Stefon Dawson: A 26-Year-Old Male With Severe Dorsal Wrist Pain Associated With Flexion and Extension of the Wrist

Stefon Dawson

Stefon Dawson is a 26-year-old cashier at the local grocery with the chief complaint of “every time I bend my wrist, it really hurts.” Stefon went on to say that the grocery store had been really short-staffed so he had been working a lot of overtime, and it was taking its toll. “I bet I pick up 10,000 groceries a day! And when Coke or Pepsi is on sale, I know its going to be really rough. I tell the customers to leave the soda pop in their cart, but they put it on the belt anyway. It’s awkward and heavy to lift. I think this and the watermelons have really done in my wrist.”

I asked Stefon about any antecedent wrist trauma, and he said no, he had twisted his ankle skateboarding when he was a kid, but had no previous broken bones. I asked Stefon what made the pain better, and he said that he felt like Motrin was helping, but it ate a hole in his stomach, so now he is using an ice pack on his wrist when he gets home at night. I asked Stefon what made it worse, and he said the heating pad and anything that required him to bend his wrist up or down. “How about side to side?” I inquired. “Not so much,” said Stefon. “It’s when I bend it up or down. You know—flex and unflex it—that it hurts. When I’m trying to get the scanner to read a code on a carton of ice cream with ice crystals, there is a lot of up and down.” I asked, “What about picking things up between your thumb and index finger?” Stefan reported, “Not so much.” I asked how he was sleeping, and he said, “Not very good. Whenever I bend my wrist, I get a sharp pain that wakes me up.” I asked, “Does the pain go down into your fingers?” He responded, “Not really, it’s pretty much on the top of my wrist over toward the right.” Stefon denied fever and chills. I asked Stefon to point with one finger to show me where it hurt the most. He pointed to the radial side of the dorsum of his right wrist. “Any other symptoms other than the pain?” I asked. “You know, Doc. I feel like the top of my wrist is always hot and swollen, and by the end of the day it actually creaks when I move it up and down. This is really painful. Do you think I broke something lifting all those big watermelons?”

On physical examination, Stefon was afebrile. His respirations were 16, and his pulse was 72 and regular. He was normotensive with a blood pressure of 120/70. Stefon’s head, eyes, ears, nose, throat (HEENT) exam was completely normal. His cardiopulmonary examination was completely normal. His thyroid was normal as was his abdominal examination, which revealed no abnormal mass or organomegaly. There was no costovertebral (CVA) tenderness or peripheral edema. Stefon’s low back examination was unremarkable. Visual inspection of the right wrist revealed swelling over the radial aspect of the dorsum of the wrist. While there was no obvious infection, it was tender to palpation and warm to touch. Stefon had a positive creaking tendon test on the right ( Fig. 5.1 ). The left wrist creaking tendon was negative. I palpated the wrist while I had Stefon actively ulnar flex and extend his wrist against resistance, which recreated his pain. Crepitus was identified. There was only minimal pain with ulnar deviation of the right wrist. The left wrist examination was normal, as was examination of his other major joints. 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