Subacute Wrist Pain In A Hypercoagulable Crossfitter - Page #1

Author: Jennifer Albrecht, DO
Co Author #1: Lara Quinlan, M.D.
Editor: Marc Hilgers, MD, PhD, FAMSSM

Patient Presentation:
A 40 year-old female physician with a history of homozygous Factor V Leiden presented with ten months of right wrist pain.

Patient first noted pain while performing handstand front flips on a Dancing with the Stars routine. Pain worsened with CrossFit exercises involving wrist hyperextension and loading, especially handstand pushups. The pain was intermittent, worse dorsally with wrist flexion, extension, ulnar and radial deviation despite exercise modification. Ibuprofen and Tylenol helped minimally. She underwent evaluation with plain radiographs in November 2012 that demonstrated ulnar deviation and shortening (Figures 1-2) but then discovered that she was pregnant and postponed additional testing. Due to her known hypercoagulable state with a family history of venous thromboembolism, the patient was anticoagulated with Lovenox intra- and post-partum and presented to our clinic still on prophylactic Lovenox. She was experiencing occasional right wrist swelling and reported limited range of motion in all planes.

Physical Exam:
Active-appearing female whose sensation and pulses were intact. Mild fullness to right wrist dorsally was appreciated without gross swelling, erythema, ecchymosis or muscle wasting. She had mild dorsal radiocarpal tenderness to palpation without tenderness over the first dorsal compartment, anatomic snuffbox, scaphoid or distal radioulnar joint. Strength was 4/5 with resisted supination and grip strength, but her strength was otherwise intact. The patient experienced pain with all resisted motions, mostly dorsal. She exhibited limited range of motion in all planes, especially flexion and extension. Phalen's, Finklestein's, Tinel's at the carpal tunnel and Guyon's canal were negative. TFCC grind was uncomfortable. Ulna was slightly hypermobile but distal radioulnar joint was nonpainful. Elbow exam was within normal limits.

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