Birger Jakobsen: A 64-Year-Old Male With a Deformity of the Left Hand

Birger Jakobsen

“You know, Doctor, my dad and older brother had this same thing,” said The Captain . Everybody in my office called him The Captain . He had that command presence vibe: all seriousness and business. “I thought I might not get it, but just about the time I turned 60, I started getting these calluses on my palm. They hurt when I try to grab anything with my hand. I guess I didn’t dodge the bullet. Like father, like son.” Birger Jakobsen was a long-standing patient of the practice. He is a 64-year-old sea captain with the chief complaint of “I can’t put on my gloves because my fingers won’t straighten out.” The Captain stated that over the last year, the calluses had turned into “bands that were tight as a hawser,” and now he found it harder and harder to straighten out his fingers. He noted that as the fingers got more bent, the pain seemed to gradually get better. He noted that the pain was worse at night after a full day at work. He tried using a heating pad and Extra-Strength Tylenol without much success. The Captain noted, “Doctor, I worry that my hand could cause one of my crew to get hurt because my hand just doesn’t work like it should. I really can’t hold a fire extinguisher, and a fire at sea is my biggest fear.” I could see that The Captain was really worried, and I tried to reassure him that we had some new treatments that weren’t around when his dad was struggling with it.

The Captain denied any antecedent hand trauma. I asked what made the pain better, and he said, “Nothing really helps, but it’s not about the pain.” It was about his hand deformity. I asked Birger what made his pain worse, and he said, “Any time I have to use my hand. Like just about everything to do with my job!” Birger denied fever and chills, but reminded me that his “blood pressure was up and I take that blood pressure pill every day. So, Doctor, I am only The Captain to my crew, please just call me Birger. I was named after my grandpa, a real tough cookie, a proud Dane. I don’t think I ever saw him smile.” I smiled and said, “Okay, Birger it is. Let’s take a look at that hand.”

On physical examination, Birger was afebrile. His respirations were 18, and his pulse was 74 and regular. He was normotensive with a blood pressure of 126/74. His head, eyes, ears, nose, throat (HEENT) exam was normal, as was his cardiopulmonary examination. His thyroid was normal. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness or peripheral edema. Birger’s low back examination was unremarkable. Visual inspection of the right hand revealed findings with the later stages of Dupuytren contracture. He had the classic findings of Dupuytren: the dense, scarlike palmar contracture with a severe contraction of the little finger ( Fig. 12.1 ). There was no rubor or color of the right hand, but there was diffuse tenderness to deep palpation of the fibrous cords. Range of motion of the right hand was limited, and his little finger was completely ankylosed. The left hand examination was normal, as was examination of his other major joints. A careful neurologic examination of the upper extremities revealed there was no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not