Author: Elizabeth Portin, DO
Co Author #1: Daren Molina, MD
Co Author #2: Andrea Ramirez, MD, M.Ed
Co Author #3: Matthew Ditzler, MD
Senior Editor: Margaret Gibson, MD, FAMSSM
Editor: Rachel Coel, MD, PhD

Patient Presentation:
A 7-year-old male pee-wee football player presented to the sports medicine clinic with gradually worsening right wrist, hand, and foot discomfort.

History:
There was no known injury or event preceding symptoms. The patient’s right wrist started to look “off” approximately 10 months prior to his clinic visit. About 2 months prior to his clinic visit, the patient noticed the right wrist swelling and pain, right hand pain and weakness, and right foot pain. He was noted to have recent intermittent limping. There was no fever, recent illness, or nocturnal bone pain. He had a history of eczema and recently diagnosed psoriasis.
Family history was notable for Type 1 Diabetes in the patient’s mother. His mother, maternal uncle, and maternal grandmother had irritable bowel syndrome. Paternal grandmother had psoriasis.
The patient had no surgical history.
The patient’s medications included ibuprofen as needed.
The patient had no allergies.

Physical Exam:
Physical examination revealed moderate swelling over the dorsal aspect of the right hand and ulnar aspect of the right wrist. There was mild to moderate thenar muscle wasting Case Photo #1 and pitting of his bilateral fingernails and toenails. Case Photo #2
Upper extremity evaluation found tenderness to palpation over the right distal radius, distal forearm, and base of the right thumb. Range of motion of the right wrist was reduced in active pronation and supination. Strength of the right wrist was 4/5 with flexion, extension, pronation, supination, and grip.
Lower extremity evaluation demonstrated no tenderness to palpation. Range of motion testing noted pain with motion of right tarsal-metatarsal joints. Strength was 5/5 in the bilateral feet and ankles.

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