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Division of Workers' Compensation (DWC)

Medical Unit - Hand and wrist

(Adopted May 15, 1997)

Problems of the hand & wrist

Introduction

Conditions affecting the hand and wrist are common among workers with tasks requiring intensive use of the upper extremity. Evaluation can be difficult, given the anatomical and functional complexity of the region. However, a systematic assessment of upper extremity symptoms contributes to accurate, timely and cost-effective diagnosis and treatment.

Scope of this guideline

This guideline is intended for use in the diagnosis and management of hand and wrist tendinitis, de Quervain's tenosynovitis, nerve entrapment syndromes and wrist pain in working aged adults whose occupational activities put them at risk for these problems. Guidelines for initial assessment (first 4 weeks) and subsequent secondary assessment (one to three months) are presented here. This guideline does not address all conditions causing hand & wrist symptoms such as fractures. This guideline does not deal with legal issue of causation or work relatedness. Treatment guidelines are designed to assist providers by providing an analytical framework for the evaluation and treatment of the more common problems of injured workers. These guidelines are educational and descriptive of generally accepted practices for the assessment and treatment of wrist pain, nerve entrapment syndromes, de Quervain's tenosynovitis and hand and wrist tendinitis. Due to the many factors which must be considered when providing quality care, health providers shall not be expected to always provide care within the stated guidelines. Treatment authorization, or payment for treatment, shall not be denied based solely on a health care provider's failure to adhere to the IMC guideline. The guidelines are not intended to be the basis for the imposition of civil liability or professional sanctions. They are not intended to either replace a treating provider's clinical judgment or to establish a protocol for all injured workers with a particular condition. It is understood that some injured workers will not fit the clinical conditions contemplated by a guideline.

Symptom duration is defined as acute (one month), subacute (one to three months) and chronic (> three months).

For the purpose of this document, a provider is defined as any health care provider acting within the scope of his/her practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician.

All health care providers acting within the scope of their practice, including those to whom an injured worker has been referred or whose treatment has been prescribed by a treating physician, shall be allowed to bill and be reimbursed in accordance with usual practices.

A provider may vary from these guidelines, if in his or her judgment, variance is warranted to meet the health care needs of the injured worker and that variance remains within the standards of practice generally accepted by the health care community, and the provider documents the need for the variance in the evaluation report or the medical treatment record in the manner that is generally accepted by the health care community.

Not every medical situation can be addressed in these regulations and medical standards change constantly. The documentation required of the provider is necessary to monitor and explain the use of variances.

In all cases, the provider shall document no later than six months from the date of injury, whether further treatment is warranted and whether the injured worker has significant subjective and objective evidence of the condition not having plateaued.

1.0 Initial assessment (first month)

1.1 Purpose

The purpose of the initial assessment of hand and wrist is to establish specific diagnosis(es). These may include hand and wrist tendinitis/ tenosynovitis, and nerve entrapment syndromes. An additional purpose of the initial assessment is to identify and document any medical, mechanical or psychosocial factors which are contributing to the symptoms and/or may influence the response to treatment. At the discretion of the physician, a shorter, less detailed evaluation may be acceptable.

1.2 Appropriate Initial Assessment Methods

1.2.1 History

As appropriate, the initial history should contain the following basic information for the medical record: the injured worker's age, hand dominance, job description, pre-injury limb function, daily physical activities, previous limb injuries and relevant medical/surgical history. A detailed symptom history may be documented, including characteristics of pain (type, location, duration, severity, radiation), associated symptoms, exacerbating and relieving movements and other factors, and the impact on function at home or work. Information concerning recent trauma and previous diagnostic or treatment procedures (including home treatments) may be obtained. The initial evaluation must address the possible presence of mechanical factors which are causing, aggravating, or precipitating the painful condition, including occupational and nonoccupational physical activities. The relationship of the symptoms to the performance of specific activities may be sought and recorded (e.g. symptoms experienced during work tasks, time off, hobbies, sports or other activities). Inquiry into any history of similar symptoms, previous diagnoses and treatments should be made. The initial history may also note any psychosocial factors which are potentially relevant to the clinical course of the condition, including work status, economic or psychological effects of the condition, and unresolved litigation or workers' compensation issues.

If tendinitis/tenosynovitis is suspected, ask about the typical symptom of localized pain aggravated by direct pressure over or use of the affected muscle-tendon unit. The discomfort may radiate in a proximal or distal direction when force is applied to the tendon. Initially intermittent discomfort may be experienced, but can progress to become a persistent burning or sharp pain. Associated symptoms descriptive of triggering, crepitus, weakness and/or limited motion may be present.

An example of a common tenosynovitis is de Quervain's tenosynovitis. The classic presentation of this condition is pain over the radial styloid; local swelling may also be present. The injured worker may describe symptoms of proximal and distal radiation of pain from this site and/or weakness of pinch or grip strength. The discomfort is exacerbated by ulnar wrist deviation and thumb flexion and adduction. Triggering may be present if the condition is chronic.

If Nerve Entrapment Syndromes are suspected, inquire about the typical symptoms insidious onset of hand paresthesias in the thumb, index, middle and/or radial aspect of ring fingers (median nerve inervation). Many injured workers will describe paresthesias more diffusely, in all fingers. Nocturnal paresthesias, if present, are particularly characteristic. Dull aching hand pain, subjective grip stiffness, weakness of grip or pinch, hand clumsiness and impaired manual dexterity are other presenting complaints. Symptoms may be vague or atypical, and non-specific wrist and hand symptoms in a manual worker should prompt consideration of CTS in the differential diagnosis.

Self-administered hand symptom diagrams have been developed and may be useful in obtaining a detailed description of the distribution and severity of hand symptoms. They may serve as an aid in the history and physical examination.

Documentation of activities as they relate to hand should be made, including the injured worker's job title and a description of tasks performed note the use of each hand in work tasks. Record any recent changes in work duties, overtime, tool design and patterns of tool use or any loss of function, lost work time, or limitation of activity or modification of work due to symptoms. Work station design and adjustability, as well as any prior ergonomic assessment or recent modifications should be noted. Record the onset of symptoms in relation to the work day, work week and specific work tasks or equipment. Any history of previous work related musculoskeletal diagnose be recorded.

Consider non-occupational activities and medical conditions that could cause or aggravate the presenting symptoms, i.e. hobbies, child handling, sports, and musical pursuits.

When the clinical picture is confusing, screening questions should be asked about neck or other upper extremity injury or symptoms. In the case of an atypical presentation of nerve entrapment syndromes, other pathologies may be considered. These include:

a. Cervical radiculopathy (especially C-6 or C-7)

b. Neurovascular compression syndromes such as:

Thoracic outlet syndrome

Anterior scalene syndrome

Costoclavicular syndrome

Hyperabduction syndrome

c. Other nerve compression syndromes:

Radial nerve entrapment: posterior interosseus entrapment, radial tunnel syndrome

Ulnar nerve entrapment: at the elbow or in the Canal of Guyon

Median nerve entrapment: Pronator teres syndrome, anterior interosseus syndrome

d. Other conditions: reflex sympathetic dystrophy, raynaud's syndrome inflammatory, or degenerative joint diseases.

Past medical history and current health status may be elicited and should be evaluated for possible clinical significance. These may include, but are not limited to:

1. Pregnancy

2. Diabetes mellitus

3. Hypothyroidism

4. Fluid retention / edema

5. Rheumatoid arthritis/degenerative joint disease of the wrist and hand

6. Gout.

1.2.2 The initial physical examination will be focused upon the affected part but may also include a basic examination of both upper extremities, including the cervical spine, shoulder, upper arm, elbow, forearm and hand. General physical signs of underlying medical diseases may also be sought. This approach can identify more distant causes of pain such as cervical radiculopathy and/or non-work related disorders contributing to or causing the symptoms (e.g. myxedema). Examination of the contralateral extremity is useful for comparison and to identify any bilateral abnormalities. Basic elements of the wrist and hand examination may include:

Inspection for swelling, erythema, thenar muscle atrophy, nodules, signs of trauma, surgical scars, arthritic bony changes, soft tissue masses, hyper/hypohydrosis, altered hair pattern, edema, cyanosis, guarding, abnormal posture or other deformities of joints or soft tissues.

Palpation of osseous and soft tissue structures for tenderness, swelling, skin temperature asymmetry, abnormal sweating, synovial thickening, masses, ganglion cysts, nodules, bony deformity, pulses, muscle spasm, myofascial trigger points, or crepitus .

Range of motion testing as appropriate of neck, shoulders, elbows, forearm, wrist and fingers for pain, range limitation, crepitus at joint or tendon sheath, tendon triggering or locking. On range of motion testing of tendinitis/tenosynovitis, the focal discomfort is typically increased by passive stretching of the affected tendon, especially with composite range of motion testing. Associated symptoms descriptive of triggering, crepitus weakness and/or limited motion may be present.

Muscle strength testing may include such specific areas as the abductor pollicis brevis, resisted palmar abduction of the thumb for nerve entrapment syndromes. Serial grip strength measurements with a dynamometer may be useful in following clinical progress of tendinitis/tenosynovitis.

Provocative maneuvers for tendinitis, muscle strain, tendon subluxation, joint/ligament instability, nerve entrapment, and if warranted, thoracic outlet syndrome. Consider more specific tests such as: Tinel's performed by percussing lightly along the projection of the given nerve, Phalen's sustained wrist flexion for 60 seconds, and Finkelstein's - pain over the radial styloid is augmented by gentle passive ulnar deviation of the wrist with the thumb held adducted in the palm. It should be remembered that positive results from Finkelstein's test may also be obtained not only in de Quervain's tenosynovitis, but also in the presence of the following conditions: inflammation of the wrist extensor tendons (intersection syndrome), and entrapment of the superficial dorsal radial sensory nerve (Wartenberg's syndrome).

Neurologic testing including reflexes: biceps, triceps and brachioradialis; sharp/dull, light touch, two-point, or vibratory sensory testing; strength testing by resisted movement and grip strength dynamometer, if available.

Circulatory evaluation of radial and ulnar arterial sufficiency.

1.2.3 Diagnostic imaging

1.2.3.1 Plain films of the forearm, wrist or hand may be done after taking a medical history, performing a physical examination, and determining that this study is medically relevant. [ 4 ]

1.2.3.2 CT, MRI, isotope, or similar scans of the wrist are not warranted unless there is a specific, suspected, clinical entity appropriate for the study. The examiner requesting this study should plainly state the reason for requesting the study and the treatment plan related to the results. [ 4 ]

1.2.4 Laboratory testing

a. Tendinitis/tenosynovitis or wrist pain: certain blood tests can be useful in establishing the diagnosis of an underlying metabolic or rheumatologic disease if such a condition is suspected on the basis of the history and physical examination during the evaluation of probable tendinitis/tenosynovitis or wrist pain. [ 4 ]

b. Nerve entrapment syndromes: during the evaluation of probable, entrapment syndromes, laboratory tests should be done if a contributing systemic diagnosis such as joint disease, diabetes mellitus, or thyroid disease is suspected. [ 4 ]

1.2.5 Diagnostic injections

Diagnostic injection of local anesthetic by the experienced, may be useful for diagnosis in the case of atypical presentations such as referred pain or the presence of multiple disorder. [ 3 ]

1.2.6 Electromyography and nerve conduction tests.

Nerve entrapment syndromes: the initial history and physical exam are the most important assessment tools and the working diagnosis may be made without confirmation by nerve conduction studies. [ 4 ]

1.3 Inappropriate initial assessment methods

1.3.1 Thermography [ 1 ]

1.3.2 Vibrometry [ 1 ]

1.3.3 Portable neurometer [ 1 ]

1.3.4 Electrodiagnostic testing to establish the diagnosis of de Quervain's tenosynovitis [ 1 ]

2.0 Initial treatment

2.1 Purpose

The purpose of initial treatment is to promote healing, optimize function and allow continued productive employment with appropriate modifications, as indicated, to avoid adverse effects. The initial treatment of nerve entrapment syndromes, tendinitis, tenosynovitis, and wrist pain is nonsurgical. Application of the conservative therapy described below will result in significant improvement in a majority of cases. Effective workplace intervention may be crucial. The period of initial (conservative) treatment should be 4 weeks with re-evaluation at least every two weeks to ascertain improvement.

2.2 Appropriate initial treatment methods

2.2.1 Education

a. All injured workers with these conditions should receive instruction concerning the anatomy and nature of their condition, risk factors, preventive measures, appropriate exercises and goals of the initial treatment methods including time frame for expected improvement. [ 4 ]

The responsibilities of the injured worker in implementing the treatment plan should be emphasized. Education should be provided by the treating physician and may be supplemented by a physical or occupational therapist in the context of referral for the instruction on gentle flexibility and range of motion exercises, joint protection, work simulation and conditioning. Educational literature, if provided, should be reviewed with the injured worker. Home hobby, craft, sport and avocational activities should be curtailed, as appropriate, if they are considered to be potentially aggravating or causative factors.

2.2.2 Activity and environmental modifications

a. If occupational factors cause or aggravate the condition, appropriate work restrictions and/or ergonomic workplace changes may be advised by the provider. These should protect the involved tissues while allowing the injured worker to perform some of the specific elements of the job.[4]

b. Modified work is strongly encouraged since initial treatment need not require time lost from work. [ 4 ]

Prescribed modified work guidelines should be as specific as possible, avoiding generic terms such as "light duty." Examples of restrictions are a reduction in daily hours, complete restriction from aggravating or high risk tasks, or specific job rotation to promote varied hand position and activities. Other examples of such modifications include work station adjustment, tool redesign, protective equipment and other engineering controls. It may be necessary to contact the company directly to discuss alternative productive work within the scope of the prescribed restrictions.

2.2.3 Immobilization/stabilization

a. Nerve entrapment syndromes: Immobilization/stabilization of the wrist in a neutral position may be used and is most effective when worn in the night.[4]

The splint should prevent wrist flexion and extension without constriction. If not properly fitted, it can lead to further nerve entrapment, muscle atrophy, vascular compression, discomfort and chafing.

If a pre-formed splint does not fit properly a custom-made splint may be fabricated.[4]

b. Severe de Quervain's tenosynovitis: immobilization of the wrist and thumb interphalangeal joint with a spica thumb splint or other similar device can be considered for up to three to four weeks. [ 4 ]

Splinting may not be necessary in milder cases and the functional restriction on thumb and hand use imposed by spica splinting is considerable.

c. Tendinitis/tenosynovitis: immobilization with appropriate splints should also be considered in case of moderate and severe tendinitis/tenosynovitis or for short-term (up to four weeks) care of wrist pain. [ 4 ]

d. Splints must fit properly and should be prescribed by the provider. [ 4 ]

The injured worker should be instructed in proper use of the splint, including the practice of range of motion exercises throughout the day. Careful monitoring of clinical progress is necessary during splinting to avoid the complications of muscle atrophy and joint stiffening.

2.2.4 Physical treatments

a. Appropriate manual/manipulative therapies, including joint and soft tissue mobilization may by used up to a maximum of 12 treatment visits. Referral to an appropriate provider should be considered."[ 3 ]

b. Various manual and/or passive modalities should not be utilized as the sole treatment. A graduated exercise program to promote strength, flexibility, and normal function should also be utilized. [ 3 ]

c. Acupuncture may be prescribed up to a maximum of 12 treatments in four weeks. [ 3 ]

2.2.5 Passive modalities

a. Active physical treatments can be supplemented by selected passive modalities (heat, cold, ultrasound, electrical stimulation, iontophoresis, phonophoresis, aquatic therapy) at the discretion of the provider for the first 4 weeks of treatment. [ 4 ]

b. Ice treatment periods should not exceed 20 minutes. Application of appropriate modalities at home may also be useful during and following the acute inflammatory phase.[3]

2.2.6 Medications

2.2.6.1 A physician may prescribe appropriate analgesic and/or anti-inflammatory medications. [ 4 ]

2.2.6.2 Local injection of steroid medication (with or without accompanying local anesthetic can be used as an initial treatment modality for cases of: 1) moderate to severe inflammation or 2) stenosing tenosynovitis which affects function, after consideration of the risks of this procedure.[4]

2.2.7 Surgical referral for nerve entrapment syndromes

Surgical consultation should be made in the initial treatment phase if there is: 1) thenar muscle weakness or atrophy 2) unremitting sensory loss or paresthesia 3) significant hand dysfunction 4) evidence of a space occupying lesion or history of acute or traumatic onset. In these instances, an EMG/nerve conduction study may be performed to confirm the diagnosis. [ 4 ]

2.3 Inappropriate initial treatments

2.3.1 Surgical treatments

a. Surgical treatment of de Quervain's tenosynovitis or hand and wrist tendinitis/tenosynovitis without a trial of therapy, including a work evaluation, is generally not indicated. [ 1 ]

2.3.2 Medication

a. Pyridoxine / vitamin B6

b. Oral corticosteroids

2.3.3 Tendinitis/tenosynovitis or wrist pain: prolonged application of passive modalities (beyond 4 weeks) [ 1]

2.4 Case management

During the first month of evaluation and treatment, the case management decisions must be made by the treating physician(s), based on the injured worker's clinical progress. Re-evaluation of the diagnosis, treatment effectiveness and work status should be performed by the physician at least every 2 weeks. Referral to an appropriate provider during the initial phase of treatment may be indicated for patient education, pain reduction and the implementation of a graduated program of flexibility and conditioning exercises. Referral should be considered for all patients with moderate to severe symptoms, those assigned total temporary disability and those undergoing surgical treatment.

The goal is to promote healing and maximize function for a gradual return to occupational and non-occupational activities..

Referral to a surgeon competent in the treatment of hand and wrist disorders is appropriate after failure of conservative treatment.

3.0 Secondary assessment (reassessment at 4 weeks)

3.1 Purpose

The purpose of the secondary assessment is to identify the reason(s) for delayed recovery from wrist/hand symptoms and/or functional impairment after initial evaluation and treatment. This requires review of both the working diagnosis and differential diagnosis, as well as the contributing factors and the treatment approach.

3.2. Appropriate secondary assessment methods

3.2.1. History

The interval history should document the treatment measures prescribed and implemented, and the evolution of symptoms during this treatment. The previously recommended modifications of occupational and nonoccupational activities should also be reviewed. Current work status should be noted. If there has been no significant improvement, or worsening of symptoms, the history should be carefully reviewed to address other co-existing or contributing musculoskeletal pathologies and systemic illnesses as per the initial assessment section.

3.2.2 Physical examination

A reexamination should assess any changes in the upper extremity, especially tenderness, atrophy, range of motion, serial grip strength, and response to provocative maneuvers.

Attention should be paid to any changes in the provocative and sensibility tests. If symptoms have worsened or remain unimproved, the physical exam should include an evaluation for undiagnosed proximal upper extremity and neck pathology.

3.2.3 Diagnostic imaging

3.2.3.1 If not previously performed or unavailable, plain films of the forearm, wrist or hand may be considered after the medical history and physical examination indicate that this study is medically relevant. [ 4 ]

3.2.3.2 CT, MRI, isotope, or similar scans of the wrist are not warranted unless there is a specific, suspected, clinical entity which may be diagnosed by the study. The examiner requesting this study should justify the rationale for requesting the study and for supporting the treatment plan. [ 4 ]

3.2.4 Laboratory studies

Certain laboratory studies may be useful in establishing the diagnosis of an underlying metabolic or rheumatologic disease if such a condition is suspected. [ 4 ]

3.2.5 Diagnostic injections

Diagnostic injection of local anesthetic may be useful for diagnosis in the case of atypical presentations (e.g. referred pain, presence of multiple disorders). [ 3 ]

3.2.6 Electromyography and nerve conduction tests

3.2.6.1 Wrist pain and tendinitis/tenosynovitis

Electrodiagnostic studies are appropriate if neuropathy is suspected from the history and physical examination. [ 4 ]

3.2.6.2 Nerve entrapment syndromes: [ 4 ]

Nerve conduction studies may be useful in the re-evaluation phase and should be reserved for:

1)Cases of persistent or worsening symptoms and clinical signs despite a trial of conservative treatment;

2)Cases where the diagnosis remains in question and the history and physical exam are suggestive of another type or location of nerve pathology.

Electrophysiologic studies can be falsely negative in 10 to 20 percent of individuals with clinical CTS and false-positives in asymptomatic people do occur rarely. Therefore the results must be considered in the context of the history, physical exam and presence of occupational risk factors.

A complete evaluation should include distal median and ulnar nerve sensory and motor nerve conduction studies under controlled limb temperature conditions. The laboratory standards for an abnormal test should be consistent with published values and stated in the report. Nerve conduction studies are also useful to determine the site of nerve impingement if a more proximal location is suspected, and can be helpful in the detection of a generalized polyneuropathy.

3.2.7 Ergonomic evaluation

If continued occupational exposure to exacerbating factors is contributing to delayed recovery a worksite evaluation by a specialist trained in ergonomics may be necessary. [ 4 ]

3.2.8 Psychological evaluation

A psychological evaluation with justification may be appropriate in cases where little clinical improvement is noted. [ 3 ]

3.3 Inappropriate secondary assessment methods

3.3.1 Vibrometry [ 1 ]

3.3.2 Portable neurometer [ 1 ]

4.0 Secondary treatment

4.1 Purpose

4.1.1 Nerve entrapment syndromes: the goal of secondary treatment is the symptom-free return to full employment (in a graded manner) with the provision of appropriate immediate and long-term work and activity modifications to prevent recurrence. Continuance of conservative treatment is warranted if symptoms are improving. If there has been no improvement, or clinical progression despite the injured worker's compliance with the initial treatment protocol (including adherence to work restrictions) further treatment strategies are recommended. These should also be considered in the injured worker who has initial improvement but plateaus with persistent symptoms during the continuation of conservative care. If there has been documented consistent improvement of symptoms and physical findings with adherence to the Initial Treatment Protocol outlined above, continued conservative treatment is warranted for up to two to four more months (for a total of approximately six months), with re-evaluation every two to four weeks.

If there has been documented, consistent improvement of symptoms and physical findings with adherence to the initial treatment protocol outlined above, continued conservative treatment is warranted.

4.1.2 Hand and wrist tendinitis/tenosynovitis: The purpose of secondary treatment of hand and wrist tendinitis/tenosynovitis is to optimize recovery from persistent symptoms. Most cases will respond to continued nonsurgical therapy. Secondary treatment for wrist pain will be diagnosis specific and designed to optimize recovery from persistent wrist pain causing conditions.

4.2 Appropriate secondary treatment methods

4.2.1 Education

As part of the continuing medical and physical treatment programs, all patients should receive instruction reviewing their clinical progress, time frame for expected improvements, risk factor, preventive measures, appropriate exercises and treatment options. [ 4 ]

Such instruction should be provided by the treating physician and may be supplemented by a physical or occupational therapist as part of an appropriate referral for flexibility and strengthening training.

4.2.2 Activity and environmental modifications

4.2.2.1 Restriction of occupational and nonoccupational activities which stress the affected area (via direct pressure, forceful or repetitive motion or static tension) should be continued or gradually relaxed based upon the clinical status. [ 4 ]

Prescribed modified work guidelines should be as specific as possible, avoiding generic terms such as "light duty." Further direct communication with the employer can facilitate the permanent implementation of job task, tool, and workstation modifications to speed recovery and prevent recurrence.

4.2.3 Immobilization

a. de Quervain's: immobilization/stabilization for de Quervain's tenosynovitis of the wrist and thumb joint with a spica thumb splint or other device should usually not be continued for more than four weeks. [ 4 ]

b. Hand and Wrist Tendinitis: Immobilization/stabilization with appropriate splints should be reduced as soon as the symptoms improve (e.g. use limited to performing exacerbating tasks), and discontinued when the symptoms are mild.[4]

Continuous splinting should not exceed 4 weeks duration; intermittent or nocturnal splint use may be applied for longer periods. [ 4 ]

Institution of splinting can be considered as a secondary treatment for persistent or worsening cases. [ 4 ]

c. Nerve entrapment syndromes: If splinting has been on a continuous basis, it may be reduced to nighttime use only or PRN use for aggravating activities. [ 4 ]

4.2.4 Physical treatments

a. Graduated exercises as described in initial treatment may be continued during the rehabilitative process. [ 4 ]

b. Manipulation/mobilization for joint dysfunction (not for nerve entrapment): After six treatment visits, an evaluation should be made to determine subjective and objective improvement. If there is no documented subjective and objective improvement, this modality should be discontinued. [ 3 ]

c. Referral to an appropriate provider for training in flexibility and strengthening exercises can be considered for tendinitis/tenosynovitis. The duration of secondary physical treatment referral should not exceed 4 to 6 weeks. [4 ]

d. Acupuncture [ 3 ]

e. Biofeedback [ 3 ]

4.2.5 Passive modalities

Use of thermal modalities in conjunction with physical treatment may be useful in the treatment of tendinitis, tenosynovitis, de Quervain's, and wrist pain.

4.2.6 Medications

a. Tendinitis/tenosynovitis/wrist pain: oral nonsteroidal antiinflammatory medications (NSAIDs) may be continued judiciously after consideration of their cumulative adverse effects risk. Opioids should be reserved for pain refractory to other medications. [ 4 ]

b. Nerve entrapment syndromes: if anti-inflammatory agents have been used continuously in the initial six to eight weeks of treatment, they should be discontinued as the risk of side-effects outweighs potential benefits. [ 4 ]

They may be re-instituted for brief trials in the event of symptom flare.

Acetaminophen may be used periodically. [ 4 ]

4.2.7 Injection

4.2.7.1 Tendinitis/Tenosynovitis

a. If not used during the first month, local injection of steroid medication (with or without accompanying local anesthetic medication) can be used for cases of persistent symptoms after consideration of the risks of this procedure. [ 4 ]

b. Repeat corticosteroid injections can be given at intervals, to a maximum of three injections during the course of the second and third months. [ 4 ]

c. The suspected presence of focal infection (e.g. tuberculous tendinitis) is a contraindication to steroid injection. Extra caution is warranted in the injection of steroids around the extensor pollicis longus tendon at or distal to Lister's tubercle given the elevated risk of tendon rupture. [ 4 ]

d. Steroid injection therapy must be accompanied by the activity modifications discussed above.

4.2.7.2 Nerve entrapment

Nerve entrapment corticosteroid injection (with or without local anaesthetic) can be considered if significant symptoms (especially paresthesias) persist. [ 4 ]

Injections are only occasionally curative, usually in the injured worker who has been symptomatic for less than three months. A significant percentage of people have attenuation of their symptoms with injection, a good prognostic sign if surgery is eventually necessary. Symptoms frequently return within weeks to months. If there is improvement in symptoms, the injection serves as a diagnostic aid. If relief is prolonged (weeks to months), repeat injections can be given, to a maximum of three, at intervals not less than six to eight weeks apart.

Contraindications-drug allergy, bleeding disorder, space-occupying lesion.

Potential complications-local hematoma, infection, tendon rupture, reflex sympathetic dystrophy, and inadvertent injection of the median nerve with worsening symptoms. Transient median nerve symptoms occur frequently.

4.2.8 Surgical treatments

4.2.8.1 Tendinitis/tenosynovitis

a. Surgical intervention can be considered for cases showing little or no improvement after failure of conservative therapy. [ 4 ]

b. Many cases of refractory tendinitis/tenosynovitis are due to the presence of conditions which are not amenable to nonsurgical treatment (e.g. anomalous tendon slips, strictures, large calcifications, tendon subluxation. [ 4 ]

4.2.8.2 Nerve entrapment syndromes: surgical consultation in the re- assessment phase is indicated if: [ 4 ]

a. the diagnosis of nerve entrapment syndromes has been reasonably established and other pathologies excluded; and

b. atrophy or weakness is present; or

c. there is unremitting sensory loss or paresthesias or markedly abnormal nerve conduction studies; or

d. the injured worker has failed a three to six month course of adequate conservative therapy; or

e. the symptoms and physical signs continue to progress during conservative therapy.

Surgery should be performed only by a hand, orthopedic, plastic, or neuro surgeon with extensive experience in the selection of candidates for surgical intervention and in the procedure itself. Surgical aftercare should be managed by the surgeon.

4.2.8.3 Surgical procedures are indicated for an appropriately diagnosed, surgically correctable lesions.

4.3 Inappropriate secondary treatment methods

4.3.1 Medications

a. Use of oral corticosteroids is rarely indicated. [ 1 ]

b. Pyridoxine / vitamin B6 [ 1 ]

c. Muscle relaxants [ 1 ]

4.4 Case management

If the injured worker has not resumed near normal work duties after eight weeks of full conservative therapy including adherence to a graded exercise program, a referral to a physician trained and experienced in the evaluation and treatment of occupational disorders or an orthopedic surgeon is recommended. Consultation should include a complete evaluation and recommendations for treatment and return to appropriate work. If psychosocial issues are judged to contribute to delayed recovery or heightened disability, it may be appropriate to have a psychiatric evaluation. If the condition becomes chronic or disabling despite full conservative treatment including appropriate medical, rehabilitative, and ergonomic interventions (and surgery if indicated), the injured worker should be evaluated for permanent disability.

5.0 Primary references

1. Amadio PC: Carpal tunnel syndrome, pyridoxine, and the workplace. J Hand Surg:12A(5p2):875-880,1987.

2. American Academy of Neurology: Practice parameters: carpal tunnel syndrome (summary statement) 2/22/93.

3. American Academy of Orthopaedic Surgeons (1991). Clinical Policies: De Quervain's Stenosing Tenosynovitis; pp. 1-2.

4. Anderson BC, Manthey R, Brouns MC (1991). Treatment of de Quervain's tenosynovitis with corticosteroids: A prospective study of the response to local injection. Arthritis and Rheumatism 34(7); 793-798.

5. Arons MS (1987). De Quervain's release in working women: A report of failures, complications, and associated diagnoses. Journal of Hand Surgery 12A; 540-544.

6. Baker EL, Ehrenberg RL: Preventing the work-related carpal tunnel syndrome: physician reporting and diagnostic criteria. Ann Int Med 112(5):317-319,1990.

7. Birkbech MQ, Beer TC: Occupation in relation to the carpal tunnel syndrome. Rheum and Rehab 14:218-221,1975.

8. Chidgey LK (1992): Chronic wrist pain. Orthopedic Clinics of North America 23(1); 49-64.

9. Clark DD, Ricker JH, MacCollum MS (1973). The efficacy of local steroid injection in the treatment of stenosing tenovaginitis. Plastic and Reconstructive Surgery 49; 179-180.

10. Crow RS: Treatment of the carpal tunnel syndrome. B Med J 1: 1611-1615,1960.

11. deKrom MC, Kester ADM, Knipschild PG, Spaans F: Risk factors for carpal tunnel syndrome. Am J Epi 132(6):1102-1109,1990.

12. deKrom MC, Knipschild PG, Kester ADM, Spaans F: Efficacy of provocative tests for diagnosis of carpal tunnel syndrome. Lancet 335:393-395,1990.

13. Dellon AL: Clinical use of vibratory stimuli to evaluate peripheral nerve injury and compression neuropathy. Plas Recon Surg 65(4):466-476,1980.

14. Duncan KH, Lewis RC, Foreman KA, Nordyke MD: Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: results of a questionnaire. J Hand Surg 12A(3):384-391,1987.

15. Elliot BG (1992). Finkelstein's test: A descriptive error that can produce a false result. Journal of Hand Surgery 17B; 481-482.

16. Faithfull DK, Lamb DW (1971). De Quervain's disease - A clinical review. The Hand 3(1); 23-30.

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Appendix 6.0 Extensor and Flexor Tendon Compartments

Extensor compartments

1. Abductor pollicis longus and extensor pollicis brevis (de Quervain's tenosynovitis)

2. Extensor carpi radialis longus & brevis (Intersection syndrome)

3. Extensor pollicis longus

4. Extensor indicis proprius, extensor digitorum communis

5. Extensor digiti minimi

6. Extensor carpi ulnaris

Flexor compartments

1. Flexor carpi radialis

2. Flexor carpi ulnaris

3. Flexor digitorum superficialis &profundus

4. Flexor pollicis longus

Appendix 6.0: Wrist Pain - Differential Diagnosis (adapted from Chidgey article)

Bone/Joint

Fracture (occult/nonunion/malunion)

Avascular necrosis: scaphoid, lunate

Joint subluxation: distal radioulnar joint

Carpal instabilities (static/dynamic): scapho-lunate dissociation, etc/

Arthritis/ArthrosisPost-traumatic, osteoarthritis, rheumatoid, gout, pseudogout, infection, etc.

Osteomyelitis

Bone cyst

Ganglion cyst (intraosseous/extraosseous)

Tumor (benign/malignant): enchondroma, osteoid osteoma, etc.

Other: carpal boss, os styloideum

Ligament

Tear/avulsion ((no/) static/dynamic instability): triangular fibrocartilage, intercarpal ligament tears/ruptures etc.

Sprain

Tendon

Subluxation: extensor carpi ulnaris

Tendinitis: six extensor and three flexor wrist compartments (noncalcific/calcific)

Muscle

Muscle strain

Chronic compartment syndrome

Nerve

Neuroma

Neuropathy: median, ulnar, posterior interosseous, cutaneous sensory nerves, proximal source

Compression/entrapment, toxic/metabolic, inflammatory, etc.

Circulatory

Ischemia

Thrombosis

Aneurysm

Other

Appendix 7.0

Description of IMC Appropriateness Levels

Yes


Acceptable or appropriate in most cases
Level 4 Level 3 Level 2 Level 1

Good Research Based Evidence

Yes

No

No

No


Clinical Evidence

Yes

Yes

Some

No


Consensus Of The Health Care Community

Yes

Partial

No


Clinical Utility Of Appropriateness Level For Common Low Back Problems

Appropriate and recommended
Appropriate in uncommon individual cases. Document the case-specific clinical factors or circumstances which make this procedure reasonable and necessary for this injured worker.
Inappropriate