Victor Flores: A 36-Year-Old Male With Pain and Paresthesias Radiating Into the Base of the Thumb

Victor Flores

“I didn’t see this one coming, Doc,” said Victor. “We all have to speak up, but I didn’t think that speaking up would cost me my job.” Victor Flores is a 36-year-old dental lab technician with the chief complaint of “I am getting electric shocks from my wrist that shoot into the base of my thumb ever since I got handcuffed at the protest for social justice last month.” Victor stated that the police sat him on the curb with the handcuffs on for about 10 hours. He said that he repeatedly complained that the handcuffs were too tight, but his complaints were ignored. He said that after a while, his right hand went numb and then just ached. Eventually, the police took off the handcuffs and told him to get out of there. “I was so glad to get those handcuffs off. It wasn’t until the next day when I realized that my thumb was still numb. And I keep getting the electric shocklike jolts into the base of my thumb. It is really annoying.” I asked Victor if he had experienced any other numbness or weakness, and he replied, “Doc, it’s funny that you asked as I have started noticing that the back of my hand feels kind of like it’s made of wood—kind of numb, with a dead feeling. It doesn’t sound like a big deal, but it makes it impossible to do my work. I use my hands all day long making dentures and dental crowns. The numbness and electric shocks made it impossible for me to hold my tools, and eventually my supervisor told me that he was going to have to let me go as he was getting too many complaints about my work from our customers.”

I asked Victor what he had tried to make his symptoms better, and he said that nothing he had tried had given him much relief. “My sleep is all jacked up because the electric shocks jolt me awake when I roll over.” I asked Victor to describe any numbness associated with his pain, and he pointed to the radial aspect of the dorsum of his right hand, and he then rubbed the back of his thumb, index, and middle fingers. “Doc, a couple of things, or maybe I am just imagining them, but only half of my ring finger is numb, and the numbness doesn’t go all the way down to the tips of the fingers. Do you think I am imagining this? It just doesn’t make any sense.” I asked Victor about any fever, chills, or other constitutional symptoms such as weight loss, night sweats, etc., and he shook his head no. He denied any antecedent wrist trauma or anything else that might account for his symptoms.

I asked Victor to point with one finger to show me where it hurt the most. He pointed to the base of his right thumb. He went on to say that he could live with the numbness, but the electric shocks were really bothering.

On physical examination, Victor was afebrile. His respirations were 16, his pulse was 72 and regular, and his blood pressure was 120/70. Victor’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was his cardiopulmonary exam. 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. Visual inspection of the right wrist was unremarkable. There was no rubor or color. There was no obvious infection or olecranon bursitis. There was a positive Tinel sign over the superficial radial nerve at the wrist ( Fig. 6.1 ). I performed the wristwatch test, which was markedly positive on the right and equivocal on the left ( Fig. 6.2 ). A careful neurologic examination of the upper extremities revealed decreased sensation in the distribution of the right superficial radial nerve ( Fig. 6.3 ). “Victor, I think those handcuffs damaged a nerve in your wrist, and that is what is causing your symptoms.”

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