Harry Boyden: A 58-Year-Old Male With Right Wrist Pain

Harry Boyden

Harry Boyden is a 58-year-old chef with the chief complaint of “my right wrist is killing me.” Harry went on to say that he wouldn’t have bothered coming in, but he was getting where he couldn’t hold a fry pan in his right hand because his wrist hurt so much. I asked Harry if he had anything like this happen before. He shook his head and responded, “Just my feet. You can’t stand on that hard kitchen floor all day long and not have your feet hurt by the end of the day. Doctor, I can live with the feet—sore feet are just an occupational hazard. Usually I just take a couple of Motrin and give them a good soak, and that will usually set me right after a day or so. What worries me this time is that this damn right wrist is hurting all the time, especially when I try to pick up a fry pan and toss the food so it won’t burn, something I used to do about 1000 times a day. Now just the weight of the pan when I lift it really hurts, but that flick of the wrist that you need to toss the food and then catch it hurts so bad that I have been working the pass so I don’t drop a hot pan and burn myself or someone around me. This is a real problem. I’m pretty tough, but this really has me worried because at my age executive chef jobs aren’t that easy to come by. I worked my whole life to get where I am, and I don’t want this stupid wrist pain to cut my career short! I don’t want to go back to being a line cook. Like everybody else in the food industry, if I don’t work, I don’t eat. The other thing is, this damn wrist has my sleep all jacked up. Even when I am sleeping, every time I move my wrist the damn pain wakes me up! Hell, some mornings, I have to brush my teeth with my left hand.”

I asked Harry about any antecedent trauma and he just shook his head. “Doc, this kind of snuck up on me. At first, my wrist had this deep ache that would get better with some Motrin and rest. Over the last 6 weeks, the Motrin just quit working. But Doc, like I said, I gotta work.” I asked Harry what made his pain worse and he said, “Any time he used his wrist, it hurt like hell.”

I asked Harry to point with one finger to show me where it hurts the most. He grabbed his right wrist and said, “Doc, I can’t really point to one place. It kind of hurts all over. And you know, the crazy thing is, sometimes I feel like the wrist is popping.” I asked if he had any fever or chills and he shook his head no. “What about steroids?” I asked. “Did you ever take any cortisone or drugs like that?” Harry again shook his head no and replied, “Too many drunks and stoners in the food industry as it is.” I laughed, then said that maybe it was a time to stop eating out. Harry smiled and said, “Doc, you’re safe when I’m the one cooking for you and yours. Get my wrist better and I will cook you a meal to remember!”

On physical examination, Harry was afebrile. His respirations were 18 and his pulse was 74 and regular. His blood pressure (BP) was slightly elevated at 142/84. I made a note to recheck it again before he left the office. 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. There was no peripheral edema. His low back examination was unremarkable. I did a rectal exam, which revealed no mass and a normal prostate. Visual inspection of the right wrist revealed no cutaneous lesions or obvious mass. The wrist was slightly warm to touch, but there was no obvious infection or swelling. Palpation of the right wrist revealed mild diffuse tenderness, with no obvious effusion or point tenderness ( Fig. 1.1 ). There was mild crepitus, but I did not appreciate any popping. Range of motion was decreased with pain exacerbated with flexion and extension of the wrist. The tuck sign for extensor tenosynovitis was negative bilaterally ( Fig. 1.2 ). The left wrist examination was normal, as was examination of his other major joints, other than some mild osteoarthritis in the right hand. A careful neurologic examination of the upper extremities revealed no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

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