Occupational hand disorders

18 Occupational hand disorders



Steven J. McCabe




Synopsis




image Upper extremity problems that are attributed to the workplace require experience, a knowledge base, and skill set that set them aside from non occupational injuries.


image To evaluate causation requires a careful history and physical examination as well as knowledge of the disease process and literature.


image The Workers’ Compensation environment creates external forces on the provider and patient that can adversely affect patient management and recovery.


image Management of work related upper extremity disorders should include nonsurgical care when it is known to be efficacious.


image Return to meaningful employment and high quality of life are the desired outcomes.



Introduction


There are several reasons why upper extremity problems relating to work activities are considered as a distinct entity. Some upper extremity problems are closely identified with work activity and hence could correctly be called occupational injuries. High pressure injection injuries and vibration induced problems are closely identified with a certain occupational activity. In addition to these problems that are closely identified with specific work, there are upper extremity problems that seem to occur in greater than expected numbers, i.e., their incidence rate may be higher, in certain working populations. Although tendon entrapments are often seen in the nonworking population their occurrence is often attributed to work activity. The surgeon is often called upon to determine causation or if the upper extremity problem is related to the work activity. Second, illness related to the work place requires considerations for management not needed in problems unrelated to work. Documentation and justification of attribution to the workplace, guiding the return to some form of modified work and full duty work are examples of issues in management that are more profound in the work related injury. Finally, the outcomes of treatment in upper extremity problems related to the workplace are qualitatively and quantitatively different than similar problems not related to the workplace. Return to previous work is an outcome of interest unto itself. The surgeon will be involved in determining the return to regular or modified work activities, the completion of active medical care, and the assignment of a permanent impairment rating.



Hints and tips




• Some upper extremity problems are closely associated with work activity.


• Work related upper extremity disorders require management considerations that are different than nonwork related problems.


• Return to full activity at work is one important outcome goal.



Causation


Physicians and surgeons are often called on to judge whether a specific work activity could cause the upper extremity problem of a patient. To do this, the surgeon must bring to bear all the evidence that is available from the history of injury, the time course of events since the injury, the physical examination, information from diagnostic tests, as well as knowledge of the upper extremity problem diagnosed in the patient.



Patient history



Initial events


The history must be detailed and thorough. It is important to consider the sequence of events, the history of injury, the behavior of the patient, co-workers, and medical providers at the time of the injury. Often a careful history will reveal features of the injury that were previously unclear such as the nature of a crushing injury or the lack thereof. A severe injury will usually demand an immediate response and care. When a patient was able to complete vigorous work for the remainder of the day following an injury and reported the injury some days later, many severe injuries can be excluded. Similarly a review of the original medical records is often informative. The description of the emergency room doctor or first examining physician provides contemporaneous information on the severity of injury. Severe swelling, bruising, or radiographic evidence of soft tissue swelling or fracture at the time of the injury will all document the nature of the original injury. Similarly a lack of physical findings at the time of the injury may be important for lingering symptomatic problems. The initial behavior of the patient and documentation of the injury before the initiation of the Workers’ Compensation system of care and the influence of society will be informative for future management. For an observed traumatic event, immediate contemporaneous actions and information are the result of the injury whereas later behavior is a result of the injury, and the influence of a number of other societal factors that have to be considered.



The course of illness


Through education and experience, surgeons understand the expected course of an illness and can detect when there is variation from this. When the course of illness varies to some large degree it is sometimes possible to determine that the symptoms and physical findings of a current evaluation could not be consistent with an injury that is described in the history and verified by review of initial medical records. In other words, knowledge of the natural course of an injury can be used to make strong statements about the lack of causation.



Physical examination


A detailed perceptive history and physical examination are required for careful evaluation of a work related injury. The surgeon must use all of her senses to gather information. Open ended questions, active listening, and fact checking are all important. Classic techniques such as repetition to check important physical findings, distraction, and use of a tool box of physical examination skills specific to the situation must be developed and practiced. Adequate time must be devoted to obtain accurate impressions and information.



Knowledge of the disease process and its causation


The concept of causation has evolved as our understanding of illness has changed. The concepts of Hill have stood the test of time as guidelines to evaluate associations as possibly causative however it is clear there are no single or combination of characteristics of an association that can prove causation. The concept of causation requires in depth knowledge of the content of the research to measure associations as well as their context and characteristics. It is difficult to suggest associations are causative from observational data alone. Therefore for many illnesses of the upper extremity related to the workplace there will always be some uncertainty as to the accuracy of their attribution. This problem is magnified when considering an individual patient.



The role of force and repetition


In 1991, Gerr and associates reported that: “Sufficient evidence is available at this time to conclude that several well-defined soft-tissue disorders of the upper extremities are etiologically related to occupational factors. These disorders include tendinitis of the hand and wrist, CTS, and hand-arm vibration syndrome. Force, repetition, and vibration have been established as risk factors in the etiology of these disorders.”1 These conditions are discussed further below.


Szabo has well advised against the use of “cumulative trauma disorder” or “repetitive strain injury” as diagnostic labels, suggesting the term “work-related musculoskeletal disorders” to describe an amorphous category of upper extremity problems, often characterized by pain, with no clear diagnosis or anatomic basis for symptoms, and clinical course that is not easy to understand given the traditional concepts of illness and injury.2 It is plausible that highly repetitive activity of high enough force can lead to symptoms and disorders of the upper extremity but it seems most appropriate to consider these as attributes leading to potential causation rather than a diagnosis of an illness. Upper extremity pathology with a clear clinical diagnosis such as carpal tunnel syndrome or de Quervain’s tendonitis should be managed according to the standards available for the problem. A new diagnostic category is not required and confuses the management of the patient. Upper extremity problems without a clear diagnosis should be dealt with as such. A pseudo-diagnostic label will not help the patient recover from an illness.


Although the concept of causation is philosophical, practically, the best evidence that can be gathered would be the results of a randomized experiment where the causative agent is randomly distributed to two otherwise equivalent groups. Unfortunately, it is typically not possible to randomize the exposure to work activities. Failing this, it is important to understand this uncertainty and try to understand the consequences and minimize the negative impacts of this uncertainty.


What is the purpose of this attention being delivered to determine if the upper extremity problems are related to work and why is it the surgeon’s responsibility to arbitrate this decision?



1. To provide the best management, the surgeon should have an accurate evaluation of the patient’s illness, which includes the pathology located in the upper extremity, how that is experienced by the patient, and the external factors that can influence the management and recovery.


2. It is important to the patient. In a work-related disorder the financial benefits of the Workers’ Compensation system may be the only source of financial security for the patient.


3. An accurate and definitive decision about work attribution may be the best way to avoid the negative effects that accompany the Workers’ Compensation system of insurance coverage. A rapid and accurate decision either affirmative or negative will reduce the potential for conflict and will be in the patients’ best interest.


4. The surgeon is in the best position to gather and weigh all the evidence that is available.


5. It is important to be truthful.



Clinical care in illness related to the workplace


Injuries at the workplace can be broadly divided into acute traumatic injuries and those without a single identifiable traumatic incident.


When a worker suffers a verifiable traumatic injury at the workplace that is directly observed and an injury is present under any reproducible and acceptable method of its presence, the attribution to work is not an issue. Efforts are provided at the best management and rehabilitation of the injured worker.


Millender et al. has divided the more chronic occupational injuries of the musculoskeletal system into four categories that provide a useful framework for discussion (Table 18.1).3


Table 18.1 Chronic occupational injuries of the musculoskeletal system















Category 1 Diagnosis is easily established, good methods are available for treating the condition, and the prognosis for returning to work is good.
Category 2 Diagnosis is established, but neither nonsurgical nor surgical treatment is always successful in returning the patient to the original job.
Category 3 The condition combines definite physical problems and additional nonmedical issues.
Category 4 Diagnosis is unclear

Reproduced from: Millender LH, Louis DS, Simmons BP, eds. Occupational Disorders of the Upper Extremity. New York: Churchill Livingstone; 1992.


In category one, most patients are highly motivated and when the appropriate treatment is provided for the patient, the upper extremity problem resolves. The patient can resume work and there are no lingering effects.


In category two, some difficulties may arise as permanent impairment is possible. When the patient is left with permanent impairment the easiest resolution is for the injured worker, upon recovery, to return to the same regular duty work that pre-dated the injury. If this is not possible, then a modified job with the same employer may be possible. Failing this, the worker may have to consider new work with a new employer, or retirement. This can be a difficult decision that requires coordination with a case manager or rehabilitation counselor. There are some patients with conditions usually well treated either nonsurgically or surgically by the hand surgeon, who do not seem to have the capacity to recover to the extent that would let them return to their original job. This group of people may be difficult to identify before treatment begins but eventually they can be identified by a recovery that falls below the threshold that allows them to return to their pre-injury job. This group of patients is difficult for the hand surgeon to manage, and care should be taken to avoid a repetitious exposure to invasive treatments and repeated surgeries that never quite reach the expected result.


In category three, the patients may have pain that is out of proportion to their physical injury. They can be angry and frustrated at the lack of improvement, despite adequate medical care. Patients may have definite upper extremity pathology but this is difficult to improve to a degree that will be satisfactory to the patient. Surgeons will immediately recognize this group of patients, as features of the history and physical examination will be identified as falling outside the expected norms for the conditions being cared for. This embellishment of symptoms and physical findings may represent frustration on the part of the patient, an attempt to make the surgeon realize the depth of their problem, or conscious magnification of symptoms and findings. Unfortunately, this is a group of patients that is difficult for the surgeon to manage. An honest approach will result in anger on the part of the patient, but management that deals with the upper extremity problem as an isolated independent part of the patient will not succeed.


In category four, the diagnosis of the upper extremity problem is unclear. Many of these patients will have vague diagnoses and may have had surgical procedures. They may have previous experience with other Workers’ Compensation injuries and may have seen other hand surgeons. For example the patient may present with a problem whose existence is controversial, its pathology unproven, its treatment ill-defined, and its outcome uncertain. The patient may be in conflict with their employer and may be terminated from employment. When the worker has this type of an upper extremity disorder, there may be conflict at every aspect of the patient’s interaction with the surgeon and healthcare system. The role of the hand surgeon is to take a careful history, perform a physical examination, recommend the appropriate diagnostic tests and provide honest recommendations for further management. Going for a surgical “Hail Mary” will be a disappointing misadventure.


At each step of care, the surgeon must be aware of the play of internal and external forces that promote and limit recovery. The structure of the Workers’ Compensation system can create perverse incentives the surgeon must be perceptive about and must guard against. The surgeon may have perceived or real pressures to do things that are uncomfortable from an ethical standpoint. For example the surgeon may be pressured to return the injured worker back to the workplace early after surgery on limited work such as “one hand duty.” Workers with pain in one extremity from a workplace injury or recent surgery may be required to go to the workplace and answer the phone or even perform useless or demeaning tasks or simply sit in a room or lie on a stretcher. This so-called presenteeism is a warping of societal norms that has occurred to circumvent the negative impact of workers compensation protections. The physician wants to do the best for the patient but feels those decisions are beyond the scope of their influence. The presence of “one hand work” creates the aura of reasonableness creating a plausible justification for the surgeon to agree to this. An alternative perspective is that the early return to the workplace is important in the recovery of the injured worker.


The patient may feel trapped in a closed system. The patient can be suspicious of the compensation system and lose the sense of control of their healthcare. Attempts to recover this control can be self-destructive and misunderstood.

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Feb 21, 2016 | Posted by in General Surgery | Comments Off on Occupational hand disorders

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