Dr. A. Mortazavi MD Occupational Medicine Specialist

Transcription

1 Dr. A. Mortazavi MD Occupational Medicine Specialist

2 Musculoskeletal problems : 10 20% of outpatient visits traumatic (injury-related) or atraumatic( degenerative or overuse syndromes) acute or chronic most helpful part of the history in determining the diagnosis mechanism of injury With acute traumatic injuries, patients typically seek medical attention within 1 6 weeks of onset.

3 1- emergency referral (immediate) Neurovascular injury Fractures (open, unstable) Unreduced joint dislocation Septic arthritis When to Refer 2- urgent referral (within 7 days) Fractures (closed, stable) Reduced joint dislocation Locked joint (inability to fully extend a joint due to mechanical derangement, usually a loose body or torn cartilage)

4 3- Indications for early orthopedic assessment (2 4 weeks) Motor weakness (neurologic) Constitutional symptoms (eg, fever not due to septic arthritis, weight loss) Multiple joint involvement 4- Indications for routine orthopedic assessment (for further management) Failure of conservative treatment (persistent symptoms > 3 months) Persistent numbness and tingling in an extremity

5 DEFINITIONS OF COMMON ORTHOPEDIC CONDITIONS Strain: A strained muscle or tendon has been pushed or pulled to its extreme by exposing it to an extreme load. results from an unexpected external force, such as a fall. The symptoms of strain should resolve within a few days to several weeks.

6 Sprain ligament has been stretched beyond its limit, causing tears or disruption in fibers. edema and local venous congestion develops over hours to days. A complete tear of a ligament is sometimes called a third-degree sprain.

7 Peripheral Neuropathies The peripheral nerves crosses a joint or is in a tunnel external compression, vibrating hand tools, repeated forceful hand exertions, or sustained posture extremes (eg, overhead work) adequate intensity and duration exposures compresses the nerve paresthesias and pain denervation and weakness.

8 Shoulder examination

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13 INJURIES OF THE SHOULDER

14 Impingement Syndrome, Rotator Cuff Tendinosis or Tears, Supraspinatus Tendinitis, Saubacromial Bursitis repetitive-motion work activities, especially overhead position in forward flexion or abduction subacromial bursitis irritation of the supraspinatus tendon or tendonitis beginning of ulceration (partial-thickness tear) of the tendon full-thickness discontinuity or rupture of the rotator cuff long head of the biceps may be damaged Acromion develops osteophytic.

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16 Posttraumatic impingement syndrome minor injury to the arm or shoulder: painful inhibition of normal motion : self-imposed immobilization of the shoulder imbalanced rotator cuff muscle function impingement syndrome

17 Pain: Clinical Findings anterior shoulder pain may be gradual or acute pain is limited to the lateral arm about the deltoid insertion on the humerus. Occasionally, pain is referred to the distal arm, elbow, and rarely, to the hand. Night pain is a common complaint shoulder pain: when the arm is abducted to degrees or flexed forward to 90 degrees or internal rotation. no active elevation past 90 degrees of flexion or weakness to external rotation. Two common tests for impingement are the supraspinatus isolation test (empty can test), and the Hawkins-Kennedy test.

18 supraspinatus isolation test: downward resistance is applied to the arm after the shoulder is abducted to 90 degrees and forward flexed 30 degrees and the straight arm is rotated so that the thumb is pointing to the ground. Weakness, when compared to the opposite side, indicates disruption of the supraspinatus tendon.

19 Hawkins-Kennedy test: the arm is passively flexed forward to 90 degrees and the elbow is flexed to 90 degrees. When the examiner internally rotates the shoulder, pain indicates impingement of the supraspinatus tendon

20 Differential Diagnosis Angina Cervical radiculopathy Acute shoulder sepsis (quite rare, systemic signs: elevated ESR and WBC) Osteoarthritis of the glenohumeral joint (plain radiographs) degenerative arthritis of the acromioclavicular joint (steroid injection) With progressive age: increasing incidence of asymptomatic partial or full-thickness cuff tears ( after 70 years of age, most people will have cuff tears).

21 Imaging & Diagnostic Studies x-rays (AP) in internal and external rotation and an axillary and an outlet view sclerotic change at the greater tuberosity or evidence of (AC) joint degenerative arthritis MRI

22 fastest way in treatment: inject the subacromial space( corticosteroid and local anesthetic (eg, triamcinolone 40 mg and 1% lidocaine 4 cc). then started on progressive resistance exercises The diagnosis is made when the patient s symptoms are relieved immediately after injection surgery or arthroscopic surgery: 1- respond temporarily to the injection 2- recurrence after two or three injections and who have participated in proper exercises (removal of acromion and AC joint, bursectomy, and cuff debridement,.)

23 Prevention Avoidance of prolonged or repeated overhead work rotator cuff strengthening exercises Treatment resolve the patient s pain and restore normal function and muscle balance anti-inflammatory medications, pendulum exercises (reduces the pressure, increase the circulation) Resistance exercises such as with an elastic band (Thera-Band), with the arm at the side, elbow flexed 90 degrees, applying force in internal and external rotation.

24 Shoulder Osteoarthrosis glenohumeral and/or acromioclavicular (AC) decreased range of motion of the shoulder pain with shoulder motion. tenderness and swelling over the AC joint. Differential Diagnosis adhesive capsulitis, distinguishable by x-ray. Imaging -x-rays (internal and external rotation as well as an axillary and an outlet: narrowing of the glenohumeral or AC joint with subchondral cysts and osteophyte formation.

25 Prevention treatment of the tear in patients with Massive rotator cuff tears Treatment: Conservative treatment includes rest, NSAIDs, and therapy. Steroid injection in glenohumeral or AC joint Surgery(arthroscopic or open distal clavicle resection, arthroplasty)

26 Frozen-Shoulder (Adhesive Capsulitis) diffuse capsular inflammation : marked restriction of glenohumeral joint motion diabetes or other endocrine or autoimmune conditions. Symptoms: attempt to move the glenohumeral joint beyond that allowed by the inflammation and adhesions All ranges of motion are limited

27 Differential Diagnosis osteoarthritis of the glenohumeral joint (radiographs) Imaging Standard radiographs are normal(rule out underlying arthritis) Treatment short period of sling immobilization Shoulder motion will recover gradually with therapy over 6 18 months. Recovery of motion can be facilitated initially by distension of the glenohumeral joint with saline with lidocaine, and triamcinolone. This is followed by gentle manipulation of the arm into external rotation.

28 Shoulder Dislocations Stability shoulder capsule and specific ligament forces applied to the arm held in a position of abduction and external rotation: humeral head is driven forward, tearing the anterior and middle glenohumeral ligaments and capsule from the margin of the glenoid Rarely, dislocate posteriorly with automobile accidents, grand mal seizures, or electroshock therapy.

29 Clinical Findings Acute anterior shoulder dislocation severe anterior shoulder pain. Patients guard against shoulder motion by holding the elbow flexed with the ipsilateral forearm in the opposite hand. Any attempt at motion is associated with severe pain.

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31 Imaging AP and axillary radiographs Anterior dislocations: humeral head displaced inferiorly to the glenoid posterior dislocations: the humeral head is at the same level as the glenoid on the AP radiograph. The diagnosis can be confirmed axillary view. Prevention - General fall prevention - good seizure control - Strengthening of the dynamic stabilizers of the shoulder may be helpful in chronic dislocators. Treatment Anterior and posterior dislocations are reduced by closed techniques immediately.

32 Following reduction, patients are immobilized with the elbow at the side and the arm in a position of 10 degrees of external rotation for 3 weeks. Patients are allowed to return to their usual activities at 6 8 weeks If patients become recurrent dislocators, repair of the torn capsular arthroscopically or with open surgery.

33 Clavicular Fractures -direct blow to the shoulder -rarely from falling on an outstretched hand Middle-third fractures are most common Clinical Findings The proximal fragment of the clavicle is elevated by the action of the sternocleidomastoid, distal fragment downward. Local swelling (bleeding) The patient supports the involved extremity with the opposite hand. Rarely, Fx can perforate the skin, producing an open fracture.

34 Imaging & Diagnostic Studies Plain radiographs of the clavicle. Prevention avoidance of falls and workplace safety. Treatment -Immobilization of the fracture is provided by the application of a figure-of-eight bandage or a sling. Surgery (open reduction with internal fixation ): distal third fracture, highly displaced fractures, fractures with tenting of the skin, or for early return to work or sporting activity. Open fractures

35 Proximal Humeral Fractures direct fall onto the arm or elbow. Clinical Findings pain over the proximal shoulder region or radiating the length of the arm. Local swelling( bleeding). Differential Diagnosis Dislocation of the glenohumeral joint

36 Imaging & Diagnostic Studies plain radiographs of the scapula and shoulder. An axillary view is necessary to rule out a dislocation of the head fragment. Prevention Fall prevention. treatment of osteoporosis.

37 o Treatment Nondisplaced or minimally displaced fractures of neck or greater or lesser tuberosities: temporary immobilization o Displaced fractures of one or both tuberosities: indicative of a rotator cuff tear. o Displaced fractures: surgical treatment by open reduction and internal fixation. o The goal of physical therapy: restore normal range of motion and strength around the shoulder.

38 Brachial Plexus Neuropathy (Thoracic Outlet Syndrome( Compression of the vessels and nerves of the brachial plexus and/or subclavian vessels occurs in the interscalene triangle, behind or below the clavicle or subcoracoid space, or more distally at the pectoralis minor. thoracic outlet compression: 1- Cervical ribs 2-congenital fibrous bands 3- rarely a nonunion or malunion of the clavicle Women are affected more frequently than men, usually between the ages of 20 and 50.

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40 Clinical Findings neurogenic disorder is more common than the vascular pain and/or paresthesia radiating from the neck or shoulder and down to the forearm and fingers difficulty with overhead activities The hand may feel swollen or heavy The lower trunk of the brachial plexus is involved more commonly numbness, tingling, and weakness in the ulnar innervated intrinsic muscles and symptoms on ulnar side of the forearm and hand.

41 Differential Diagnosis -cervical disk disease at the C7 T1 level (C8 radiculopathy) - Entrapment of the ulnar nerve in the cubital tunnel or Guyon canal (physical examination, EMG) overhead exercise position: produce symptoms Adson maneuver, Wright test, Roos Test or shoulder hyperabduction to 180 degrees (observe the palm for pallor indicating an accompanying vascular compromise)

42 Adson s Test

43 Imaging & Diagnostic Studies Plain radiographs of the cervical spine (congenital differences such as cervical ribs and long transverse processes or even hypoplastic first ribs) MRI and angiographic, EMG(muscle weakness).

44 Prevention Identification and correction of postural triggers are an important part of management. Computer users: lowering the keyboard and mouse to elbow height moving the monitor closer and to an appropriate height (eg, top of monitor at eye level) standing workstation.

45 Treatment reduce the mechanism of thoracic outlet compression : postural strength training reduction of obesity general physical fitness Minimize Overhead activities or carrying heavy loads surgery : release the anterior scalene muscles resect of the first rib or fibrous band. clavicular malunion (clavicular osteotomy )

46 Lateral Epicondylitis (Tennis Elbow) repeated forceful pinching or power grasps, wrist dorsiflexion or supination (eg, turning a door knob). work with the wrist in sustained extension pain radiating into the dorsal aspect of the forearm (maybe at night and at rest) tendon tears and necrosis at the attachment of the extensor carpi radialis brevis (ECRB) to the lateral humeral epicondyle and the extensor carpi radialis longus origin along the supracondylar line.

47 Symptoms can be reproduced by: 1- asking the patient to straighten the elbow then extend the wrist against resistance (Cozen test) 2- extend the middle finger against resistance with the wrist straight; 3- grasp the back of a chair with the elbows straight and attempt to lift it (Chair test).

48 Differential Diagnosis radial head osteoarthritis (radiography) fractured radial head or neck (history of trauma and radiographic views) Radial tunnel syndrome(symptoms are usually more distal) entrapment of the posterior branch of the radial nerve(in refractory cases) C6 radiculopathy or a shoulder tendinopathy

49 Imaging & Diagnostic Studies clinical examination. in major trauma or refractory symptoms: Imaging( rule out fracture or arthritis), MRI (rule out intra-articular pathology) Prevention General strengthening of elbow and forearm musculature proper instruction in the use of hand tools and/or modification of the hand tool to reduce high-force pinching or gripping or repeated forceful wrist or finger flexion.

50 Nsaid and ice (night pain) Steroid injection Removing or modifying the offending activities avoid forceful pinching or gripping especially with wrist extension. Forearm muscle strengthening: Treatment initiated with low loads with slow progression. (start with wrist curls using 250 g weight and increasing the load each week or two). Surgery: rarely necessary.

51 Medial Epicondylitis (Golfer s Elbow( repeated forceful finger or wrist flexion or wrist pronation, especially when the elbow is flexed. Clinical Findings local tenderness over the medial epicondyle or common proximal flexor origin. The symptoms can be reproduced by resisted wrist flexion..

52 Imaging & Diagnostic Studies clinical examination. in major trauma or refractory symptoms: imaging(to rule out fracture or arthritis,mri ( rule out intra-articular pathology) A nerve conduction study( rule out ulnar neuropathy) Prevention General strengthening of elbow and forearm musculature and proper instruction in the use of hand tools and/or modification of the hand tool reduce high force pinching or gripping or repeated forceful wrist or finger flexion. Treatment rest of the involved tissues and modified activity. Steroid injection is generally not recommended(ulnar nerve damage).. The need for surgical relief is rare.

53 Ulnar Neuropathy at the Elbow (Cubital Tunnel Syndrome) the second most common nerve entrapment (First: carpal tunnel syndrome) Risk factors: old elbow injuries with enlarging osteophytes, cubitus valgus deformity at the elbow, or subluxation of the nerve out of the groove. Work-related medial epicondylitis, contact stress or sustained elbow flexion (eg, telephone use) neuropathy.

54 Clinical Findings neuropathic symptoms (eg, numbness, tingling, aching, burning, shooting, or stabbing pain, allodynia, weakness) in the ulnar innervated fingers (eg, small and ring fingers) and less frequently in the medial aspect of the forearm and elbow. Symptoms aggravated by elbow flexion or resting the elbow on a work surface.

55 physical examination Tinel sign or tenderness over the ulnar nerve. Full elbow flexion for 60 seconds (with wrists straight) trigger the symptoms. Sensory examination in the ulnar distribution on the fingers may be abnormal (eg, 2-point discrimination, pin prick). severe condition :Weakness and atrophy of the interossei/thumb adductor muscles.

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57 Differential Diagnosis compression of the ulnar nerve in Guyon canal at the wrist (uncommon), cervicothoracic C8 T1 radiculopathy, brachial plexus neuropathy (eg, thoracic outlet syndrome). physical examination or nerve conduction: identify the location of the entrapment.

58 Imaging & Diagnostic Studies Diagnosis: clinical data and nerve conduction studies ultrasound and MRI : identifying morphological changes of the nerve within the cubital tunnel. Prevention eliminate sustained elbow flexion (use of telephone head set instead of handheld telephone) sustained contact stress, such as resting the arm on arm-rest that presses on the unlar groove, should be avoided

59 Treatment conservative pain relief activity modification, such as avoiding elbow flexion of 90 degrees or more or pressure over the medial epicondyle region. Night-time elbow splints : maintain the elbow in approximately 45 degrees of flexion. surgical decompression : -interosseous muscle atrophy -who do not respond to conservative management.

60 Olecranon Bursitis irritation and swelling in bursa between the olecranon prominence and the overlying skin. Acute type; usually not work-related, but a sudden trauma at work might precipitate an inflammation. chronic type : - more common in men - caused by repeated contact stress on the elbow

61 Clinical Findings gradual swelling and pain, Signs of increased warmth suggest a septic process Pressure exacerbates the pain. Differential Diagnosis Sepsis and inflammatory diseases, like rheumatoid disease, crystalline deposits, or CRESTsyndrome (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia)

62 Imaging & Diagnostic Studies Aspiration of the bursa and specific blood tests MRI in complex cases may be indicated Prevention - protection of repetitive trauma on the posterior face of the elbow. -Use of a protective pad in specific jobs highly exposed to elbow trauma Treatment simple immobilization For acute and painful cases: an elastic bandage and steroid injection (after infection is ruled out with an aspiration of the bursal fluid) For recurrent bursitis, arthroscopic bursal resection may be required.

63 Elbow Osteoarthritis rare condition almost in males repetitive strenuous use of the arm in activities ranging from weight lifting to operating vibrating heavy machinery. Elbow OA is marked by osteophytes formation Clinical Findings: Progressive diffuse pain. During the early course: osteophytes in the olecranon fossa cause pain in maximal extension. osteophyte in the trochlea or in the coronoid process: impingement pain may be noted in extreme flexion.

64 Differential Diagnosis secondary OA or rheumatoid arthritis. Imaging & Diagnostic Studies Imaging is necessary. Plain radiograph or CT of the elbow (osteophyte). Treatment Conservative management: decreased biomechanical exposure, pain relief, intra-articular, steroid injections, physical therapy, and splinting. surgery : conservative treatment fails OA is advanced

65 Ganglion Cyst most common soft tissue tumor of the hand. mucin-filled cystic lesions second to fourth decades. asymptomatic or produce pain with direct pressure or during wrist motions. Refer when they change size or become symptomatic. Clinical Findings: over the dorsum of the wrist (can on the volar side) well circumscribed and feel fluid filled. transilluminated with a small penlight (large cases) in the hand( on the volar ): small, round, firm mass near the base of the digits.

66 Imaging & Diagnostic Studies diagnosis: clinically. Radiographs ( if the mass feels bony or calcified in nature) Confirm diagnosis (if the physical examination is inconclusive): MRI, CT scan, or ultrasound Prevention The evidence is limited: Modifing: work involving repeated wrist motions.

67 Treatment Asymptomatic lesions, ( small and present for less than a year): observed, resolve on their own. Avoiding weight-bearing with wrist extension can decrease pain. Aspiration : recurrence rates 50 70%. Injection with steroid: increased incidence of skin depigmentation, subcutaneous fat atrophy. Surgical excision: symptomatic ganglia that do not respond to conservative treatment.

68 De Quervain Tenosynovitis (First Dorsal Wrist Extensor Compartmen Tenosynovitis) first dorsal compartment of the wrist. abductor pollicis longus and the extensor pollicis brevis. overuse of the thumb and wrist particularly with radial deviation, as in repetitive hammering, repetitive lifting.

69 Clinical Findings localized tenderness and swelling over the radial side of the distal radius.. When the patient grasps the fully flexed thumb into the palm and then ulnar deviates the hand at the wrist, exquisite pain develops and reproduces the patient s complaint (Finkelstein test)

70 Differential Diagnosis Chronic nonunion of the scaphoid bone, osteoarthritis of the first carpometacarpal joint, (in 25% of white women older than 55 years of age) Imaging & Diagnostic studies clinical diagnosis no specific radiographic findings. ( rule out carpometacarpal osteoarthritis and nonunion of the scaphoid bone) Prevention lift with the palm facing upwards (full supination) rather than with the palm down, avoid using the thumb. Tools can be modified to reduce repeated forceful thumb motion

71 Treatment activity modification( lifting with the palm in supination) avoiding repetitive lifting and thumb abduction, and use of a thumb spica splint to immobilize the thumb. NSAIDs, Steroid injection (local anesthetic and steroid given into the tendon sheath over the area of the radial styloid) surgical decompression of the common extensor sheath: in patient who do not respond to local injection.

72 Trigger Digit (Stenosing Tenosynovitis) Stenosing tenosynovitis of the flexor tendon to a finger or of the flexor pollicis longus to the thumb may produce pain when the digit or thumb is forcibly flexed or extended. Motion of (PIP) joint of the finger or (IP) joint of the thumb produces symptoms, painful snap joint to collapse suddenly much like a trigger. Rf: repetitive finger flexion. Systemic diseases : diabetes, thyroid dysfunction, and rheumatoid arthritis. most cases are idiopathic.

73 Clinical Findings In the early stage: pain and no triggering. Sometimes, nodule can be palpated (near the MCP joint) with passive flexion of the PIP joint. In the later stages: the digit may become locked in extension (or more rarely in flexion)

74 Imaging & Diagnostic Studies Imaging studies are not needed and are usually normal. Prevention Avoidance of repetitive digit flexion against a load good diabetic control Treatment At the early stages: splinting in extension at night injection of steroid and local anesthetic into the area of the synovial sheath. Surgery: Patients not responding to injection or developing recurrent

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76 Carpal Tunnel Syndrome entrapment or pressure neuropathy of the median nerve (as it passes through the carpal tunnel volar to the nine flexor tendons) Occure any age more common in women. Rf: Pregnancy, increasing age, obesity, hypothyroid, space occupying Lesion (Rheumatoid arthritis) Direct blow to the dorsiflexed wrist or an injury associated with a Colles fracture.

77 Work risk factor: repeated or sustained forceful gripping or repetitive wrist and finger movements. : association between carpal tunnel and the use of a keyboard or computer mouse is controversy Patients with CTS: keyboarding, especially with the wrist in extension or forearms in full pronation, exacerbates their symptoms.

78 Clinical Findings: paresthesias in the median nerve (volar surface of the thumb, index, and long fingers, radial half of the ring finger). progression of the syndrome: awakening at night with pain, tingling, burning, or numbness Characteristically, patients tend to stand up and massage the area or shake the wrist and fingers. Triggening of Symptoms: driving or sustained gripping. Further progression hand weakness result in permanent damage, skin sensory deficit and thenar motor atrophy and weakness.

79 Phalen sign: hold the wrists maximally flexed for 60 seconds, may develop symptoms carpal compression test : direct pressure with the thumb over the carpal tunnel area. Tinel sign : Tapping with a reflex hammer at the volar wrist may recreate shooting pains into the tips of the digits. The diagnosis: EMG-NCV

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81 Differential Diagnosis nerve compression occurring proximally. cervical radiculopathy (C5, C6,C7) Imaging & Diagnostic Studies Imaging are not needed. Nerve electro diagnostic( confirming and estimating severity of nerve dysfunction)

82 Prevention Avoidance of repeated or sustained forceful gripping or repetitive wrist and finger movements, prolonged wrist flexion or extension, or direct pressure on the carpal tunnel. Use tools or jigs with less forceful pinch or gripping Tools reduce sustained posture extremes : split keyboards or asymmetrical computer mice.

83 Treatment Treat Underlying conditions (rheumatoid arthritis, hypothyroidism) In the absence of signs of neuropathy: reducing provocative or repetitive activities. Wrist splints holding the wrist in neutral, (Splinting consistently at night for a period of 4 6 weeks can be curative in the early stages) injections of cortisone into the carpal tunnel (For patients not responding to rest and splinting) Surgery: Patients who fail to respond whose symptoms recurrent When patients present with signs of nerve injury, constant numbness, loss of sensibility, or thenar atrophy, early surgery is preferred. diagnosis should be confirmed by electrodiagnostic studies before surgery is undertaken

84 Hand Arm Vibration Syndrome neurologic and vascular signs and symptoms Rf: use of electric and pneumatic vibrating hand tools over months or years. ( chipping hammers, riveting guns, blowers, grass trimmers, grinders, sanders, and rock drills) clinical pathology is usually confined to the distal upper extremity. most commonly with outside work performed in colder climates.

85 Clinical Findings The classic presentation: cold-provoked blanching of the fingers: vibration white fingers (VWF) or occupational Raynaud phenomenon. At lower exposures: neurologic symptoms predominate: problems of hand coordination and fine manipulation. Progression: intermittent numbness, tingling, and pain (see Stockholm Workshop Scales for severity assessment). Hand and arm pain and hand paresthesias are relatively common.

86 At earlier stages: reversed if vibration exposure is minimized or stopped. Rarely in severe cases(collagen vascular disease or obstructive arterial disease ): skin trophic changes and gangrene. examination :??????? skin perfusion evaluation, digit sensory testing where available(with monofilaments or 2-point discrimination, and provocative maneuvers

87 Differential Diagnosis Raynaud disease and entrapment neuropathies ( CTS and thoracic outlet syndrome). In addition, because VWF is a vasospastic disorder, routine noninvasive vascular imaging will usually be normal. Thoracic outlet syndrome (TOS): effects on large arteries and the brachial plexus. ( vascular expressions of TOS are unusual and can be visualized by Doppler, angiography, MRA, or multidetector CT)

88 Imaging & Diagnostic Studies Sensory function : vibration and thermal perception threshold tests (VPT and TPT),limited availability. Nerve conduction studies: digital nerve function and rule out or rule in a component of CTS. The value of using finger systolic blood pressure or laser Doppler to evaluate vasospasm, under conditions of cold provocation, has a long established acceptance, but application is highly specialized. Routine noninvasive vascular tests are not useful, unless an obstructive pathology is under consideration.

89 Prevention tools with lower levels of handle acceleration (m/s2) The handle vibration level of vibrating hand tools should be available from the manufacture and compared to national (ANSI; EU) and international (ISO) standards. reducing the minutes of tool use per day Monitoring of exposure duration and symptoms The use of antivibration gloves or tape wrapped around tool handles( reduce vibration exposure levels at higher frequencies) Smoking cessation (reduces arterial vasospasm) Treatment minimizing exposure to vibrating hand tools. If CTS is also present, carpal tunnel surgery may be useful

90 Kienböck Disease avascular necrosis (AVN) of the lunate. often idiopathic but can be associated with chronic steroid use. It may be bilateral. present in young men. Preiser disease : A similar condition can occur in the scaphoid. very high levels of exposure to vibrating or percussing hand tools: AVN of both carpal bones. Clinical Findings wrist pain centered over the lunate but it may be vague in nature. swelling and synovitis of the wrist. Stiffness with wrist flexion and extension may be present.

91 Differential Diagnosis Wrist sprains, scaphoid nonunions, and osteoarthritis of the wrist. Imaging & Diagnostic Studies PA, lateral, and oblique views of the wrist sclerosis of the lunate, lunate collapse or loss of lunate height, lunate fragmentation, and eventually degenerative changes in the radiocarpal and midcarpal joints. Stage 1 Kienböck is diagnosed on MRI: decreased vascularity of the lunate. The disease occasionally occurs bilaterally and radiographs of the opposite side should also be performed.

92 Prevention generally idiopathic, sometimes high levels of exposure to vibrating or percussing hand tools. Treatment Treatment depends on stage of the disease. earlier stages and those with open physes: casting or splinting and can show revascularization of the lunate over 1 2 years. significant lunate collapse: surgery. radial positive (radius longer than the ulnar): radial shortening or other joint leveling procedures. Revascularization procedures can also be done. Once degenerative changes have begun in the wrist, salvage procedures including proximal row carpectomy or partial or total wrist arthrodesis may be needed

93 Dupuytren Contracture thickening of the palmar fascia, which is the layer of tissue between the skin and the underlying tendon sheath. begins as a small nodule or nodules grow over time to form cords contracture of the digit at the proximal interphalangeal and metacarpophalangeal joints. more common over the ulnar digits. often seen in individuals of Northern European descent, more common in males hereditary predisposition.

94 Clinical Findings At the early stages:subcutaneous, nonmobile nodules at the palm. At later stages, palpable subcutaneous cords,extend into the digits and cause puckering of the overlying skin. relatively fixed contractures of the MP and PIP joints and an inability to lay the hand flat on a table. Differential Diagnosis joint sprains, missed fractures, and tendon injuries, masses of the hand such as ganglion cysts or nerve sheath tumors. Imaging & Diagnostic Studies No imaging is needed. Radiographs of the involved digits: ( assessing underlying arthritis) MRI: differentiating from other types of masses.

95 Prevention primarily genetic in nature some studies : association with alcohol abuse, smoking, and very high levels of physical exposure (vibration and force) during the working life. Treatment asymptomatic Patients: observation when the contractures reach around 30 degrees: functional deficits. Splinting and therapy: not particularly effective. Collagenase injections : have acceptable midterm results. gold standard : Surgery: needle fasciotomy or open partial fasciectomy, with the open procedure remaining the.

96 Scaphoid Fractures fall on the outstretched hand. In elderly patients (osteoporosis) the same mechanism: Colles (distal radius) fracture acute fall and snuffbox tenderness: should be treated as if they have a scaphoid fracture since early diagnosis and immobilization play a key role in healing. nonunion almost: degenerative changes at the wrist. Clinical Findings tenderness over the anatomic snuffbox or volarly over the distal pole of the scaphoid. swelling, ecchymosis, and limited range of motion.

97 Differential Diagnosis Fx radial styloid, De Quervain s tenosynovitis, CMC arthritis. Imaging & Diagnostic Studies PA, lateral, oblique views of the wrist, scaphoid view. Often the fracture is only visible on one of these three views. Nondisplaced scaphoid fx are often not apparent on initial plain radiographs, so repeat radiographs 1 2 weeks later or MRI or CT scan.

98 Treatment immediately immobilized with a thumb spica splint or cast until radiographs can be repeated in 1 2 weeks or CT,MRI. nondisplaced Fx : short arm thumb spica cast. Immobilization is continued until fracture union is seen radiographically, usually at least 12 weeks. displaced Fx: open reduction and internal fixation. Symptoms in scaphoid nonunion occur long after the original injury. In scaphoid nonunion :Surgical treatment with bone grafting.

99 Mallet Finger injuries to the extensor tendon of the finger near the DIP joint. Rf: high velocity load to the end of the digit, such as when a ball hits the end of the finger leading to a stretch or rupture of the extensor tendon. Clinical Findings Pain at the DIP joint inability to actively extend the DIP joint is the usual presentation. Fractures may or may not be present.

100 Imaging & Diagnostic Studies A lateral view of the phalanges : fractures and subluxation of joint. Treatment Most injuries: conservative treatment (even if they are several months old) The DIP joint is splinted in extension full-time with a Mallet splint for 6 8 weeks. The splint allows time for the tendon to recover. surgical pinning: fracture with joint subluxation.

101 Radius or Ulnar Fractures result from a fall or trauma. In young patients, the trauma is usually fairly high energy. In osteoporotic patients it is often a fall from standing. Clinical Findings pain, swelling, ecchymosis, and deformity of the forearm or wrist. check skin: for any breaks that may indicate an open fracture. neurovascular examination. Differential Diagnosis Sprains and soft tissue injuries.

102 Imaging & Diagnostic Studies PA and lateral views of the forearm or PA, lateral, and oblique views of the wrist (depending on the site of injury) Prevention Osteoporotic patients should be carefully treated and monitored Forearm guards may be used in high-risk sporting activities such as martial arts. Treatment radial shaft are treated surgically in adults. Isolated ulnar fractures treated with casting or splinting depending on location, displacement, and age of the patient. Distal radius fractures: treated with either casting or surgery again depending on the age of the patient, activity level, displacement of the fracture, and intra-articular involvement.