Lifestyle
Social Networks: The Next Great Successors
There’s been a lot of talk in recent weeks about social networks and the way they do business.
Whether it’s Facebook and their skimming of personal information, or Twitter and their millions of fake user accounts, people are beginning to have less and less trust in social media.
And, with movements calling for users to leave the various networks or at least boycott their services, it’s not hard to imagine them shutting their doors in the near future.
So, what would happen if the three biggest social networks — Facebook, Twitter, and Instagram — suddenly had to close down tomorrow? Who would take their place?
Join us, today, as we take a closer look at the next in line for the social network throne, and get yourself ready for the next big thing in social.
social networks
Facebook, Replaced By Nuzzel
Easily one of the most instantly-recognizable social networks of our time, Facebook, like Myspace before it, won’t be around forever. So, when Old Blue eventually takes its final curtain call, who’s most likely to take its place?
We’d like to introduce Nuzzel.
While Nuzzel isn’t necessarily a Facebook clone, it’s an aggregator that brings together the updates from your other social networks to form a single timeline. This gives it that social home type of feeling, bringing you news, shares, and other interesting events in one single place. Whatever’s trending, you’re getting it, with Nuzzel.
Twitter, Replaced By Mastodon
Twitter’s always been a bit of a problematic network, because of its various rules and the fact that the user base can be a little aggressive. Then there’s the fact that, recently, they’ve come under fire for allowing thousands of fake user accounts without consequence.
It’s this kind of questionable design that makes Mastodon seem all the more attractive. This platform is open source, which means the code it’s made from is available to use and edit the way the user prefers. Users choose their own incidences, but can message each other in others. Rules differ from instance to instance, depending on what the users decide, making the entire thing completely democratic.
Instagram, Replaced By Pixlr-o-matic
A lot of the attraction with Instagram is in users being able to take snapshots and apply awesome filters to their pictures, to achieve dozens of different effects. Create slick, professional-looking media easily, from your phone or computer, and share them to other users of the same network.
While Pixlr-o-matic doesn’t bother with the social network back-end, you’ll actually find this functionality isn’t entirely necessary. Get creative, with dozens of filters, colors, frames, and other effects, and share your photos easily across your other social networks, or directly between devices.
A World Of Social Networks, Waiting To Be Discovered
The Internet’s a big place. There’s a lot to discover, and no shortage of social networks to enjoy. We’ve seen some of the biggest ones yet come and go, and there are likely to be more to come.
Interested in learning more about this and other awesome online stories? Check out the rest of our fantastic blogs, today!
If you’re alive and have read the news in recent years, chances are you’ve heard about CBD oil at some point. It’s a multipurpose extract made from cannabidiol (CBD), a non-psychoactive chemical derived from marijuana. Patients are using it as a treatment for everything from pain to anxiety and depression.
With more and more research coming out on the topic every day, it’s a product that is quickly changing the medical landscape for patients and medical practitioners alike.
CBD oil has taken the medical world by storm in recent years.
To be honest, though, the concept of using cannabis as a treatment can be discouraging to people. They imagine it’s something illicit, and no matter how much research they read, they worry it might be psychoactive.
But with the explosion CBD’s popularity in recent years, there are new opportunities to evaluate the way we feel about this product. Join us today, as we take a closer look at CBD benefits and how it could be an extremely effective solution for people suffering from pain, anxiety and more.
An Average User’s Experience with CBD Oil
While our test subject had never tried CBD products before, they actually had two family members using CBD oil treatment for anxiety. The reports they got back from them were remarkably similar: both confirmed the treatment was fast acting and relieved their stress almost instantly.
Both also confirmed this occurred without any of the side effects of marijuana.
In another case, a colleague of theirs from work used CBD oil to treat her undiagnosed nausea. She claimed the product helped for long periods of the day, before eventually wearing out.
She also learned you can use CBD oil to treat your pets, safely and effectively. A client used a CBD salve on his dog, who had been suffering from an aggressive form of cancer. The results were remarkable: the dog was happier, more active, and more responsive than he’s been in years, all immediately following from his veterinarian-recommended CBD treatment!
The end result was our subject learned a valuable lesson about what CBD is actually used for: easing nausea, managing muscular pain, and soothing anxiety. As a person who’d never tried CBD treatment, herself, the versatility of this came as a big surprise.
CBD Oil: What It Is
As we’ve mentioned, CBD is a non-psychoactive ingredient extracted from hemp and marijuana plants. Without the psychotoxic effects that are associated with hallucinogens like marijuana, it is remarkably safe for use in a variety of everyday scenarios.
Strains of CBD Oil with little to no THC help to treat various medical problems. The oil itself comes in a host of different forms, from syringes to tinctures and topicals, capsules, edibles, vapes, and dabs. Each form, in turn, brings with it its own selection of benefits and issues.
Studies suggest that CBD oil may be beneficial for a host of problems, including:
- Aches and Pains
- Anxiety
- Arthritis
- Auto-Immune Diseases
- Chronic Pain
- Diabetes
- Epilepsy
- Headaches and Migraines
- Insomnia
- Mood Disorders
- Multiple Sclerosis
- Neurological Disorders
While the FDA has not confirmed these, there is a wealth of informal research and thousands of inspiring reviews, online.
Is It Legal in America?
CBD is different to medical cannabis, which as we all know is still not legal everywhere in the United States. Instead, oil products can be found in retailers across the country, as well as many online CBD stores.
Your only job when dealing with any of these outlets is to read the fine print. Always do your research when buying CBD products online. Go with a reputable retailer, with good reviews and a lot of insightful information to read up on ahead of time. Remember: if there’s little to nothing on them, there’s probably a reason why.
Always look for quality rather than the cheapest prices.
There are numerous physical and mental benefits of CBD oil products.
CBD Dose
Interested in high-quality CBD oil products from a reputable online retailer? CBD Dose is one of the most exciting brands currently operating online. Check out our awesome digital catalog and find CBD products that fit your lifestyle today!
CBD Oil Where To Buy
So you’ve gone over to your favorite search engine and typed “CBD oil where to buy?”
Everybody’s got to start somewhere.
CBD Dose is a premium cannabidiol (CBD) website, offering a range of high-end products for CBD lovers of all walks of life. And, while we’re proud of that fact, we also recognize that not all of you may know exactly what this product is, where to find it, and what the potential benefits are for you.
Join us today, for more on CBD Oil Where To Buy, and get to make a change.
Trying to find out about CBD oil where to buy? You’ve come to the right place!
What It Is
If you’ve paid attention to the news recently, there’s a good chance you’ve heard more and more about CBD oil. You’ve probably also heard debates over its legalization and various battles to have it recognized as a medicine. “CBD Oil Where To Buy” seems to be the question on everybody’s lips, and seemingly with good reason.
But what is it?
In as simple a manner as possible: CBD oil is a hemp oil, derived from the non-psychoactive plant cannabis sativa. It’s been applauded by the people who’ve used it for its various positive health effects.
It comes in three forms, usually: green (unfiltered), blue (filtered, but not “cooked down”), and gold (filtered, carboxilated or cooked down). The benefits of each form may vary from producer to producer, but it’s shown promising results in the treatment of some of the following:
- Pain management
- Anxiety
- Inflammation
- Skin care
- Heart health
As we’ve mentioned, when considering CBD oil as a health and wellness treatment, keep in mind that it is non-psychoactive. This means that, though it is derived from a cannabis plant, using it will not in any way leave you in an altered state. You may find it relaxes you, but you can put concerns about hallucinations, rambling, or embarrassing behavior out of your mind.
So, your next question after “What is CBD oil?” should be “CBD Oil Where To Buy?”
Learn more about CBD Oil Where To Buy with us, today!
CBD Oil Where To Buy It
Depending on which state you live in, “CBD Oil Where To Buy?” is a question that could have a lot of answers. Your safest bet is to research retailers in your area, or further out if needs be. Then, check out reviews online to make sure that what they offer is safe, effective, and not overpriced.
CBD Dose is a supplier of high-end CBD products, sourced from reliable suppliers and sold at a fraction of the normal costs. With our extensive experience in the industry and a product line including some of the highest-quality products available anywhere, we are proud of our product and its efficacy.
For more on CBD oil where to buy, get in touch with us or check out the CBD Dose online store, today!
Deciding to cut down your own tree is a big step. It’s a job with a lot of work and a fair share of danger involved, and certainly not one to just start doing without proper planning beforehand.
You need to know what you’re doing, what you shouldn’t be doing, and everything to do when what you should be doing turns sour unexpectedly.
That’s why we’ve assembled this, our professional 12-step guide to tree removeal for taking care of your own tree problem quickly and efficiently.
Ready to get cutting? Good – because so are we!
Web Stark Media and Tree Worx Florida bring you this 12 Step Tree Removeal Guide
1. Safety First
Getting the right safety gear in place before you start can save you time and potential injuries, down the line. These should include (but certainly won’t be limited to):
- Logger’s helmets help to protect your head, specifically, from falling wood and debris.
- Earmuffs and face screens to safeguard your ears and eyes.
- Safety glasses to stop dust getting into your eyes.
- Kevlar chaps to stop a chain if you happen to drop the bar against your leg.
2. Bring A Lookout
As with all things in life, tree-felling is better with friends. And much, much safer. Bring an assistant to watch out for falling branches or, in a worst-case scenario, unexpectedly falling trees while you’re busy with the chore of sawing. And listen when they give you the tap – if it’s early into the cut and your partner lets you know something is happening, drop your saw and leave.
3. Felling Wedges
A set of plastic felling wedges will prevent your saw from becoming pinched in the crease of a heavy tree trunk during a cut.
4. Felling Zones
Being able to accurately estimate a felling zone is crucial to the tree felling process. The ax trick is a method that is roughly adequate for this job. Hold an ax handle out from yourself at arm’s length and eye level. Close one eye and back away from the tree until the top of the ax handle is level with the tree top and the bottom is in line with the base. This should be roughly far enough away to have the tree land safely at your feet, though remember it is just an estimate, and it’s always good to give it just a little more room.
5. Clearing Cutting Zones
Cutting down a tree can teach you quickly how little you’re ever really sure of in life. Even with lots of time to prep, a felled tree could fall in a direction that takes you completely by surprise. Clear three different escape routes through the brush around the tree, in roughly 45 degrees from each other, so you can easily choose a new one if you have to in a pinch.
6. Figure Out Your Tree
Any tree removeal tutorial worth its salt will tell you to look out for treacherous trees before anything else. Check your tree for the following, and don’t cut it down if you see them:
- dead branches, either kept up by other branches or by partial connections to the tree
- it is clearly leaning heavily in a specific direction
- important buildings or structures nearby that would be damaged in a fall
7. Knowing A Notch
Make sure your notch has a depth of one-fifth of the tree trunk’s diameter. You’ll want to create a wedge shape in the side of the tree, measuring around 30° down from and 60° up from that line. Then, from the other side of the tree, use a saw and wedge to create a cut into the tree that meets the tip of the notch you started with. As you push the wedge further into this cut, you’ll create a hinge, from where the tree will tip over.
You can plan where this notch will start by scoring the tree trunk with a piece of chalk, making sure it’s at a comfortable height.
8. A Note On Making The Notch
Use a chainsaw to cut into the tree from the top, then from the bottom, creating your triangular notch. If you do this perfectly, a wedge of wood will fall out. If (like most people) you don’t do this perfectly the first time, you’ll have to cut further into the wood either from above or below to have the two cuts meet and the notch of wood fall out.
9. Big Trees Need Wedges
The bigger the tree, the more chance you have of getting your chainsaw caught in the space you’ve cut when the trunk of the tree leans back on it. Stop cutting with the saw when you’ve penetrated far enough into the tree to pound a wedge in behind it. Keep the right there in the cut with the saw running and the chain brake locked, and tap in the wedge to loosen up the gap. Then simply finish the cut.
10. Fell That Tree!
Use your chalk to score a line from the opposite side of the tree to the apex of your notch, and cut into it with a saw along that line. This is the felling cut. Once the tree starts leaning, pull your saw out of the cut and walk away along one of your escape routes, depending on the way the tree is falling. And remember to keep your eye on the fall at all times. This is an especially important moment for your lookout to be prepared.
11. Cut Low, Progress High
One the tree is safely on the ground, begin sawing off branches starting at the bottom of the trunk and moving upwards towards the top.
12. Time To Make Firewood
Lastly, cut the log into 16″ lengths of firewood. Cut three-quarters of the way into the log, then roll it over and complete the cut from the other side.
Tree Worx Tree Removeal: Now You’re Ready
Ultimately, tree removeal is a long, tedious, and dangerous process. If you do decide to handle it yourself, however, at least now you’ll know the twelve most important steps to keep in mind as you work.
If you decide to let a professional handle it, however, get in touch with Tree Worx for tree removal service in Volusia County.
For those of you considering tree removeal in an area with houses, power lines, or other structures nearby, check out the following video for an alternative to the method described above:
Gold’s Gym Ormond Beach hosted a charity event with a lot of heart over the weekend of August 4. Members participated in specialty classes designed specifically for this event and made donations while having fun.
Ormond Beach Gold’s Gym Back to School Charity Event
And the results were better than anybody could have hoped for. On the following Friday, Gold’s Gym informed their Facebook followers they had raised more than $2,300 for the Jewish Federation. This is money used to buy backpacks and school supplies for Volusia County children.
“This is a cause that is very close to our hearts. It brought us a lot of joy to play a part in this donation,” said the official announcement.
Community and gym members alike were invited, over the course of the weekend, to participate in a series of fun spin and fitness classes. The end goal: to encourage attendees to donate generously.
Ormond Beach Gold’s Gym Giving A Check To The Jewish Federation
Handing over a check for $2,308 to representatives from the Jewish Federation on Thursday, smiles, and gratitude filled the room. Gold’s Gym had made the impact they’d set out to make. More importantly, though they’d made a difference.
The Jewish Federation of Volusia and Flagler Counties
The Jewish Federation of Volusia and Flagler Counties is an organization which works hand-in-hand with local Jewish communities. Part of their mission statement is strengthening the Jewish identity on a local level, and meeting their unique needs.
For more information on how you can help support the Federation and the work they do, call 396-672-0294 or visit them, online.
And to those of you interested in fitness in the Ormond Beach area, why not stop in at your local Gold’s Gym and break a sweat, today?
And, to Daytona community members, read our recent article on Gold’s Gym’s exciting new move to the Shoppes at One Daytona.
Patients with wrist pain commonly present with an acute injury or spontaneous onset of pain without a definite traumatic event. A fall onto an outstretched hand can lead to a scaphoid fracture, which is the most commonly fractured carpal bone. Conventional radiography alone can miss up to 30 percent of scaphoid fractures. Specialized views (e.g., posteroanterior in ulnar deviation, pronated oblique) and repeat radiography in 10 to 14 days can improve sensitivity for scaphoid fractures. If a suspected scaphoid fracture cannot be confirmed with plain radiography, a bone scan or magnetic resonance imaging can be used. Subacute or chronic wrist pain usually develops gradually with or without a prior traumatic event. In these cases, the differential diagnosis is wide and includes tendinopathy and nerve entrapment. Overuse of the muscles of the forearm and wrist may lead to tendinopathy. Radial pain involving mostly the first extensor compartment is commonly de Quervain tenosynovitis. The diagnosis is based on history and examination findings of a positive Finkelstein test and a negative grind test. Nerve entrapment at the wrist presents with pain and also with sensory and sometimes motor symptoms. In ulnar neuropathies of the wrist, the typical presentation is wrist discomfort with sensory changes in the fourth and fifth digits. Activities that involve repetitive or prolonged wrist extension, such as cycling, karate, and baseball (specifically catchers), may increase the risk of ulnar neuropathy. Electrodiagnostic tests identify the area of nerve entrapment and the extent of the pathology.
Also Read: Orthopedic Doctor: Types Of Fractures
Musculoskeletal problems are responsible for up to 20 percent of all visits to primary care offices in the United States. 1 Family physicians are often the first to evaluate and treat wrist pain. Wrist pain is traditionally classified as acute pain caused by a specific injury or as subacute/chronic pain not caused by a traumatic event (Tables 1 and 2). Injuries that cause acute pain may result in contusions, fractures, ligament sprains or tears, and instability. Subacute or chronic pain may result from overuse, have neurologic or systemic causes, or be a sequela from an old injury. Patients with these injuries may have a history of repetitive wrist movement, either occupationally or recreationally. The addition of sensory disturbances, such as numbness or tingling, points to nerve involvement.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.xml.
History and physical examination lead to the correct diagnosis in most cases. The location, nature, timing, and quality of the pain are important clues for narrowing the differential diagnosis. In acute wrist injuries, plain radiography should be obtained with anteroposterior, lateral, and oblique views. When the diagnosis remains unclear, further imaging, such as bone scan, ultrasonography, computed tomography, or magnetic resonance imaging (MRI), may help identify the cause. Because nontraumatic wrist pain has a wide differential diagnosis, the patient history should include a review of systems with neurologic or constitutional symptoms, as well as a social history of vocational and recreational activities. The following case studies discuss the background and presentation of three causes of wrist pain, as well as diagnostic tests and strategies.
Case 1. Scaphoid Fracture
A 21-year-old man presents with dorsal left wrist pain after falling onto his outstretched hand while inline skating. He noted immediate swelling and painful wrist extension. Physical examination reveals soft tissue swelling with limited motion, mostly in extension, secondary to pain. There is bony tenderness along the distal radius as well as the anatomic snuff box. His sensory and vascular examination results are unremarkable.
BACKGROUND
The wrist comprises eight carpal bones (Figure 12), but only the lunate and scaphoid articulate with the radius and absorb significant impact during a fall onto an outstretched hand. The scaphoid is the most commonly fractured carpal bone. The primary vascular supply to the scaphoid originates distally from retrograde branches of the distal radial artery, making the proximal pole of the scaphoid relatively avascular and at higher risk of nonunion and avascular necrosis. Fractures of the proximal and distal portions of the scaphoid each account for 20 percent of scaphoid fractures, and the middle portion accounts for the remaining 60 percent.
Figure 1.
The bones of the wrist.
Reprinted with permission from Daniels JM II, Zook EG, Lynch JM. Hand and wrist injuries: part I. Nonemergent evaluation. Am Fam Physician. 2004;69(8):1941.
The peak incidence of scaphoid fractures occurs at about 15 years of age. Because of the weakness of the distal radius compared with the scaphoid, scaphoid fractures are not common in older persons. In young children, the supportive cartilage surrounding the ossific nucleus of the immature scaphoid creates protection, making physeal injuries of the radius more common.
Also Read: Orthopedic Doctors In Florida: Facts About A Proximal Humerus Fracture
PRESENTATION
The typical history of a patient with a scaphoid fracture is a fall onto an outstretched hand with the wrist dorsiflexed and radially deviated. Most patients with scaphoid fractures present shortly after a fall, but in some cases, the initial pain improves, causing a delayed presentation.
Physical examination may reveal a swollen wrist. Tenderness is usually located dorsally around the distal radius. Patients may have painful wrist extension and loss of grip strength if they present a few days after the injury.
There are no reliable clinical tests to rule out a scaphoid fracture. Swelling of the anatomic snuff box (Figure 2) increases the likelihood of a scaphoid facture. The combination of snuff box swelling, scaphoid tubercle tenderness, and pain with axial pressure on the first metacarpal bone has a sensitivity of approximately 100 percent. However, the specificity of each test is 9, 30, and 48 percent, respectively. Diminished grip strength compared with the contralateral side increases the positive predictive value for a scaphoid fracture. The differential diagnosis of a suspected scaphoid fracture is listed in Table 3.
Figure 2.
Anatomic snuffbox. The scaphoid is located below the snuffbox.
Reprinted with permission from Phillips TG, Reibach AM, Slomiany WP. Diagnosis and management of scaphoid fractures. Am Fam Physician. 2004;70(5):880.
DIAGNOSTIC TESTS
Conventional radiography (anteroposterior, lateral, and oblique views) alone can miss up to 30 percent of scaphoid fractures. Based on retrospective studies, sensitivity improves if additional views are added (i.e., posteroanterior in ulnar deviation, pronated oblique, and supinated oblique). In many cases, repeat radiography is needed in 10 to 14 days to observe sclerosis, which indicates a healing fracture.
If the diagnosis cannot be confirmed with plain radiography, a bone scan or MRI can be performed. Bone scan has a sensitivity near 100 percent but produces false-positive results up to 25 percent of the time. MRI within one day after trauma has a sensitivity of 80 percent, but late examination (more than 10 days after injury) has a sensitivity and specificity comparable to bone scan.
DIAGNOSTIC STRATEGY
If a scaphoid fracture is suspected based on history and physical examination, plain radiography should be performed, including specialized views such as a posteroanterior in ulnar deviation and a pronated oblique. If radiography is negative for fracture but clinical suspicion is high, the wrist should be protected in a thumb spica cast with the option of repeat plain radiography in 10 to 14 days or a bone scan one to two days after injury. If repeat plain radiography is negative but wrist pain persists, MRI should be performed to clarify the diagnosis.
Case 2. Ulnar Neuropathy
A 39-year-old right-handed woman presents with a four-week history of wrist pain and numbness and tingling in her right hand. There is no history of trauma or injury to the neck, elbow, or wrist. She works mostly at a desk job but has not had any changes in her work schedule. Physical examination of the wrist reveals no soft tissue swelling, muscle atrophy, or skin changes. She has painful wrist extension, as well as reproduction of the tingling in her fifth finger with tapping over the pisiform. Grip strength is normal and no other bony tenderness is appreciated.
BACKGROUND
The ulnar nerve originates from the C8 and T1 nerve roots (Figure 3), and extends from the medial cord of the brachial plexus through the axilla, innervating the muscles of the forearm and the hand. Proximal to the wrist, dorsal and palmar cutaneous branches split off, whereas the rest of the nerve courses through the Guyon canal (Figure 4) to the palmar surface of the hand. This triangular canal is bordered medially by the pisiform, laterally by the hamate, anteriorly by the tendon of the flexor carpi ulnaris, and posteriorly by the transverse carpal ligament. In the canal, the ulnar nerve splits to a superficial sensory branch, which supplies sensation to the hypothenar eminence, and to a deep motor branch that innervates the hypothenar muscles, adductor pollicis, and flexor pollicis brevis. The ulnar nerve may be compressed anywhere in the Guyon canal, causing motor, sensory, or mixed deficits. Compression is usually caused by ganglion cysts or repetitive trauma.
Ulnar nerve entrapment is the second most common neuropathy of the upper extremity, surpassed only by median nerve entrapment (i.e., carpal tunnel syndrome). Although the true incidence of ulnar neuropathy at the wrist is not well documented, it is accepted to be the second most common site after compression at the elbow. Ulnar neuropathies are slightly more common in men than in women. Peak incidence is in men older than 35 years.
PRESENTATION
The typical presentation in ulnar neuropathy is wrist discomfort with sensory changes in the fourth and fifth digits. Grip weakness may be present in chronic cases. History usually reveals no specific injury. Activities that involve repetitive or prolonged wrist extension, such as cycling, karate, and baseball (specifically catchers) may increase the risk of ulnar neuropathy.
Physical examination of a patient presenting with these neurologic symptoms should include cervical spine, shoulder, and elbow examinations to rule out a proximal lesion. Reproduction of pain on neck movement could indicate cervical disk disease; pain with shoulder motion could indicate a brachial plexus problem; and reproduction of symptoms with compression of the nerve at the ulnar groove could indicate compression at the elbow. Compression of the ulnar nerve at the Guyon canal should cause weakness of the hypothenar muscles innervated by the deep motor branch and sensory disturbances of the fifth digit innervated by the superficial sensory branch.
Clinical tests include a positive Tinel sign on percussion of the ulnar nerve over the Guyon canal, as well as a positive Phalen sign (maximum passive flexion of the wrist for more than one minute) with paresthesias in the fourth and fifth fingers. Unlike in carpal tunnel syndrome, sensitivity and specificity of these tests for ulnar neuropathy at the wrist are not known. The differential diagnosis of suspected ulnar neuropathy at the wrist is listed in Table 4.
DIAGNOSTIC TESTS
Plain radiography evaluates wrist anatomy well, and can identify fractures, dislocations, or soft tissue masses that may have led to nerve compression.
Ultrasonography of peripheral nerves is helpful in identifying compressive etiologies of nerve injury and in visualizing structural nerve changes. It is noninvasive, relatively inexpensive, and well tolerated by patients.
Electromyography and nerve conduction studies can be helpful in identifying the area of entrapment and documenting the extent of the pathology. Motor and sensory conduction velocities are more useful in acute entrapments, whereas electromyography is a better choice for chronic neuropathies because it shows axonal degeneration more clearly. The sensitivity and specificity of these electrodiagnostic tests in the primary care setting are unknown because existing studies are limited to a small number of patients with known neuropathy.
MRI can detect abnormalities of the ulnar nerve, flexor tendons, vascular structures, and the transverse carpal ligament around the Guyon canal. Neurogenic edema can be seen as early as 24 to 48 hours after denervation compared with electromyography, in which changes after denervation are not seen for one to three weeks. Imaging criteria for neuropathy on MRI are not well defined, and several studies have found MRI abnormalities in healthy, asymptomatic patients.
DIAGNOSTIC STRATEGY
If ulnar neuropathy is suspected, plain radiography should be ordered first. If no obvious mass or lesion is found, electrodiagnostic tests should be ordered to localize the lesion, measure its severity, and aid in the prognosis. In the setting of inconclusive or nonlocalizing electrodiagnostic test results, ultrasonography or MRI may be useful.
Case 3. De Quervain Tenosynovitis
A 31-year-old woman presents with several months of worsening radial left wrist pain that started insidiously. She denies any specific trauma. She has no numbness or tingling in the wrist, hand, or fingers. Her pain worsens with gripping and grasping, and with picking up her nine-month-old daughter. Physical examination reveals no discoloration and minimal soft tissue swelling along the radial styloid and anatomic snuff box. There is soft tissue tenderness about the anatomic snuff box and radial styloid. She has limited motion of the thumb, with pain mostly in extension and abduction. Her sensory and vascular examinations are unremarkable.
BACKGROUND
Two major dorsal tendons of the thumb are involved: the extensor pollicis brevis and the abductor pollicis longus (Figure 5). [ corrected] These tendons comprise the lateral border of the anatomic snuffbox, with the extensor pollicis longus medially and the scaphoid bone at the bottom. The two tendons have similar function in bringing the thumb into radial abduction. These tendons run in a synovial sheath in the first extensor compartment of the hand. Inflammatory changes in the sheath and tendons result in a tenosynovitis. Recurrent or persistent inflammation may result in stenosing tenosynovitis.
PRESENTATION
The typical presentation includes subacute radial wrist pain at the thumb base and into the distal radius. In retrospect, patients may identify a new or repetitive hand-based activity as the cause, but the etiology often is idiopathic. De Quervain tenosynovitis is more common in women, particularly those 30 to 50 years of age. New mothers are especially noted to have this problem from picking up a child.
Physical examination may reveal a minimally swollen wrist. Tenderness is usually located over the radial tubercle and sometimes around the soft tissues of the anatomic snuff box. Thumb motion is invariably painful. Neurovascular examination should be unremarkable. The Finkelstein test is confirmatory because it has good sensitivity and specificity. It is performed by making a fist over the thumb and then moving the hand into ulnar deviation, which passively stretches the thumb tendons over the radial styloid A grind test of the thumb, which is performed by axial compression and slight rotation of the metacarpophalangeal joint, should be negative in those with de Quervain tenosynovitis but positive in those with first carpometacarpal osteoarthritis. The differential diagnosis of suspected de Quervain tenosynovitis is listed in Table 5.
DIAGNOSTIC TESTS
The diagnosis is clinical based on history and examination. In cases where osteoarthritis of the carpometacarpal joint is considered, pain relief with diagnostic lidocaine (Xylocaine) injection of the first extensor compartment excludes arthritic cause. Radiography, electromyography/nerve conduction studies, blood tests, and MRI or ultrasonography may be used to evaluate for alternative diagnoses.
DIAGNOSTIC STRATEGY
If the history and examination are consistent, no further diagnostic testing is needed. For suspicion of fracture or arthritis, radiography is an appropriate first step. If suspected, radial nerve abnormalities may be ruled out with electromyography or nerve conduction studies. If there is concern for infectious tenosynovitis, a complete blood count and measurement of inflammatory markers, such as erythrocyte sedimentation rate and C-reactive protein levels, are appropriate. If the patient does not respond to treatment or if the diagnosis is in question, an MRI or musculoskeletal ultrasonography may be ordered to further evaluate the first extensor compartment.
Data Sources: A PubMed search was completed in Clinical Queries using the key terms scaphoid fracture, ulnar neuropathy, and de Quervain’s. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Also searched were Essential Evidence Plus, the Cochrane database, the National Guideline Clearinghouse, and UpToDate. Search date: August 2011.
Also Read: Long Bone Fractures and Complications
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