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

2

Work Comp Injuries

1. Worse functional outcomes

2. Longer recovery

3. Increased overall expense

3

Work Comp Injuries

4

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

5

6

The “Much Dorkier” Big 4

•Distal Phalanx Fractures

•Scaphoid Fractures

•Distal Radius Fractures

•Carpal Tunnel Syndrome

7

Phalanx Fractures

9

Introducing…

10

Distal Phalanx Fracture

11

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

13

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

14

Scaphoid Fractures

16

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

17

• 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

18

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

19

SNAC Wrist

Scaphoid Nonunion Advanced Collapse

20

Scaphoid Fracture – Treatment

•Nonoperative • Thumb spica cast – 3 months (!!)

• Stable, nondisplaced fractures• Concern for occult fracture

•Operative• Screw fixation +/- bone graft

• Displaced fractures• Nonunions

21

Distal Radius Fractures

23

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

24

Distal Radius Fractures – Patterns

25

Distal Radius Fracture – Treatment

Nonoperative

26

4-6 weeks duration

Distal Radius Fracture – Treatment

Operative

27

Distal Radius Fracture – ORIF

•Volar plate and screw construct the most common method of fixation for most fractures

28

Carpal Tunnel Syndrome

30

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”

32

33

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

51

Take Home Points

•Ultimately try and set realistic expectations and treat work comp patients similarly to non-work comp

• Can be difficult at times

52

Thank You!53