SHE
Management System
Safety, Health and
Environmental Guidelines
| |
|
       | LEVEL 2
PROCEDURES - Section: 02.091.SHE Upper
Limb Conditions |
| This
is a subject on which there is much literature At
the present time, the DSS rely on only two prescribed diseases Those currently prescribed are: PD.A4 Cramp of the hand or forearm due to repetitive movements in any occupation involving prolonged periods of handwriting, typing or other repetitive movements of the fingers, hand or arm. PD.A8 Traumatic inflammation of the tendons of the hand or forearm or the associated tendon sheaths in any occupation involving manual labour or frequent or repeated movements of the hand or wrist. A working party reported in 1990 to the Industrial Injuries Advisory Council having considered whether there is 'conclusive evidence of occupational causation to prescribe any further types of repetitive strain injuries' than those currently prescribed and the requirements in relation to prescribed diseases are set out in section 76 (2) of the Social Security Act 1975 and require the Secretary of State for Social Security is satisfied that the disease:
The terminology used in describing these upper limb conditions is often imprecise and sometimes actually misleading. a) Work Related Upper Limb Disorders This is the phrase now used by the Health and Safety Executive and forms the title of their 1990 published guide to employers on the prevention of such disorders. It is intended as an update and replacement for the Guidance Note MS10 published in September 1977. The publication is the first of a series to be devoted to this subject. The phrase they use for the title is not entirely satisfactory however and there are many painful disorders in the upper limb which can be made more painful by the activities of certain jobs. There are underlying conditions where work can provoke symptoms and the important question there is not whether the condition is 'work related' but whether it is caused by work. b) Repetitive Strain Injury (RSI) This was a phrase originating out of Australia and which has been adopted mainly by Trade Unions, as an all embracing term to include any ache, pain or disorder associated with the upper limb. If one were to define it in its narrowest sense, it would in fact be restricted to the condition Peritendonitis Crepitans which is the only condition with a clear cut physical sign which can definitely be attributed to rapid repetitive movements. The term RSI also implies causation. i) Repetitive One mans definition of repetitive may well differ from others. How often does a task have to be carried out in order for it to become repetitive? Repetition in its self is not necessarily harmful. ii) Strain Stress applied to any tissue will produce strain but it may, like an elastic band, return to its previous state when the stress stops. This applies to muscle, skin and other tissues but there is no evidence that such stresses, even if rapid and repeated, produce permanent changes in the tissues with the implication of harm which is often implied in the everyday sense of the word strain. iii) Injury An injury is a single event. There never was any injury, its more of a syndrome. c) Cumulative Trauma Disorder This is a term which is popular in the USA but is open to the same criticism as RSI in that it lumps together many different conditions and implies a common causation. d) Tenosynovitis This is a term which as again been used as an all embracing definition, the main culprits being GP's and Factory Doctors. It is probably a lot easier for them to simply write tenosynovitis on a medical certificate or on the medical notes than to arrive at a specific diagnosis based on specific and readily identifiable symptoms. Any vague ache or pain in the hand or forearm has often been referred to as tenosynovitis and these ill-founded diagnoses on medical certificates formed the basis for alleging that tenosynovitis is a common disease and certainly influencing the HSE in describing tenosynovitis on Guidance Note MS 10 (September 1977) as the 'second commonest prescribed disease in the United Kingdom.' Tenosynovitis can, in fact, only mean inflammation of the synovial sheath around the tendons. It is a lot easier to say RSI or Teno in informal discussion on the subject but for the purpose of formal reports, where there is yet to be a specific diagnosis, let us refer to these problems as UPPER LIMB DISORDERS which may, or may not, be caused by work. DEFINITION OF TERMS In these sort of cases, a number of diagnoses arise and it is important for the reader to have some understanding of the various terms used in the medical evidence we see. Having said that, it is not always possible, as our experience in handling more and more of these claims will determine, to put each and every Claimant into a specific diagnostic box. If there is an obvious diagnosis then all well and good but in many cases the Consultant Orthopaedic Surgeon who we use will find that symptoms and signs are mild, confusing or misleading and there is no specific diagnostic box appropriate. Our Hand Specialist in most cases will be left with no alternative but to say that he cannot explain the Claimants symptoms and simply by doing so, he runs the risk of being labelled pro-defendant. On the other side of the coin, there are those surgeons who insist on reaching a formal diagnosis even if, it is wrong. It would be useful to identify the areas of the hand or wrist to which reference is made in the various terms. The
radial side is the thumb side whilst the little finger side is termed the ulnar
side. 1. Tenosynovitis This is a recognised medical diagnosis. The term literally means inflammation of the synovial sheath of the tendons. These may be flexor tendons on the palmar aspect of the wrist, extensor tendons on the back of the wrist, or the small separate collection of extensor tendons on the radial aspect of the wrist which controls the extension of the thumb. In the wrist, the synovial sheath provides protection for the tendons as they pass under the retinaculum which, in simple terms, is a strap around the wrist which holds the tendons down and in place. The synovial sheath contains a tiny amount of fluid to provide this lubrication. If there is aggravation at this site, the synovial lining, which produces the fluid, becomes irritated and produces more fluid. The build up of fluid is evident by visible swelling on the wrist along the line of the affected tendon. Inflammation of synovial sheath can also be due to a number of specific diseases such as rheumatoid arthritis, tuberculosis or infection. True tenosynovitis is relatively rare. 2. Peritendonitis Crepitans This is a form of tenosynovitis but there is a clear distinction between inflammation or irritation of the tendon within the synovial sheath and similar irritation proximal to the tendon sheath where there is unlikely to be a fluid build up as there is no fluid sheath. Instead, there is a dry rubbing of the tendon which produces crepitus, a creaking sensation which is discernible both to the patient and to the medical examiner. There is no doubt at all that this condition can be brought on by work and indeed one would tend to come across this condition following a period of excessive or unaccustomed use of the forearm. It is, however, a temporary brief problem arising in someone untrained in the job which will settle after a period of rest and can be avoided by reintroduction gently to the same work or by simple modification of the system of work. It is not a permanently disabling condition. 3. Stenosing Tenovanginitis This is a type of tenosynovitis where there is a constriction of tightening on the tendon at the mouth of the tendon sheath. The common sites for this are: (a) on the radial aspect of the wrist involving the three extensor tendons to the thumb producing a condition also known as DE Quervain's Syndrome. This is certainly a naturally occurring condition, mostly affecting middle aged women, giving rise to painful snapping sensations. On the balance of probabilities, this condition is unlikely to be work related but at best we can only say that it is a very rare condition in the work context. (b)
Trigger Finger (c)
Trigger Thumb 4. Carpal Tunnel Syndrome This condition is due to pressure on the median nerve, the main sensory nerve to the hand, which normally supplies the skin of the thumb, index and middle fingers and part of the ring finger, as it runs through the carpal tunnel from the forearm into the hand. The tunnel is partly bone and partly a dense fibrous structure called the flexor retinaculum. Through the tunnel run some 9 tendons (strong fairly solid objects) and the median nerve (relatively soft and compressible). Any situation which takes up room in the carpal tunnel is likely to compress the contents and the median nerve is likely to suffer first. This condition can be aggravated, but not caused, by work and one should assume that it is spontaneous and naturally occurring unless there is very good evidence to the contrary. One in two hundred women in the 35-55 age range of the normal population suffer from it as a spontaneous and naturally occurring condition. It is predominantly a female complaint often related to mild hormonal disturbance, either during pregnancy, through the taking of contraceptive pills or to menopausal changes. A fracture of the wrist, such as the common Colles fracture may produce some irregularity of the bony margins of the carpal tunnel causing pressure on the median nerve. Symptoms are of tingling, pins and needles and numbness, possibly associated with pain, in the distribution of the median nerve in the hand. Symptoms are noted particularly at night. Release of any compression on the median nerve can be undertaken surgically though often the carpal tunnel, when opened surgically, is found to look more or less normal and there is a school of thought that in the majority of cases, it is a circulatory change. If a patient has mild carpal tunnel syndrome, with intermittent symptoms, flexion of the wrist will induce symptoms. Work which involves repeated or prolonged flexion of the wrist will, therefore, provoke symptoms but there is no evidence that work actually causes the underlying condition. 5. Tennis Elbow This condition occurs on the outer, lateral aspect of the elbow, aggravated by extending the wrist and fingers against resistance. Recent studies have suggested that it is a relatively common condition affecting up to 3% of the population, occurring most frequently between the ages of 40 and 60 years and has an equal male/female ratio usually affecting the dominant arm. Less than 5% of cases are related to sport and a precipitating factor is absent in many cases. Most patients are not manual workers. The pathology of tennis elbow is uncertain but there is likely to be strain, or actual tearing, of muscle fibres at the epicondyle at the lower end of the humerous. On that basis, the problem could certainly be work related where there was excessive exertion of the forearm muscles and once it has developed, this condition will be troublesome in those doing manual work and recurrence is likely to arise when manual activities are resumed. 6. Golfers Elbow This is a similar sort of condition to tennis elbow but involves the medial epicondyle with pain in that area of the elbow and difficulty and pain in flexing the wrist. 7. Ganglion These are cysts containing viscous, mucinous fluid and are found in the vicinity of joints and tendons in various parts of the body with the majority occurring on the wrist, particularly in the 20 - 30 age group and with a 3 to 1 ratio in favour of females. There is no evidence that ganglions in the wrist or hand have an occupational cause. 8. Cervical Spondylosis Pain in the forearm, wrist and hand can in fact relate to degenerative change in the intervertebral discs of the cervical spine. It may, or may not, give rise to pain in the neck and it may be that a patient will complain only of symptoms confined to the arm. Many engaged in repetitive work will assume a link between such work and this arm pain when in fact it is nothing more than referred pain (via the roots of the brachial plexus) from the degenerative change in the neck. There is no evidence whatsoever to suggest that these degenerative changes in the neck are caused by any particular job and are all part and parcel of the wear process of life. By the age of 65, 90% of the population are likely to have degenerative changes, visible on X-rays, of the neck. Symptoms can certainly be induced by an awkward work position and can often be relieved by the alteration of relevant heights either of tables or chairs. 9. Arthritis Arthritis of the trapezio-metacarpal joint at the base of the thumb is a common constitutional condition present particularly in ladies of post-menopausal age. There is no evidence that this condition is caused by work though there can be no doubt that in any arthritic joints, the use of the joint, whether at home or at work, will precipitate pain. Continued work can, of course, make the pain worse but the condition is nothing more than a premature ageing of the joint, unrelated to work. 10. Dupuytren's Disease Here, fibrous bands or nodules may run from the palm of the hand into the fingers, principally the ring and little fingers, particularly in men often with a family history of such disease, ultimately resulting in contrature of a flexing of the affected fingers. It is, principally, a hereditary disease manifesting itself (usually) late in life with no contribution by reason of occupation or recurrent trauma. 11. Cubital Tunnel Syndrome This is a problem attributed to compression of the ulnar nerve in the cubital tunnel at the elbow. The patient experiences a deadness rather than a pins and needles sensation often associated with nerve compression. Osteo-arthritis is present in 30-40% of cases. In most cases there is no reason to believe that the condition is caused by work though a recent publication has described ulnar nerve symptoms in three professional drivers who rested the inside of their right elbow on the lower edge of the open window of their vehicle for long periods at a time. Their symptoms resolved spontaneously when they stopped doing that. There is a tendency, unfortunately, amongst the medical profession generally to attribute many of these complaints to work when there is no sound basis for such connection. It is important, therefore, that we instruct Orthopaedic Surgeons with a particular interest in the upper limb and who share our view that in most cases, work has no part to play or is merely incidental to the development of the condition. Leaders in the field are Mr. J. P. W. Varian FRCS, Blackrock Clinic, Rock Road, Blackrock, Co Dublin and Mr. J. C. Semple FRCS, 79 Harley Street, London, W1N 1DE The
under noted surgeons have similar views to Mr. Varian and Mr. Semple, Mr.
M. H. Mattewson FRCS, 18 Queen Ediths Way, Cambridge, CB1 4PN Mr. Varian and Mr. Semple, are willing to attend factory premises to view the process and indeed to undertake medical examinations to that factory where it is more appropriate to do so though, of course, there needs to be a bulk attendance to enable that course to be adopted. However, both are very busy men and it is becoming increasingly difficult to call upon their services hence the recommendation to share the work load with those others identified in the list above. Bibliography A. Brown, Claims Controller, Leicester CMB. The origin of how this excellent document came to our notice are unknown. We have found it most useful and have presumed it is public domain. If this is not the case we apologise and will withdraw it on request. |
 |
Revised: December
01, 2004. |
| Design by drakesvision |