Warren Billiter: A 46-Year-Old Male With Severe Wrist Pain Associated With Ulnar Deviation of the Wrist

Warren Billiter

Warren Billiter is a 46-year-old electrician with the chief complaint of “I have a catch in my left wrist, and it hurts like hell.” Warren stated that he just completed a huge remodel, and because they got behind, he had been putting in 14-hour days, 7 days a week for the last month. “I think that this is what caused my wrist problem. Doc, this job was brutal, but the money was good and the guy I work for was really up against it. You know how it is, one of these jobs where nothing goes right from the start.”

I asked Warren about any antecedent wrist trauma, and he said he had broke his arm falling out of the hay loft when he was a kid, but now it was just the usual aches and pains that go along with working with your hands. “Being an electrician ain’t no spectator sport.” I asked what made the pain better, and he said that a couple of Aleves washed down with a couple of Miller’s seemed to help. I asked Warren what made it worse, and he said the heating pad and anything that required him using his thumb to pinch. “You know, like picking up a bolt and washer. What really kills me is picking up my new grandson. He’s a real chunk. When I grab him under the arms to get him out of his crib, I almost want to whimper it hurts so bad. Twisting a screwdriver is just brutal, especially when I am tightening down something.” I asked how he was sleeping, and he said, “Not worth a crap! I can’t lay on my left side, and that’s the side I like to sleep on.” He denied fever and chills. I asked Warren to point with one finger to show me where it hurt the most. He pointed to the radial side of his left wrist. “Any other symptoms other than the pain?” I asked. “You know, Doc, I feel like the inside of my wrist is always hot and swollen. By the end of the day, it actually creaks when I move it. I’m not kidding, I can actually feel it creak, and sometimes it catches. What the hell, Doc?”

On physical examination, Warren was afebrile. His respirations were 16 and his pulse was 72 and regular. He was normotensive with a blood pressure of 120/70. Warren’s head, eyes, ears, nose, throat (HEENT) exam was normal except for a big scar through his upper lip. “What happened here?” I asked as I pointed to his lip. “They tell you not to walk behind a horse for a reason, Doc.” I laughed and said that I would try to remember that.

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 angle (CVA) tenderness or peripheral edema. Warren’s low back examination was unremarkable. Visual inspection of the left wrist revealed swelling over the radial aspect of the wrist as well as thickening of the tendons ( Fig. 4.1 ). While there was no obvious infection, it was tender to palpation and warm to touch. I performed a Finklestein test on both wrists ( Fig. 4.2 ). The right wrist was negative, with the left being markedly positive. I palpated the wrist while I had Warren actively ulnar deviate his wrist, and crepitus was identified. The right 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