Return to work barrier series: Management of hand injuries

Management of Hand Injuries

Return to Work Barrier Series

Presented by Dr Desmond Soares and Amanda MacKillop

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Facilitator:

Hello everyone. Thank you for joining us for today's webinar. The topic and expert speakers for the session is brought to you by the Office of Industrial Relations. The Office of Industrial Relations is committed to driving initiatives across the whole scheme that improves safety, wellbeing and return to work outcomes for both employers and workers. My name is Allicia Bailey. I'm the Manager of Engagement Services and I'm going to be the facilitator for today's webinar.

Just so you know the presentation will go for approximately 45 minutes and this is to allow us some time at the end just to have your questions answered by our presenters. A copy of the slides will be emailed through to you following the session and it will be made available on our website in a few weeks' time. So feel free to share this resource with your networks.

I have the pleasure of introducing you all to Dr Soares and Amanda MacKillop. Dr Soares and Amanda will be sharing the presenting for today and they will focus on the top five work related hand conditions treated within the Workers' Compensation Scheme. The aim of today's webinar is to improve your understanding of the clinical issues associated with these types of injuries and it will be really interactive. So please feel free to comment throughout using the chat box and also to participate in a few quizzes throughout.

Slide 4

So enough from me. I'll now hand you over to Dr Soares.

Amanda MacKillop:

Hi everyone. My name's Amanda. I am an Occupational Therapist. I've been working since 2007 and in hand therapy for full time since 2010. I work for Advanced Therapy Solutions. We're a private practice on the south side of Brisbane with five locations and we specialise in hand and knuckle in rehab and return to work facilitation.

Slide 5

Dr Desmond Soares:

Today's topic is looking at common hand injuries and we're going to look at both the medical causes and things like that but also the rehabilitation and to try and help you as return to work coordinators as you try and work through the maze of how do you get your workers back to work safely and quickly. Throughout the presentation we'd welcome questions and if you would type them up then Amanda will pass them onto us. We also have a quiz at the end to just check out what we've taught you.

Slide 6

These are the statistics I was able to get from the Workers' Compensation Scheme. I'm not sure they're exactly accurate because I think that the numbers are greater than this but this would give you a good idea of the range of the common conditions. The most common is crush injuries and Carpal Tunnel Syndrome, extensor tendon injuries, De Quervain's and finally digital nerve injuries and we'll cover all of those.

Slide 7

Amanda MacKillop:

My role in this presentation is to give you the insight into the hand therapy role and then also as an Occupational Therapist the return to work side of it. What's really important and I will say it over and over again is that there is no one size fits all model and everyone is different, even down to the fact that even the same person with the same injury on both limbs, each limb can respond differently. Obviously everyone as an individual responds differently to their rehab. The duration and severity of the injury has huge influences on outcome. So too do individual factors such as genetics. Their coping styles, their pain tolerance and their participation in rehab are just a few considerations. Also really importantly is the workplace culture and how supportive the employer and colleagues are. Then also the availability of duties and whether or not these are in fact suitable.

Slide 8

Dr Desmond Soares:

So let's look at crush injuries. If you look at this slide this talks about the total impairment time, the time lost completely off work and at 140 days I think that's very high. Most of these crush injuries as you will see are simple fingertip injuries and people on average are off for about three or four weeks and then they go to partial impairment. So I think this number has been skewed by a small number of patients with a very long time off.

Slide 9

Typically people crush their hands under pallets or boxes, between trucks and loading docks, any heavy manual task. Carpenters working with saws and saw blades, they detip their fingers. Usually it's a loss of a fingertip or crushed. It's often the middle finger because that's the longest and they injure the nail and the nail bed. Just a warning, I've got some gory pictures, so if you don't like gory pictures please look away. Sometimes they're a major hand injury.

Slide 10

You can see pictures of crushed fingers where the fingertip is sort of separated and the nail's been pulled out. On the bottom you can see if they're not well managed they can heal with quite nasty deformities that leave people with a painful fingertip that is difficult to manage. So it's very important that these are well treated to get a good outcome. Even simple loss of skin can be managed with skin grafts.

Slide 11

Sometimes we'll take skin from the side of the finger or the fingertip and move it forward to try and give the person a nice pulp. You can see on those bottom pictures the left hand one is very early after surgery and the right hand one is after it's healed nicely. That's a lovely, sensible, sensate tip that they can feel properly with and it's soft and easy to work with.

Slide 12

Amanda MacKillop:

Hand therapy starts really early with these guys, so we see them at least one to three days after they've had surgery or if they haven't had surgery, after they sustain the injury. Our role is to look after the wound, monitor their swelling, get them going in terms of movement and I'll use the abbreviation 'ROM' a few times and that simply means Range of Movement exercises for both the affected joint if there's not a fracture and then the non-affected joint of the hand and finger.

Splinting has a huge role in these injuries for protection, pain management and then protecting the wound to make sure it heals well.

Slide 13

Initially and again typically the patient is seen two times a week for the first two to four weeks until we have wound closure and then once weekly until around six weeks. We can still see these patients up until around 12 weeks and that would be for – generally we see them until they have return of strength.

Slide 14

Hand therapy involves scar management, pain management. A lot of these injuries often involve the nerves of the fingers and as we know our fingers are very sensate and we feel a lot with them. So the nerves when injured can become quite tricky and quite painful. So we spend a lot of time with desensitising them, making sure the patient regains their movement and then we use our splints for dual purposes, for protecting and getting the joints moving if they become stiff. Strengthening is also important.

Slide 15

So these are initially the types of splints that you might see for a thumb or a finger crush injury to protect it while it's still healing and then once the joint – so this may be six weeks down the track if they've got ongoing impairment of the finger. So if they have contractions or cannot move the finger fully we get a bit nasty.

Slide 16

For return to work typically – so not one size fits all but this is what we see standardly – once the wound closes. Once the wound is closed they're generally okay to go back to work on suitable duties and this is usually around two to four weeks generally. Initially they'll be avoiding lifting loads you know, in excess of one kilo with the affected hand until the doctor advises otherwise and that's to protect the tissue that's damaged. If there's a fracture it might be a little lighter and for pain management they'll need rest breaks throughout the day.

If it's a crush injury to a finger and they're a little bit down the track, say four weeks and there's no fracture it's actually good to get them to do light, repetitive exercises and that really encourages that return of normal movement and helps with maintaining tissue length of the finger and hand. Usually these guys are right for normal duties and hours within three months.

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What you really have to consider when you're looking at doing up your suitable duties programs is those aggravating factors for finger or thumb crush injuries and that's going to be obviously gripping and lifting anything heavy, but pinching is often a problem for them particularly if it's with a thumb. Then fine motor dexterity tasks can be a problem particularly if we have some nerve injuries.

Slide 18

Dr Desmond Soares:

The next topic we're going to talk about is Carpal Tunnel Syndrome and again here I think the number of cases listed under the Scheme of 258 is very small. I would expect it would be more like 500 to 600 or even 1,000 per year. The good thing about these is that they have a 95% return to work rate. They don't have much time lost. Again most of my patients will be back after a total incapacity of only two to three weeks and then they have partial incapacity of a further four weeks.

Slide 19

So what is Carpal Tunnel Syndrome? In our hands we have a nerve called the median nerve. It travels down the front of the wrist. It travels under a ligament at the base of your palm and it's squashed in a very tight space here and there are nine flexor tendons that are squashing this nerve under this tight ligament over here.

Slide 20

Patients typically describe pins and needles in their hand at night. It's worse with driving. It does get worse with age and so in the 40 and 50 year old age group.

Slide 21

It's also worse with menopause and people who are hypothyroid. They typically get numbness in the median nerve distribution. That's the area coloured in blue which is the thumb, index, middle and half the ring finger. It doesn't usually affect the little finger. They can get wasting of their thumb muscles as well.

Slide 22

Typically we test for it by a thing called Tinel's sign. Tapping on the nerve gives them an electric shock and they feel like pins and needles shooting in their fingers. If you bend their wrist back so that the back of their palms and hands are facing down, they will have – it will bring on the pins and needles.

Slide 23

The way it's diagnosed to confirm it usually for WorkCover claims is by having things – nerve conduction studies. This is where little electrical currents are passed and they measure the conductivity in the nerve. One of the problems with nerve conduction studies is they don't always come up positive because you can have one nerve fibre out of 20 in the nerve that appears to be conducting normally and yet the others are abnormal.

A question?

Facilitator:

Yeah. Dr Soares if I could just interrupt you.

Someone has asked "Where do you stand on the long-standing argument of whether CTS is work-related for say a data entry operator?"

Dr Desmond Soares:

Sure. That's a great question.

So Carpal Tunnel Syndrome has a variety of causes and as I've just said, it occurs in middle-aged women. It occurs in people who are hypothyroid. Data entry does seem to be a predisposing factor. A good book to assess this is there's a book called the AMA Guides to the Causation of Injury and this is now in the second edition. This has a very long section on this and it accepts that in different jurisdictions there are different definitions but in Australia it accepts that CTS is related to – can be related to data entry. Under the Queensland legislation work needs to be a significant factor, not the only factor, not the major factor but just a significant factor. So generally I would consider that it's accepted as a WorkCover claim.

Slide 24

So nerve conduction studies are used and then we proceed to surgical treatment. Surgical treatment there's two options. You have the open versus the endoscopic or the keyhole method. My preference is the open method because it has a much lower late recurrence rate. It also has a much lower damage to other structures rate. The other benefit of it is that in work-related patients certainly, in WorkCover patients there is no difference in return to work between the endoscopic and the open. So even though that was a marketing tool, that difference only occurs in self-employed people and not in WorkCover patients.

Slide 25

Amanda MacKillop:

Okay. So again hand therapy starts really early once they've had surgery. We look after the wound and swelling making sure that the swelling is minimised. Wrist and finger exercises start really early, the first day we see them and then we give them some nerve gliding exercises and that just makes sure that the nerve doesn't get involved with all the scarring that later develops.

Slide 26

Initially we see these guys typically twice a week for the first two weeks again until the wound is closed and then usually once a week until six weeks. A really important focus in hand therapy is managing that scar. It can be quite tender through the heel of the palm for quite a long time with these patients and the – you know, the earlier we get onto scar management usually the better outcomes we have. We also look at stress loading programs and that means we're just getting the hand used to having loads through it again and then getting that strength up to scratch. That usually is started around four weeks post op.

Slide 27

A lot of things do need to be considered when we're looking at recovery from Carpal Tunnel Syndrome. Everyone knows someone who's had Carpal Tunnel Syndrome, I think. All my patients come in and they've known someone who recovered in two weeks or recovered in four weeks. It's all very different and they all seem to have a bit of an opinion but the length of symptoms are very individual. It really goes by how long you've had it before surgery and then there's a lot of genetic factors as well.

Paraesthesia which is the medical term for numbness, tingling and pins and needles, and scar tenderness are common throughout the recovery phase. We need to allow the nerve time to recover and in fact paraesthesia can be present for up to 12 weeks following surgery. We allow 12 weeks as the norm to accept that they will still have some Carpal Tunnel symptoms. The development of pillar pain which is that tenderness across the base of the hand, at the heel of the hand is quite common and can be around for even up to six months. But we do encourage – it's not something that's limiting. We do encourage them to push through that and that's actually beneficial for their recovery.

Slide 28

Facilitator:

Can I just pose to both of you, I don't know who would be most appropriate to answer this, but one of our participants has said that one of the main barriers they find when someone has actually hurt a finger is being able to get them back to work particularly in cases where the employee could actually use the other hand or they've even suggested using their feet to complete a task? So what is your opinion in terms of actually giving time off?

Dr Desmond Soares:

Generally if someone's got a wound and it's very painful I'll give them the first 10 days off but my common practice is that people go back to some form of suitable duties at two weeks and they would start then because that gets them integrated back into their workplace, they're seeing their friends and they don't stay at home and get depressed and scared. It's very important that they start using their hand, their injured hand and their normal hand. We will always put a splint on their injured part of their hand so they are safe, we will protect them and we don't put them at risk but they can still use their hand and that's very important.

If they tend to hold their hand protected in what we would call the 'injured bird posture' where they've got their arm tucked up against their chest then they actually have a very bad outcome. They end up with a very stiff hand that doesn't do well and so it's important that they're using their hand every day.

Amanda MacKillop:

Just to give OTs a bit of a plug this is where getting a health professional into the workplace is really helpful for one of the main reasons being they take our opinion – they hold that quite highly. If someone like an OT goes into a workplace and says "No actually, you're okay to do this", it really does help with their confidence and getting them back to work a lot earlier. Speaking of that continuing with Carpal Tunnel I've kind of broken it up into two types of workers, that being the administrative/office based and then later the heavier. I'll have a chat to you about that in a minute.

Typically once the wound is closed these guys are okay to get back to work fairly early, you know, around two weeks, gradual upgrade to normal duties and hours typically over four to six weeks in surgery and initially they'll want to be avoiding lifting loads, you know, with that hand over a kilo until at least after four weeks when that scar has settled in.

Slide 29

The thing with these guys that we need to consider when going back to work early are the static resting postures, particularly when you're typing having your heel resting on the – sorry your heel of hand resting of the desk and will have a limited endurance for repetitive tasks such as typing. It is not a nice procedure to go through so there is a lot of pain and swelling. Typing is actually good for them but a lot of typing isn't. They will need breaks and this is where returning to gradual hours is helpful.

Slide 30

The heavier occupations again typically it depends on what is available. If there are some lighter more supervisory we get them back at around two weeks but if they're going to be required to do some manual handling and that at least until after four weeks. If so, looking at usually around 2kg lifting limit initially. This will vary dependent on where they are obviously and how they're going at the time with gradual upgrade to normal by around 8-10 weeks if they're in a really heavy role.

A lot of considerations include bilateral versus unilateral. That means have they had both hands done or just the one. Do they cope with pain and how are they healing? Individual factors, so you know, how heavy has the scar developed and the type of availability of suitable duties.

Occupations involving vibrations will be particularly aggravating to these patients. So if there aren't a lot of duties that avoid vibration they might be off work a little longer or might take a little bit longer to get back to normal. So too those are that work in confined spaces or at heights and you know, if you're crawling around on your hands that's quite painful for these patients and then if they're having to support themselves on ladders and have full strength of the arm it's not recommended they go back until they're fully recovered.

Slide 31

Dr Desmond Soares:

Thank you Amanda. We're going now to extensive tendon injuries. These have a very high return to work rate and they also have a very short time loss as you can see.

Slide 32

So that's a picture of the extensor tendon looking at your hand starting from the tip of your finger to the middle knuckle to the central knuckle and then onto the back of your hand. You can injure the extensor tendon at all of those various spots with the blue arrows on your screen. The bottom-most one is known as a mallet injury and then at the PIP joint or the MCP joint which are the two knuckles in your hand and then over the back of the hand or the back of the wrist.

Slide 33

A mallet finger typically is where you've been struck on the end of the finger and typically this is often a sporting injury but it can occur in a workplace as well where you strike your finger directly against a hard surface with a direct blow.

Slide 34

The key question here is you need to sort out whether this is a tendon injury or whether a piece of bone's been pulled off and the only way to diagnose that is with an X-Ray. Please X-Ray, get every mallet finger X‑Rayed.

Slide 35

They can be managed without a surgery by placing them in a splint.

Amanda MacKillop:

In a splint if it's a bony mallet. So when I say "bony mallet" we mean there's a little fracture involved. They're in a splint full time for six weeks and if it's purely the tendon that's come off the bone they're in a splint for eight weeks. Then with return to work we often recommend wearing the splint just for protection for another two weeks with most people.

Slide 36

The splint is – there's a lot of really bad off-the-shelf splints that immobilise joints of the finger that you don't need to immobilise and therefore make the hand a lot more restricted. Having a custom made thermoplastic splint by a hand therapist is preferred. It gives you the best outcome.

Slide 37

Dr Desmond Soares:

So just some examples. Here you can see there's a bony mallet injury where pieces of bone has been pulled off and then by putting in a splint you bring the finger to join up the piece of bone and you would consider surgery if that doesn't heal on or if the deformity remains unacceptable.

Slide 38

This is one of the surgical methods. There's a cute little plate made of metal with a screw and as you can see in the top picture it holds the bony broken piece back in place and it allows early movement.

Slide 39

If the tendon's been pulled off and it hasn't healed properly sometimes we reattach it using an anchor much like you would use a wall plug at home and with an anchor and a suture and tie the tendon back in place.

Slide 40

Going further up the finger, now if you have cuts and tendons – sorry gory picture warning again – you can repair those by stitching the tendon and then it's very important that these are protected because even though you've put stitches in the tendon it has to heal with scar formation which takes probably 12 weeks to be about 80% strength and that's where Amanda and her team come in with very important splinting and controlled exercise.

Slide 41

Amanda MacKillop:

Hand therapy starts really early again. It's really important to get – if it's a mallet get this finger properly supported early and then if they've had surgery to repair the tendon further down the hand we want to get the tendon gliding safely. We look after the wound and swelling.

Now in terms of splinting we mentioned before about the mallet finger timeframe. So just to recap your patient will be looking at having a splint on – or sorry your worker will be looking at having a splint on their finger full time for eight – sorry, for six to eight weeks and then potentially for another two weeks at work. We see these patients twice a week initially for the first two weeks usually for wound, swelling, splint check and range of movement exercises.

Slide 42

This is again just a picture of the type of splint that someone with a mallet finger would have and you can see that really only one finger is affected. So they can use the rest of the hand and thumb.

Slide 43

This is going a bit further up the finger. So they would have – and I apologise. This slide is actually wrong. Just ignore 'Weeks 0-4' and 'Weeks 5-6'. That shouldn't be there. This is actually the set of splints that the patient would have for the full six weeks. The first one on the far left they wear during the day full time and then they come out hourly to do their exercises. That's really important that they're awarded that time at work and it will only take a few minutes, 5-10 minutes to do hourly exercises and this makes sure that the patient isn't left with a finger deformity.

Facilitator:

Amanda can I just ask you, are you familiar with nerve wraps and do they get used often in the treatment of CTS? Are you aware of that type of treatment?

Amanda MacKillop:

A nerve wrap?

Dr Desmond Soares:

Yep. So a nerve wrap is a surgical device that is marketed by some companies with the goal of preventing scarring around the nerve. There is no real data that it needs to be used in a normal Carpal Tunnel Syndrome. The only time you would use one is in a situation where somebody's had a major injury with lots of scarring around the wrist. Then it has a beneficial role. It's also very, very expensive and there's no data in the literature that says that it does any better.

Slide 44

Amanda MacKillop:

Okay and then moving onto the laceration to the back of the hand. So anywhere below these knuckles on the back of the hand they will require a two-part splint. For the first four weeks they require a splint that goes around the fingers of the hand and it props up the finger that has been injured and they'll be in a wrist splint for four weeks. Des is just pointing that out for me. Then the five – so for the weeks five to six we stop the wrist splint and then they're just in the hand piece only. If you have a look at that picture under five to six weeks, the fingers of the middle and the ring fingers have been affected. That splint when you go to make your fist prevents those two fingers or whatever finger has been affected from fully bending and therefore protecting the tendon repair.

Slide 45

In terms of return to work and I've just discussed these guys as a whole, so including mallet and finger and hand lacerations. Usually these guys are in a splint for at least six weeks and when they're in a splint they really have minimal use of the hand unless it's a mallet. A mallet they have a lot more freedom. They're usually okay to go back on supervisory duties pretty early and if you could get them into some admin role, light repetitive duties such as typing, mousing and sorting paperwork is okay. For lifting limits usually it's around a kilo or less until the doctor advises. Gradual upgrade to normal duties within normal hours and duties sorry, within three months.

If the patient had been away for longer than six weeks we also then have to consider overall deconditioning. It doesn't take long for our muscles to waste away as I'm sure you're all aware. So that's really important when getting someone back to work. If they've been off longer than six weeks and suddenly they're cleared for normal just be careful risking other soft tissue injury that's non-related.

The risk factors for these guys are – and imagining the affected finger, if you push against it when you go to straighten it, that is a major risk factor for return to work. You don't often find yourself in that position but getting the finger caught will be a risk factor and something you need to consider when you're giving them or coming up with your light duties program.

Slide 46

For the hand lacerations, so for the ones where you're in the two-piece, so the hand piece and the wrist splint, again the wrist will be immobilised for four weeks and then they'll have the hand piece only for another two. Once you're in the hand piece you're often okay to get back to work. It depends entirely again on what is available. Generally they can go back to work earlier if there are supervisory or administrative based duties and it's not entirely dissimilar to the finger laceration injury.

Slide 47

Dr Desmond Soares:

Our next topic is De Quervain's tenosynovitis. De Quervain was a Frenchman who described this and it's basically pain on the thumb side of your wrist. It's pain in the wrist. It happens commonly in young mums when they've got a baby that's about six months old and is too fat to walk and they hold it up. It also happens in many workers and we'll talk about why. Again I don't believe the number 110 claims. That's far too small. I probably see about 25 a year and I don't think I do a quarter of all the ones in Queensland. Again following their treatment they do get back to work relatively quickly.

Slide 48

So there's a very complex anatomical picture but it's the tendons over here on the radial or the thumb side of your wrist. It typically affects meat workers, guys who are holding knives, welders are the other guys, anyone who's holding tools or gripping all day and as I said, young mums.

Slide 49

The test is called Finklestein's test. So you stick your thumb inside your fingers and then turn your wrist down towards – away from your thumb and you usually get a sharp pain that runs up the radial border of your wrist. These can be treated in a splint.

Amanda MacKillop:

The splint is custom-made. It's a thermoplastic splint and it's the most effective in the attempt of trying to settle this without surgery. Off-the-shelf splints can be quite flimsy for lack of a better word and don't immobilise the structures that we require to be immobilised very well.

Dr Desmond Soares:

I also give them some anti-inflammatory drugs. So they can take Voltaren or Neurofen or anything like that and if they're very sore I'll give them an injection of Cortisone into the actual tendon sheath. In two out of three people the injection and the splint will settle them down so that's all they need. In one out of three it continues and then we'd usually proceed to surgery.

Slide 50

When we do the surgery usually it is under local anaesthetic and sedation as with most of these hand surgeries and we release the tendon. It usually has two or three slips of the tendon in the one tunnel which is why it gets squashed and there is a risk to the nerve with suppressed feeling on the back of your hand. So occasionally that can be a complication following the surgery.

Slide 51

Amanda MacKillop:

We start hand therapy again early with these guys. We are looking after the wound and swelling and getting early active range of movement started very quickly. They're no longer in a splint after their surgery. They're actually free to be ranging their thumb and wrist as freely. They have two appointments within the first – two appointments per week within the first two to four weeks and then once weekly until around six to eight weeks. After about four weeks our hand therapy focuses on scar management and desensitisation. There's actually a nerve that runs very closely to the incision and the site can actually be quite sensitive for a few weeks to months after surgery.

We advise our patients at home and at work obviously to avoid any kind of provocative task for at least four to six weeks and then commence wrist strengthening after six weeks.

Slide 52

Return to work considerations – a lot of these guys seem to be office based with mousing being one of the major dramas. So – and I'll get onto that a little later – typically after surgery they're right to go back pretty early around two weeks and we're looking at gradual upgrade to normal hours and duties over a four to six week period. You want to avoid those heavier lifting tasks initially.

Slide 53

Talking about mousing. So mousing is often a problem because a lot of people do that side-to-side action and wrist deviation with mousing and that is a major aggravator and maybe perhaps even a cause of De Quervain's. Typing can be a problem and more so looking at poor mousing and poor typing posture. So if they've developed unusual typing or mousing habits and then obviously gripping, lifting and carrying tasks can be an issue.

Facilitator:

Can I just interrupt you guys? If someone has actually sustained damage to the nerve what are the chances of a full recovery for that worker?

Slide 54

Dr Desmond Soares:

So depending on – we're going to come to nerve injuries as the next topic, but if you're talking about damage to the median nerve like in Carpal Tunnel, it usually just get squashed and it almost always fully recovers. If someone actually has a cut to a nerve, so a sharp object has penetrated the nerve then we repair it. Then it does heal but you don't get healing as good as what God gave you. You have slightly less feeling. So for example you can tell 2.5mm or more apart instead of 2mm apart. So it feels slightly different to normal but it's safe. You won't burn yourself. You won't hurt yourself. You won't injure yourself. But we're going to cover that in the last topic.

Amanda MacKillop:

Continuing with De Quervain's. For those workers who are in heavier occupations they go back to work a little bit later for obvious reasons, 2kg lifting limit initially or thereabouts with gradual return to normal typically by 8-10 weeks. Again we have to consider have they had the one hand done or both? We do often see both. Pain and healing – how are they going with managing that. Individual factors and then again type and availability of suitable duties.

Slide 55

Facilitator:

How reliable and valid is Finklestein's test?

Dr Desmond Soares:

It's a very good test. It's very, very accurate. So it would be positive in over 90% of people. If they don't have Finklestein's test they don't have De Quervain's.

Amanda MacKillop:

Okay and return to work consideration for those with De Quervain's going back to more heavier roles or more manual handling dependent roles, you just have to be careful about that wrist side-to-side action. So that wrist deviation, almost the Queen waving action and again repetitive pinching because the thumb is really involved in this.

Slide 56

Dr Desmond Soares:

Okay and now our final topic is digital nerve repair. Again I think there was more than 100 in Queensland last year because the nerves in the hand get easily cut. A small penetrating wound anywhere on the palm you must think of the nerve. Again these do return to work fairly early in a splint and then with function.

Slide 57

So on the picture here you can see the structures in yellow are the nerves and you have a common nerve, the median nerve at the wrist and then the ulnar nerve on that side which hasn't been drawn in. It then splits into little branches and you have one nerve running on each side of each finger to supply each finger. So each finger has two digital nerves, one on each side on the palm and that's where they get injured because they're the first thing directly underneath the skin.

Slide 58

When patients have had an injury to the digital nerve they'll describe their finger as feeling numb or different. They might describe pins and needles and so any worker who's had a cut on the palm of their hand with a change in feeling of the skin should be explored. They need to have this checked out and it needs to have microsurgical repair to try and put the nerve ends together. When we stitch them together they don't heal instantly. The nerve still has to grow back and it grows back from the point of injury to the end of the finger at a millimetre per day. So somebody who's cut their palm of their hand it might take them you know, three or four months to get full recovery.

Facilitator:

Do you think there could actually be a false positive in Finklestein's test due to the flexibility of the wrist? Is that reasonable?

Dr Desmond Soares:

No. So people with very flexible wrists are more likely to get tendonitis because they tend to put their joints in such crazy positions that they do stretch the tendons. But Finklestein's test is very, very sensitive and very specific for De Quervain's. Yep.

Slide 59

Amanda MacKillop:

Hand therapy we start early and I apologise. I meant to put a picture up. I couldn't find one in time but the splint – of the splint sorry – and the splint that we use is depending on how many fingers are involved but it's usually hand-based and the purpose of the splint is to prevent the fingers affected from fully straightening and that will pull and often damage the repair that the doctor has done. So they wear that typically for the first three weeks and then perhaps for another two weeks after that for at risk tasks. We look at wound and swelling management. They actually can fully flex in the splint. So they can get their fingers all the way down in the splint and use the hand lightly but they're not able to be gripping forcefully. We usually see them twice a week for the first two to four weeks, once weekly then until about six to eight weeks.

Slide 60

These patients often have a lot of pain. As the nerve recovers it recovers too much and it feels too much. A big part of our job and the patient's job at home is to work at that nerve recovering by touching and exposing it to different sensations and really helping to normalise that nerve which does take a while. We look then at making sure scar management – so the surgical scar doesn't become a problem in terms of range of movement and then add some graduated strengthening after six weeks.

Slide 61

Facilitator:

In terms of getting these workers back to work you guys touched on mousing being a bit of an issue. How do you stop or do you have any recommendations for how you minimise side-to-side wrist deviations with normal mouse use without actually going to the extent of purchasing additional equipment or, you know, a separate brace or something like that?

Amanda MacKillop:

Yep. So when you cannot get a vertical mouse - they often eliminate the problem – you get either an Occupational Therapist or even if you can do it yourself, when you control the mouse instead of having the elbow supported and controlling it side-to-side with the wrist actually telling the patient and it will take practice to get faster and faster, to keep the wrist still and control the mouse with the movement of the elbow and shoulder. That really helps to eliminate the intrinsic movements of the wrist when you're controlling a mouse. So, it will require practice and patience – or workers will have trouble doing that maybe initially. Some people pick it up pretty quickly, but it is effective.

Dr Desmond Soares:

The other alternative as Amanda mentioned is the joystick mouse which is the vertical mouse. So it's like a joystick that you would play computer games with but it has mouse buttons on it. It works very well as well.

Amanda MacKillop:

Back to work for digital nerve repairs, for office based patients usually they're back after three weeks once they're out of the splint. The splint can be quite intrusive in terms of typing. It fixes the hand at a right angle position and it's quite difficult to get the fingers out of the way when typing. Gradual upgrade to normal duties and hours over six weeks avoiding any kind of force or gripping or lifting with the hand until after six weeks.

Slide 62

Heavier occupations they go back to work a bit later. Usually around four weeks when the scar has kicked in we know everything's a bit stronger. If they're on supervisory duties or one-handed duties they can get back to work at two weeks or earlier. Obviously they'll have a lifting kg – sorry, a lifting limit of around one kilo but getting them back to normal by about 8-10. Considerations – they are quite painful as I mentioned before. So how are they coping with that? How nasty was the injury for the amount of nerves that were involved? Was the repair done under tension? All that comes into consideration and then again the type of workplace that you're going into. Careful with gripping and lifting and again vibration. Too much vibration can be quite aggravating.

Facilitator:

Amanda in terms of again workers getting back one of our participants has highlighted that often with these types of injuries the worker is so much more aware of the event and the damage that it did actually cause and you know, how painful that can be. They have alluded to the fact that sometimes it can create a sense of fear in the work environment. They've suggested that an accident investigation may remove risk potential for future injury but learnt behaviour needs to be addressed and the employee needs to be supported.

So I guess in your work as an OT helping assist these people get back is changing their behaviour such as, you know, the mouse suggestion that you've given us before – are there any other strategies to help improve or modify behaviour to remove this fear?

Amanda MacKillop:

I think being proactive and knowing the kinds of, if we're looking at office, the kinds of duties that are potentially going to lead to a soft issue injury. So just giving them basic information on ergonomics is a really great thing to do and letting them know that we can't actually work and I might get shot for saying this but we can't work at maximum speed for eight hours five days a week without, you know, suffering some sort of soft tissue injury down the track. So you know, do incorporate some breaks throughout the day to get up, stretch, have a bit of a walk and then you know, do some upper limb stretches, wrist back and forth, neck side-to-side. Is that answering your question?

Dr Desmond Soares:

Yep. I think that's the key thing for any employer is thinking about task rotation. Okay, if you want somebody to type eight hours a day, buy a robot. But people can't do that eight hours a day non-stop. They do have to stop. They do have to go to the toilet. They should stretch every now and then and they should do different tasks. So do a bit of typing, a bit of filing, do something different makes a great deal of sense in terms of saving and preventing injuries.

Slide 63

Amanda MacKillop:

Going back to digital nerve repair just one way that we can track the nerve recovering in hand over here is by mapping it and this is a little filament test where we have little different thicknesses of filaments and we get the patient to tell us when they detect it. It just tracks the nerve recovery. So that's one month. It's such a very slow recovery. So it's often a good way to see whether it is improving and how quickly.

Dr Desmond Soares:

This is actually the map of a young lad who crushed his finger on a truck loading dock and the skin and it was a pretty nasty injury. I actually went back and grafted the nerve, that is put a tube for the nerve to grow back down as a secondary procedure and this was his recovery as Amanda was tracking it over some months.

Slide 64

Overall finally, when people have had an injury and they've completed all their treatment one of the terms that's used in the WorkCover situation is when they're 'stable and stationary'. So most people get fully better but some people don't get fully better and they have a permanent impairment, that is they've lost some function. In the legislation there's definitions for these things and 'stable and stationary' means that their function has not changed in the last three months. So they haven't gained any more movement or gained any better function or feeling in the last three months. At that point under the legislation if they're not changing any more they have still lost some function, their injury is considered stable and stationary and they get assessed for permanent impairment. What have they lost? In the legislation we use the American Medical Association guides to permanent impairment and these are assessments usually done and then the patient can be awarded a payout under WorkCover as a compensation payment. So that's just for your information as well. One of the final outcomes is they don't get fully better.

Slide 65

Overall thank you very much for your interest and your questions and your attendance. If you have any further questions please send them in right now while we'll run through some quiz questions to see what you've understood.

Slide 66

Just if you need to contact either Amanda or myself that's going to be up on the screen for you and feel free to contact us if you'd like advice. We're very happy to help.

Slide 67

Slide 68

So if you have a patient with De Quervain's what types of tasks should you avoid or minimise when returning to work? Now I've been told that you can type them into the top right hand box and we'll give you about 30 seconds to a minute to see what you come up and then we'll put up what Amanda thinks is the right answer.

Amanda MacKillop:

And if no one responds it's my fault because I have come up with these questions and I've made them too hard.

Dr Desmond Soares:

She's very mean. Anyone still awake or out there?

Slide 69

Amanda MacKillop:

Okay. So to answer – so we're looking at that repetitive risk deviation, the Queen waving repetition of the wrist, repetitive thumb movements, repetitive pinching and looking at their typing and mousing postures and correcting them where possible.

Slide 70

The second question. What is the typical duration a worker with an extensor tendon injury will be required to wear a splint and therefore be unable to use the affected hand at work?

Dr Desmond Soares:

We need some elevator music for this one, don't we? Da, da, da, da, da, da… ding.

Amanda MacKillop:

Okay.

Slide 71

Okay. So going back to those splints that we had a look at before most will be in a splint at some way, shape or form for six weeks, a little bit longer for a tendinous mallet and then also as a tag-on answer some of these patients then also wear it for an additional two weeks on top of that for if they're in a particularly risky job.

Slide 72

Dr Desmond Soares:

Question three. Name some tasks that would typically aggravate a patient who has Carpal Tunnel Syndrome and therefore should be minimised or avoided with return to work?

Amanda MacKillop:

Having a think about where the cut is on the hand would be a clue. Okay.

Dr Desmond Soares:

That's the last one I think.

Slide 73

Amanda MacKillop:

And so static resting postures at the heel of the palm, vibration, working in confined spaces or at height and then forceful or tight gripping.

Slide 74

Facilitator:

If you don't mind guys I might just cut us a bit short only because we've got a few good questions that I'd really like to spend the last couple of minutes to try and include for me.

Dr Desmond Soares:

Sure.

Facilitator:

One of our participants has identified that they mainly see hand injuries in the construction industry I guess due to the types of task that these guys do. They have alluded to a bit of a stigma being in the construction industry that there is no such things as light duties in construction. Have you – I'm probably aiming this more at Amanda – have you actually seen light duties within construction or have you any experience sort of in return to work rehabilitation of these types of injuries in the industry?

Dr Desmond Soares:

I regularly get workers telling me that "There are no light duties in my job", and I say "That's fine. That's okay. We'll find you host employment where you're doing something else. So we'll find you light duties in that way." It depends. In construction there are plenty of light duties. They have spotters all the time, guys who stand there with a 'Stop/Go' sign or guys who stand alone looking to make sure that the crane is working safely or to make sure that something's not going to fall on someone's head. So there are plenty of options for that role.

People need to be able to drive to work and back. So we need to think about their hand – is their hand safe enough to drive but once they are able to drive then certainly I think it's always good to get them back into the workplace because it's good for their mental health.

Amanda MacKillop:

Yeah. I've been out to a few work sites and often, you know, presented with the front that "No. There's no duties available", but they can often fall into the trade assistant role. They won't like it but they can do some, you know, grabbing some stuff for the other employees, general tidy. Again they'll hate doing that but that's always available and just the light sorting of maybe a storeroom or you know, helping with setting up or packing away some construction at the work site. So most of the time we can find something.

Facilitator:

Just going back to treatment options for these types of injuries and you have reiterated many times that there is no one size fits all. So please let us know if you can't give a definite answer on this but is there sort of any recommendation in terms of how many Cortisone injections are usually required to treat these injuries? How many would you determine is not effective for the patient?

Dr Desmond Soares:

So typically that's with De Quervain's or Trigger Finger. We haven't talked about Trigger Finger today. If somebody gets an excellent outcome from the first Cortisone injection and by that I mean that they've got four, six, eight weeks of really good relief and then their symptoms start to come back, then it's worthwhile giving them a second one. If they didn't get much relief from the first one it's unlikely to help again. With De Quervain's usually I say to people "If you've got good relief for the first one and then your symptoms came back I might give you a second or after that it will just go on to release", because otherwise it just goes on and on and on.

Now the exception to that is somebody who's pregnant for example, who doesn't want to have an anaesthetic while they're pregnant. So we care for the baby, care for the mum and we get them through that pregnancy and then deal with it after then.

Amanda MacKillop:

Just to add onto that, Cortisone injections do two things. They numb the area and then they inject the steroid which helps with reducing inflammation and healing. So often when people get an injection they can't feel pain anymore and they feel "Great. I'm going to get back to everything normally", but as an extra kind of precaution quite effectively what works with De Quervain's as an example is we do splint them for two weeks after getting an injection and that just helps to make sure that the structures affected are in fact immobilised and rested. The Cortisone is then able to do its job and then in three months' time we don't usually see when the injection has worn off any return of symptoms or, you know, unlikely because they've had that rested period. It just makes it a bit more effective.

Facilitator:

How often do you guys - I guess in your experience how often do people have another Carpal Tunnel issue post-surgery?

Dr Desmond Soares:

So in my personal experience with an open release Carpal Tunnel symptoms coming back is less than one percent. So 99% success rate. They do very well. It's a great operation. They're happy patients. But probably the one in 100 or less than that, that do come back, it may be because they are very strong scarers. They form a lot of scar and they can actually form a scar and form a ligament again that is pressing on the nerve. I've only seen that twice in my 12 years of practice really. So it's not a common thing.

Amanda MacKillop:

No and I'd agree.

Dr Desmond Soares:

But if they have an endoscopic or the keyhole release then that is much more common and there is good data that shows that keyhole release is associated with late recurrence, recurrence say five to 10 years after the first operation. So if I see somebody who's had a keyhole release I would then perform an open release if that was done by somebody else.

Facilitator:

Okay and so they can still use following surgery for scaring?

Amanda MacKillop:

Absolutely. Yeah we use that very commonly post operatively for scars. It works very well. We typically only get our patients to wear it at night time though.

Dr Desmond Soares:

Yes.

Facilitator:

We have got a fair few questions still coming through for the Finklestein's test. I think a lot of our listeners are extremely interested in these. So can you help clarify I guess how the pain for De Quervain's Syndrome differs from the sensation of tightness with this test? We've had a participant who has performed this test many times with the pain actually subsiding.

Dr Desmond Soares:

Yep. So Finklestein's test is putting your thumb in your fingers, bending towards the – away from your thumb and you get a sharp pain. It's not tightness. Okay. They have to say they have pain and the pain is over the wrist and it goes up their forearm. That's Finklestein's test. So people say "My wrist feels tight", yeah sure. That's normal scarring. So tightness is not Finklestein's. There's got to be pain and it's a sharp pain.

Amanda MacKillop:

And it will often – sorry to cut in there – you would get them to do it with both hands.

Dr Desmond Soares:

And one will be different.

Amanda MacKillop:

And one will be different.

Dr Desmond Soares:

Yep.

Facilitator:

Perfect. Thank you so much and thank you for allowing me the opportunity to interrupt you.

Amanda MacKillop:

That's okay.

Dr Desmond Soares:

If there are any other questions I'm happy to have you pass them onto us.

Facilitator:

Absolutely.

Dr Desmond Soares:

Justice will pass them onto us and we'll try and reply back so that they can go onto the website either in a typed form or something like that. Thank you very much for having us.

Amanda MacKillop:

Thank you.

Slide 75

Slide 76

Facilitator:

Perfect. Thanks guys. We did actually get a fair few questions come through so we will endeavour to send them through and get a response out to the participants because everyone was quite engaged which was fantastic.

We have run out of time so I do have to cut it short I'm sorry. But I just wanted to thank Dr Soares and Amanda again. The interaction was incredible. So thank you so much for pulling this all together.

Slide 77

For everyone listening we do have a few upcoming webinars left for the year. They're on the screen now. So visit our worksafe.qld.gov.au website to register for those because there are only a couple left.

Slide 78

On behalf of the Office of Industrial Relations I'd like to thank you so much for participating in today's session. We love to hear how effective these initiatives are for our stakeholders and what you actually want in the future. So please take the two minutes to complete the survey that we'll shoot to you now. So have a wonderful week, stay cool and bye for now.

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