Hand and Wrist Injuries in the Work Place€¦ · Scaphoid Fractures - Exam •Tenderness to...
Transcript of Hand and Wrist Injuries in the Work Place€¦ · Scaphoid Fractures - Exam •Tenderness to...
Hand and Wrist Injuries in the Work Place
Christian Skjong, MDHand & Upper Extremity Surgery
September 2019
Quick Bio
• Grew up in rural Minnesota • Carleton College • University of Chicago
• Medical School & Orthopedic Residency • Brown University
• Hand & Upper Extremity Fellowship
• AMA Certified in the Evaluation of Disability and Impairment • Perform IMEs
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Work Comp Injuries
1. Worse functional outcomes
2. Longer recovery
3. Increased overall expense
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Work Comp Injuries
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National Safety Council
Goal
•To better understand and recognize 4 common hand and wrist injuries, their rehab and return to work expectations in the setting of Work Comp
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The “Much Dorkier” Big 4
•Distal Phalanx Fractures
•Scaphoid Fractures
•Distal Radius Fractures
•Carpal Tunnel Syndrome
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Phalanx Fractures
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Introducing…
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Distal Phalanx Fracture
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Distal Phalanx Fracture
•Most commonly fractured bone in the hand
•Often the result of a crushing injury
•Presentation• Tender, swollen fingertip • Subungual Hematoma
Distal Phalanx Fracture
•Subungual hematoma suggests nail bed injury that may necessitate repair
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Distal Phalanx Fractures – Treatment
•Majority heal without issue• Painless, fibrous nonunion
•Splinting for 3-4 weeks allowing IP joint motion• Tip protector
•Widely displaced fractures may require surgery• Percutaneous pinning
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Scaphoid Fractures
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Scaphoid Fractures - Exam
•Tenderness to palpation in anatomic snuffbox is indicator of possible scaphoid injury•XR (including scaphoid view) may be negative if acute injury
• Occult scaphoid fracture
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• If any concern, treat as if fracture
• Repeat XR in 2-3 weeks to look for signs of fracture healing
• Advanced Imaging - MRI
Scaphoid Fractures
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Distal Waist Proximal
Scaphoid Fractures
•Most common carpal bone fracture•Tenuous blood supply necessitates early diagnosis and appropriate treatment
• Risk of nonunion increases with • More proximal fractures• Displaced fractures• Delayed diagnosis
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SNAC Wrist
Scaphoid Nonunion Advanced Collapse
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Scaphoid Fracture – Treatment
•Nonoperative • Thumb spica cast – 3 months (!!)
• Stable, nondisplaced fractures• Concern for occult fracture
•Operative• Screw fixation +/- bone graft
• Displaced fractures• Nonunions
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Distal Radius Fractures
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Distal Radius Fractures
•One of most common orthopaedic injuries
•Bimodal distribution• Younger patients – high energy• Older patients – low energy falls
• High incidence in women over 50 years old• Decreasing bone density• Can be predictor of future fracture risk• Consider DEXA
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Distal Radius Fractures – Patterns
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Distal Radius Fracture – Treatment
Nonoperative
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4-6 weeks duration
Distal Radius Fracture – Treatment
Operative
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Distal Radius Fracture – ORIF
•Volar plate and screw construct the most common method of fixation for most fractures
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Carpal Tunnel Syndrome
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MjolnirStormbreaker “Great Odin’s raven! I’m developing carpal tunnel syndrome!”
Carpal Tunnel Syndrome
• Tricky in Work Comp setting!
• Correlation does not always equal Causation
• BUT…
• Illinois = work only has to contribute to “injury”
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Presenting Symptoms
• Numbness, tingling in median nerve distribution─ Increased at night or with work─ Relief with dependency, shaking hand
• Swelling of hand• Weakness, clumsiness, dropping objects
What is the carpal tunnel?
What is carpal tunnel syndrome?
• Pinching of median nerve
─ Numbness/tingling
─ Weakness/muscle atrophy
Carpal Tunnel Syndrome (CTS)
• Most common compressive neuropathy of the upper extremity
• Etiology─ Most cases are idiopathic (no specific cause) ─ Incidence increases with age
─ Other causes: ganglion cysts, arthritis, pregnancy
Diagnostic Nerve Testing
• EMG and NCV• Tests how well nerves are working
CTS - Treatment
• Nonsurgical─ Initial treatment for most idiopathic
cases• Night Splint• Corticosteroid injection
CTS - Treatment
• Surgical carpal tunnel release
─ Indications• Failure of nonoperative treatment
• Chronic cases with significant denervation or muscle atrophy
• i.e. already late stage
Return to Work Plan
• Ultimately treat patients the same whether work comp or not
• Set realistic expectations• Rehab/Therapy • RTW – Light Duty • RTW – Full Duty• MMI
Rehab/Therapy Expectations
• Phalanx Fractures• Start immediately vs at 4 weeks
• Depends on fracture
• Scaphoid Fracture• Start at 2-3 months
• Distal Radius Fracture • Start at 4-6 weeks – nonop• Start at 1 week - operative
Average Total Duration: 1-2x/week for 4-6 weeks
Rehab/Therapy Expectations
• Carpal Tunnel Syndrome • Normally no therapy required
• AAOS Guidelines = No benefit over patient directed
• Major limitations:• Healing of incision• Persistent palm pain
Return to Work Expectations
KEY:Every patient is different.
Return to Work Expectations
Light Duty Full Duty MMIPhalanx Desk w/in 2 wks 2 mo 4-6 mo
Manual Labor 1-2 mo 3 mo
Scaphoid Desk w/in 2 wks 3-4 mo 4-6 moManual Labor 3-4 mo 4-6mo
Distal Radius Desk w/in 2 wks 2-3 mo 4-6 moManual Labor 2-3 mo 3-4 mo
Desk: typingManual Labor: lifting, pushing, pulling
Return to Work – Full Duty
In setting of fractures =
Requires• Solidly healed bone • Full (or max attainable)
• Range of motion • Strength
Tricky!!
Return to Work Expectations
Light Duty Full Duty MMIPhalanx Desk w/in 2 wks 2 mo 4-6 mo
Manual Labor 1-2 mo 3 mo
Scaphoid Desk w/in 2 wks 3-4 mo 4-6 moManual Labor 3-4 mo 4-6mo
Distal Radius Desk w/in 2 wks 2-3 mo 4-6 moManual Labor 2-3 mo 3-4 mo
Desk: typingManual Labor: lifting, pushing, pulling
Return to Work Expectations
Light Duty Full Duty MMICarpal Tunnel Syndrome
Desk w/in 2 wks 2-4 wks 2-3 mo
Manual Labor 4-6 wks 3 mo 4-6 mo
Desk: typingManual Labor: lifting, pushing, pulling
Take Home Points50
Take Home Points
•Fractures of the hand/wrist • Require careful consideration of nonoperative vs operative treatments
•Return to work (esp. Full Duty) can be prolonged with fractures• Particularly with scaphoid fxs
•Carpal tunnel syndrome • Difficult to determine causation
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Take Home Points
•Ultimately try and set realistic expectations and treat work comp patients similarly to non-work comp
• Can be difficult at times
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Thank You!53