Author: Thomas Ricks IV, MD
Co Author #1: Alec DeCastro, MD
Senior Editor: Marc Hilgers, MD, PhD, FAMSSM
Editor: Colby Genrich, MD

Patient Presentation:
Right finger pain and coolness of the right third digit

History:
22-year-old right-handed male pitcher with a history of right-sided UCL repair who presents with one week of right-hand pain exacerbated by throwing. The patient reports that he initially felt that the tip of his third digit was cold and "wouldn't sweat;" he also noticed that the tip of his third digit would turn blue after pitching Case Photo #1 , but this would typically resolve after a few hours. He developed pain a few days later in his first webspace that he described as a "popped blood vessel." Initially, this pain was only with high pitch counts but gradually progressed over the week to include pain even at rest. Pain migrated from first the web space to include the first three digits at rest with worsened pain in the posterior aspect of his hand with pitching. The coolness in his third digit never progressed beyond this digit. He began to take notice of this pain when he noticed he wasn't getting as high of a spin rate with his four-seam fastball and every time he attempted his changeup, he had significant exacerbation of pain in the back of his hand. He reports that beyond the pain, he felt that his grip was greatly impacted by the "coolness" in his third digit but otherwise denied any blatant paresthesia or loss of sensation.

Physical Exam:
Right Shoulder: No gross deformity or atrophy. Nontender throughout the entire shoulder. Full, painless active/passive Range of Motion.
Right hand: No gross deformity or atrophy. Mild tenderness at the thenar eminence. The third digit is noticeably cooler than the rest of the extremity. Sluggish capillary refill after Allen’s Test but otherwise has patency of his palmar arch. Palpable radial, ulnar, and brachial pulses are symmetric to his contralateral side. Radial pulse does diminish with Wright's maneuver but remains palpable. Sensation intact to light touch overlying median, ulnar, and radial nerve distributions. Negative Roos stress test. No subungual petechiae.

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