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ON Series: Hand injuries for small businesses

Hand injuries are the most common for employees working in small businesses. Dr Cameron Mackay, hand surgeon and plastic reconstructive surgeon explains the complexities of rehabilitation for hand injuries. Dr Mackay gives a great example of a real life hand injury and explores opportunities to improve this worker's rehabilitation outcome.

Dr Mackay provides strategies to ensure successful rehabilitation and return to work for injured worker.

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ON Series : Hand injuries for small businesses

On series – by Office of Industrial Relations

Welcome to the webcast for Queensland stakeholders proudly brought to you by the Office of Industrial Relations. The workers compensation scheme data shows that hand injuries are the most common injuries in a small business. This webcast will provide small businesses with an understanding of how complex simple hand injuries can be. More than you expect and how you manage the rehabilitation and return to work for your workers.  Our presenter today is Dr Cameron Mackay, one of Brisbane's leading hand surgeons and plastic reconstructive surgeons. Dr Mackay will provide great insight into the intricacies of hand injuries and their rehabilitation. The Office of Industrial Relations is committed to delivering short and sharp education to small businesses to improve rehabilitation and return to work outcomes to reduce claim durations.  Thank you Dr Mackay.

Dr Mackay - Thank you. Welcome everyone.  My name's Cameron Mackay as has been said I am a hand surgeon, plastic reconstructive surgeon and I want to talk very briefly or as quickly as I can today about hand injuries and why they can have such a big impact on workers even though the fingers themselves and the hand is such a small organ.

So a couple of things we're just going to talk about is common problems and why little things can have a big impact. How we manage return to work and what the key relationships are when we're trying to manage complex injuries.

Start off with a little case injury, case example. This young worker was working on a demolition site had a laceration to his finger, its only small over his little finger. He was seen in a local clinic and sutured up and his fingers were strapped together.  Ten days later he went back to that practice for suture removal and he reports some pain and inability to move. He was diagnosed with a pain syndrome and given a certificate off work for a month and then referred to a pain specialist. Pain specialist put him on some medication and after three months, no progress.  His finger was stiff, painful and contracted. The employer was upset with the situation and dismissed him. He was referred to an independent examination by WorkCover. The independent examination found that there were no notes, no summary, no diagnosis and delayed reconstruction was unsuccessful and he had his finger amputated at nine months post injury.

The question is, what went wrong? And it sounds farfetched but this is a real case.  Firstly we have to understand the hand. The hand is extremely complicated and atomically in a very small space there are a lot of very important structures. Taking the finger tip for example, you can see within very small distance from the skin tendons, bones, nerves and it's very important in our hand function. This representation is of the organs as they are seen by the brain and the hands you can see have a very disproportion representation in the brain. They are very important neurologically and functionally. So little things can make a big difference when it comes to hands and finger tips.

Our overall goal is to return a worker to maximum function in minimum time. So we are always looking at the speed of recovery but we have to take into account the injury and getting them back to their best.  In hand injury scarring and swelling and inflammation are the enemy and can cause great contracture, pain and loss of function.

So, we talk about the basics of hand injury. We need to consider the very essential elements. And this very non-medical. We have to know what the diagnosis is. We have to know what our plan for rehabilitation is. We have to have all this documented and we have to communicate between the key people in the rehabilitation including the worker about where the case is going. Diagnosis is essential and that seems again a simple thing but in our first case example the diagnosis was not made. Treatment can't proceed properly without a diagnosis and if a diagnosis is missed this makes the problem even worse.  Things like RSI is not actually not a diagnosis and something like sprain is borderline.  When someone says RSI we need to know what that actually means. The quality of the diagnosis and the accuracy is paramount to the whole case and the diagnosis has to be scientific and based in fact.

Again looking at a case example. Doesn't need any explanation what's happened here. This worker could just have this nail removed and a bandage put on it and walk away but we've not really made the diagnosis of what's happened. If he then came back a month later saying he had numb fingers we wouldn't know what happened to the nerve. A surgical exploration can provide the answer here and we can see the nerve although the nail has passed right next to it, the nerve is intact and we know it will recover.  We know that any symptoms will be transient.

The medical plan once we've got the diagnosis is to speed up treatment.  Reduce stiffness, reduce swelling and get the worker prepared for mobility and strengthening and back to work. But we can't speed biology so certain injuries take a particular time to heal. These timelines are fixed but it's not all bad when we're planning a recovery.  These timelines allow us to set down some goals, management plans and return to work strategies.

If we see a dislocation like this in a finger, we know that this work will take six months to rehabilitate. But it doesn't mean they will be off work, it just means they will be on suitable duties for many months having therapy. This one with a fracture, we know will take longer. But if it's not done well they end up with a contracted useless fingers like this.

So our plan needs to be holistic. We have our diagnosis, we outline the path for recovery, we have early suitable duties programme. And this is the key. Having everyone addressing the return to work and suitable duties equally and with respect to the rehabilitation. And then while they are returning to work on the suitable duties having intensive therapy and rehab to maximise their function. If they deviate from the plan or things don't recover the way we would like, then we have to intervene early to get them back on track. There are a lot of other things to consider in terms of what type of work they do. Whether they will be able to do that work or whether they have to go to a host employer while their rehabilitation is taking place. The total incapacity should be no more than necessary. In most cases for a hand the rest of the patient is uninjured. So their time off work total is very minimal. Less than a week in most cases.  After that suitable duties are more than appropriate.  We have to take into account though there may be psychological difficulty, economic hardship, relationship breakdowns due to injury, anxiety, cultural issues and chronic pain. All of these things need to be accounted for and respected during the recovery.

This little chart just talks about how the workers interest is mostly the injury at the start and not at all with work but after a period of time the injury becomes less important and work becomes more important.  And if we leave things too long other issues start to creep in.

I wanted to talk about key relationships. There are relationships between the doctor and patient, the doctor and the insurer and the Allied Health staff but there's equally important relationships as stated here between the insurer and their claimant. The employers and the doctors. And the employer has a very important relationship with the employee. If they maintain good relationships during recovery it can make a huge difference to the patient's outcome.

The therapy in rehabilitation takes the form of hand therapy. The hand therapists are highly trained and do all sorts of clever things to get the hand moving quickly. This extends all the way from wound management up to work hardening and graded return to work programmes. They are essential and will take place in clinics like this where the workers will come once or twice a week to have their rehabilitation monitored.

Medically we manage a number of things during the recovery that mostly it is important to understand that we are working on therapy and their return to work. Every workplace injury is a medicolegal case so documentation is thorough and clear. Unfortunately this is uncommon and it can make it difficult if the pieces are being picked-up later.

So what could go wrong if not done properly? We mentioned this at the start. A neglected hand results in pain and swelling and stiffness. There can be conflict and later legal coaching and sometimes biology can be our enemy. This is a neglected hand that will never function properly.

Small lacerations like this can lacerate tendons and results in loss of function. Other examples are carpal tunnel syndrome, simple tenosynovitis and trigger fingers which can be miss-diagnosed and cause large problems at wrist.

This leads us to our second and last case of a worker who was injured when lifting objects repetitively off an assembly line. Note it's not an RSI. They had tendonitis of their wrist. They present only after four months of physio and all sorts of treatment with lots of negativity and full of ideas that have been fed to them by treatment over that time. They are off work, they're frustrated, they're in conflict with the employer. And what went wrong here?

It's the same things again. They needed a diagnosis and an early plan for return to work. Documentation and monitoring as well as identification that things weren't progressing well and an early intervention.  These simple things can make a big difference in a structure and an organ like the hand where small injuries really mean a lot especially to workers.

Thanks for listening today. Hopefully that's a quick summary of how hand surgery and hand injury can be important in the workplace and how we can better manage recovery.

Thank you Dr Mackay and thank you for listening to this webcast for small to medium businesses. This presentation was presented to you by the Office of Industrial Relations. To access more information on Queensland's Workers Compensation Scheme, please visit our website:

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