Hands are complex. Dr Cameron Mackay, hand surgeon and plastic reconstructive surgeon explains the doctor's role in managing hand injuries.
Dr Mackay provides a range of strategies to improve the diagnosis of hand injuries and effective rehabilitation to ensure your patient's successful return to work.
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Hand injuries rehabilitation and timeframes
Welcome to today's webcast for Queensland GP's. Proudly brought to you by the Office of Industrial Relations. The Office of Industrial Relations is committed to delivering education to better support Queensland doctors working within the workers compensation scheme. The workers compensation scheme data shows that workers employed by small business commonly experience hand injuries.
This webcast will outline the medical management of a hand injury and the common recovery and rehabilitation timeframes associated with these types of injuries. Our presenter today is Dr Cameron Mackay, hand surgeon and plastic reconstructive surgeon located in Brisbane.
Dr Mackay - Hello and welcome. Thanks for listening to this presentation today on hand injuries. I just wanted to talk today about or as briefly as I can about hand injuries which we could talk about for hours. I just wanted to talk about the large impact that hand injuries have when it's a seemingly small organ and how this can affect rehabilitation and return to work.
So I'll talk about a couple of things, some common problems. Why little injuries can have such an impact. How we manage return to work and what the key relationships are.
To do this we will have a case study to start. This 25 year old labourer had a little 5mm laceration to the lower aspect of the little finger on a demolition site. They were seen, washed and sutured and the fingers were strapped together post the procedure. They presented back at 10 days for suture removal and reported pain in the finger and the palm and they were unable to move the digit. A diagnose of CRPS given a totalling capacity certificate for four weeks and referred to a pain specialist. The pain specialist started the medication and after three months of treatment there was no progress. The finger was stiff, painful and contracted. The worker by that time had been dismissed by the employer and was referred to an IME. The IME found no medical notes or summary and the diagnosis was revised. Reconstruction of the finger and the flexor tendon was unsuccessful and the patient at 9 months had an amputation of the painful stiff digit.
So, what went wrong? And this is a real case. So it's not something we've made up. This happens and similar things happen commonly. To think about this you have to think about the hand which as we know has a number of intricate structures which are all very closely related to the skin. Tendons, nerves, arteries, bones. All within harm's way from lacerations or penetrating wounds. For example just in the fingertip we can see a number of structures that are not far from the skin if breached. A hole or laceration can easily cut the flexor tendon or enter the distal joint. Dorsal laceration can damage the extensor distal joint, nail bed or the phalanx itself. Commonly many of these structures are injured together in crush injuries. If we look at this representation of the homunculus, the cortical representation of the hands is huge. Very important for function so highly represented with a number of receptors. So pain and sensation in the digits is highly important. Small injuries are very significant and need to be managed carefully.
Our overall goal should be maximum return to of function in minimum time. In most injuries but in hands in particular. And in hands oedemas, swelling and inflammation can all cause scaring and granulation tissue. In particular an enemy to hands where it can cause significant stiffness and loss of function.
So essential elements in hand injury one-o-one. A diagnosis, a plan, documentation of both of those initial things and then clear communication about what's going on.
A diagnosis is essential to the start of treatment. This seem intuitive but often diagnosis are not present or missed. The missed diagnosis such as in our case example compounded problems significantly. And things like RSI or sprain are pretty borderline diagnosis that often don't tell us what's going on. So quality and specificity of a diagnosis is paramount.
A miss diagnosis needs to be scientific and based in fact, sufficient so we can then implement the plan. A simple example here of this workers with a nail gun injury penetrating from the dorsal aspect of the hand and extending through the whole surface could be an example of where the nail is just removed and the worker is sent on. But we don't really know what's happened in there and if in three months the worker is still reporting numbness in the digits, we're left in a position wondering what's happened to the digital nerves. The diagnosis in this case requires surgical exploration and identification of the real injury. Here we can see the nail passing luckily directly between the common digital artery and nerve just before the branching of the digital artery itself, the digital nerve itself. Sorry. So we know that in this case the nerve will be in tact but they may have some paraesthesia from neurapraxia which will recover over time without knowing that we'd be warranting, we'd be thinking about exploring it late.
So, after the diagnosis, we can then expedite treatment. We can try and avoid that granulation tissue and avoid the inflammation and swelling and stiffness that comes with it. We may have to immobilise an injury for the repair but we need to mobilise it to reduce stiffness and maximise that return of function. There are injury and recovery timelines because we can't speed biology. Certain injuries take a particular time to heal and these fixed timelines provide a framework around which we can build a return to work plan. So they are not all bad.
This PIP joint dislocation for example we know will take six months to rehabilitate. There will be significant collateral ligament volar plate disruption which will scar immensely over the first month or two and take many months to get back to full function. This one with a fraction evulsion and more of a pile-on type injury may take even longer due to the degree of trauma. If not managed properly though, we end up with contracted digits with fixed flexion deformities which are useless and very difficult to later reconstruct.
So with our timelines and proper diagnosis we can outline a pathway to recovery very early. The patient can be put onto an early suitable duties programme while having intensive therapy. And if there's any deviation from the plan of a known injury, intervention can be swift and definitive.
There are other very important issues at play. We need to know what type of work they do and whether they are still employed and whether they will be able to go back to that work or in fact they will need a host placement. Total incapacity should be no more than a week in the majority of cases. In hand injuries, really one hand is injured and everything else is fairly normal. A few days off to recover physiologically from the injuries, fair enough, but then they should be able to do duties just limiting them with the injured hand. Getting them back to do this quickly makes a significant difference even if it's in the setting of host placement.
You have to realise though there may be and economic hardship and different people have different psychological response. There are cultural issues and chronic pain which need to be identified and managed respectfully. The patient's priorities change a lot in the first few months. From initially being very worried and even frightened about the injury and the implications of the injury to the injury taking a back seat over their interest to get back to work. You can see in those first few weeks trying to push them too hard to work without respecting the injury is not going to get us anywhere. And as time goes on other matters can take hold. The key relationships really are listed here. The doctor, insurer and employer have different relationships but all of them are equally important. The doctor's main responsibility is to the patient but they have relationships with the insurer and the Allied Health team. Insurer relates to their claim but will also speak with the employer and the doctor and the employer needs to have a very good relationship with the employee and insurer. We can see that in some of these relationships one party doesn't talk to the other but there should be open communication between all of them. The hand therapy going on in the background is by a specialist hand therapist and extends from wound management all the way to counselling, work hardening and graded return to work programmes. The work is vital in hand injury and neglected hand therapy is a very large cause of poor outcomes. Hand therapy takes place in specialised clinics with specialist equipment and a good place for the patients to arrive once or twice a week for close monitoring of the injury and rehabilitation.
Medically we have to support any microvascular and soft tissue repairs while allowing stability for any bony fixation fractures. At the same time though, any join that can be moved should be moved and tendons need to start gliding before they stiffen up and become adherent. A patient should engage in their therapy and be involved in their rehabilitation right from the start and the surrounding plan should be positivity about the recovery and the potential for outcome. The joint plan managed by everyone involved will always make the worker feel comfortable and positive about their outcome. Of course every workplace injury is by definition medicolegal and should be documented appropriately. This is unfortunately uncommon and for IME assessors coming in later it can be difficult to unpick what happened.
So what can possibly go wrong? Well one case we talked about right at the beginning. Other pitfalls include neglected hand injuries such as putting someone in a plaster for a month six weeks without therapy. Development of neuromas, conflict in the workplace due to poor communication about suitable duties. Legal coaching that has become an issue along the way and of course there can be pitfalls with biology. Hypersensitivity, stiffness in PIP joints, radial wrist sensitivity from superficial nerve etc.
Small lacerations can cause big problems. Little lacerations here over the metacarpal phalangeal joint can have complete disruption in extensor hood. We need to be on the lookout for these. Equally simple things can be masked. Carpal tunnel syndrome can present all sorts of ways. deQuervains is common and commonly diagnosed simply as RSI. Trigger fingers, ganglions they are all present and need a clear diagnosis.
To finish a quick second case of a worker who was injured lifting objects off an assembly line. Diagnosis was deQuervains and they present to specialist review after four months of physio therapy with three different therapists having all sorts of different magical treatments. They're very negative about their condition and full of ideas. These quotes like “I'm overcompensating”, “we're trying not to do that” have all been imprinted on them through multiple therapy sessions. They're off work, they're frustrated, they're well intransient in the system. So what went wrong? Well similar to above, these things weren't met. The diagnosis, although clear, was not followed-up by a treatment plan and early RTW programme. Documentation and communication was absent and there was no monitoring of progress and identification of the deviation from what we expected.
By doing all of these things better, having a plan and talking about how to get the worker back to work soon, we can have better outcomes in the hands which do require more than just surgery but appropriate rehabilitation and support throughout the recovery.
Thanks for listening today, I hope that was useful in understanding hands and hand injury.
Thank you Dr Mackay and thank you for listening to this GP Webcast for Queensland GP's presented to you by the Office of Industrial Relations. Please look out for future webcasts from the Office of Industrial Relations.
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