Occupational disorders of the hand

Introduction

Work-related injuries to the upper extremity are one of the primary causes of occupational disability and absenteeism. Occupational injuries related to the upper extremity are considered a distinct entity as some pathologies are closely identified with a specific work activity (e.g. high-pressure injection injuries or vibration-induced conditions) or may have a higher incidence rate in certain working populations. Additionally, the surgeon is often called upon to judge whether the upper extremity problem is related to the work activity or to determine causation. To do this, the surgeon must gather all the available evidence from the history of injury, the time course of events, the physical examination, information from diagnostic tests, as well as knowledge of the upper extremity problem.

Work-related disorders of the hand and wrist are also associated with long absences from work and may require considerations that are not needed in illnesses unrelated to work. Specifically, documentation and justification of attribution to the workplace, guiding the return to modified or full duty work are examples of issues in management that are more profound in the work-related injuries. Finally, the outcomes of treatment in occupational injuries are qualitatively and quantitatively different than similar injuries not related to the workplace. Return to work is an outcome of interest given its association with the patient’s physical condition, pain, psychosocial factors, financial status, and workspace ergonomics. The surgeon will be involved in accounting for these factors while determining the return to work, completing active medical care or rehabilitation, and when assigning a permanent impairment rating.

Patient history and examination

A thorough history and physical examination of the injury is required. Open-ended questions, active listening, and fact checking are all important. Classic techniques such as repetition to confirm important physical findings, distraction, and use of a toolbox of physical examination skills specific to the situation must be developed and practiced. Adequate time must be devoted to obtaining accurate impressions or to clarify the nature of a crushing injury. It is also important to consider the sequence of events, the behavior of the patient, co-workers, and medical providers at the time of the injury. For example, a severe injury will usually demand immediate response and care. When a patient is able to complete vigorous work for the remainder of the day and reports 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 first examining physician provides contemporaneous information on the severity of injury. Swelling, bruising, or radiographic evidence should help describe the nature of the original injury. A lack of physical findings at the time of the injury may be equally important for lingering symptomatic problems. The initial behavior of the patient and documentation of the injury before the initiation of a workers’ compensation system of care and the influence of society will be informative for future management.

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.

Knowledge of the disease process and its causation

The concept of causation has evolved as our understanding of illnesses change. The concepts of Hill have stood the test of time as guidelines to evaluate associations as possibly causative. However, it is clear there is no single or combination of characteristics of an association that can prove causation. It is therefore difficult to suggest associations are causative from observational data alone. 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

Several soft-tissue disorders of the upper extremities, such as tendinitis, carpal tunnel syndrome (CTS), and hand–arm vibration syndrome, are related to occupational factors. Force, repetition, and vibration have been established as risk factors of these disorders. While it is reasonably plausible that repetitive forceful activity can lead to upper extremity disorders, it seems most appropriate to consider these as attributes leading to potential causation rather than a diagnosis. In some upper extremity pathologies (e.g. CTS) with a clear diagnosis, however, a new diagnostic category is not required and should be managed according to the standards available for the problem. 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, 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 often challenging to randomize the exposure to work activities. As such, it is important to understand this limitation and to minimize the negative impacts of this uncertainty.

What is the purpose of determining whether 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 pathology located in the upper extremity, how that is experienced by the patient, and external factors that can influence management and recovery.

• 2.

  It is important to the patient. In a work-related disorder, the financial benefits of a workers’ compensation system may be the patient’s only source of financial security.

• 3.

  An accurate and definitive decision about work attribution may be the best way to avoid the negative effects that can accompany workers’ compensation programs. A rapid and accurate decision either affirmative or negative will reduce the potential for conflict and will be in the patient’s 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

Occupational injuries can be broadly divided into acute traumatic injuries and those without a single identifiable traumatic cause. Millender et al . has divided chronic workplace injuries into four categories that provide a useful framework for discussion ( Table 20.1 ). In category 1, most patients are highly motivated and when treatment is provided, the upper extremity problem resolves. The patient can resume work and there are no lingering effects. Happily, in our experience, this includes most injured workers. In category 2, some difficulties may arise as permanent impairment is possible. When the patient is left with permanent impairment the easiest resolution is for the recovered worker 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, new work with a new employer, or retirement are options to consider. This decision can be difficult and requires coordination with a case manager or rehabilitation counselor. There are some patients 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 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 3, 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 examination will be identified as falling outside the expected norms of the medical condition. Embellishment of symptoms 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 findings. Unfortunately, this group of patients is difficult for the surgeon to manage. An honest approach may result in anger, but management that deals with the upper extremity problem as an isolated independent part of the patient will not succeed.

In category 4, 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 internal and external forces that promote and limit recovery. Workers’ compensation systems can create perverse incentives that the surgeon must be perceptive about and must guard against. The surgeon may have perceived or real pressures to do things that are ethically uncomfortable. For example, the surgeon may be pressured to return the injured worker back to the workplace early after surgery on limited work. 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 unnecessary or demeaning tasks or simply sit in a room or lie on a stretcher. 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 to the potential harm caused by early return to work is a belief that the early return is important in the recovery of the injured worker. Although the literature is sparse in this area, there is a belief that returning an injured worker to a routine will be beneficial and minimize illness behavior. If pushed back to work too early, however, the patient may feel trapped in a closed system, become suspicious of the compensation system, and lose a sense of control of their healthcare. Attempts to recover this control can be destructive and misunderstood.

An awareness of these forces will help the surgeon provide the best care for the patient and prevent a fatalistic approach by both. A clear focus should be on providing the best possible care for the upper extremity problem with perception of and attention applied to the other concerns of the patient.