. Range-of-motion exercises are started 10 to 14 days postoperatively.

Alternate Methods of Management

Treatment options include antiinflammatory medication by mouth or injection, splinting, and surgical excision. I have found these patients extremely disabled and have been gratified by the response to a corticosteroid injection. I attempt to needle the calcium deposit at the same time. Additionally, I use a wrist splint for several days until the symptoms resolve completely. A few patients have required a second steroid injection, but surgery is rarely necessary.

Complications

The major complication of flexor carpi ulnaris calcific tendinitis is misdiagnosis. There are several reports in the literature of patients being treated with antibiotics and even admitted to the hospital with this condition. Complications of treatment of flexor carpi ulnaris calcific tendinitis are rare. Care must be taken to avoid injecting the ulnar nerve or artery. Depigmentation and subcutaneous fat atrophy can occur if the corticosteroid is injected into the subcutaneous tissue or skin itself. The ideal site of injection is adjacent to the flexor carpi ulnaris tendon. I also attempt to puncture the calcific deposit with the needle as well.

Suggested Readings

Carroll RE, Sinton W, Garcia A. Acute calcium deposits in the hand. JAMA 1955; 157:422-426.

Greene TL, Louis DS. Calcifying tendinitis in the hand. Ann Emerg Med 1980;9: 438-440.

Moyer RA, Busch DC, Harrington TM. Acute calcific tendinitis of the hand and wrist: a report of 12 cases and a review of the literature. J Rheumatol 1989;16: 198-202.

Phalen GS. Stenosing tenosynovitis: trigger fingers, trigger thumb, and de Quervain's disease. Acute calcification in wrist and hand. In: Jupiter JB, ed. Flynns Hand Surgery. 4th ed. Baltimore: Williams &Wilkins; 1991:444-446.

Wolfe SW. Tenosynovitis. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green's Operative Hand Surgery. 4th ed. Philadelphia: Churchill Livingstone; 1999:20262027.

Yelton CL, Dickey LE. Calcification around the hand and wrist. South Med J 1958;51:489-495.

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