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Monthly Archives: March 2010

Workplace Injury of the Week: Wrist Fracture

A fracture of the distal radius or ulna (wrist fracture) is a break in one or two bones of the distal forearm near where they form part of the wrist joint.

The radius is the bone located on the thumb side of the forearm, and the ulna is the bone located on the side of the small finger.

Such fractures usually involve not only the ends of the bone but also injury to the many small ligaments in the wrist. This may further decrease stability of the wrist joint and create problems with functioning of the wrist and hand.

This type of injury most often results from a fall with the hand extended during landing. Fractures of the distal radius and ulna are described by their location and position, for example, angulated or displaced.

A displaced fracture is one in which the bone has shifted its position. An angulated fracture results in abnormal alignment of the hand on the end of the forearm.

Fractures also may be comminuted or broken into many pieces. In cases in which the force of the impact drives the bone fragments through the skin, or in which the skin is torn away from the area exposing the bone and surrounding tissues, the fracture is referred to as an open fracture. If the skin remains intact, the fracture is a closed fracture.

Treatment

Closed fractures that are not displaced may be treated with a short arm cast or splint if the fracture appears stable. Close monitoring is required because the fragments may slip out of position due to the many pulling forces of ligaments and muscles near the wrist.

Closed fractures with fragments out of position will require reduction, either closed with local or regional anesthesia, or during surgery (open reduction). Again, because of the many forces pulling on the wrist, the fragments may slip after reduction.

Turning the palm of the hand up (supination) and down (pronation) rotates the radius and ulna, which also can cause displacement of the fracture; therefore, the elbow is included in any splint or cast that is applied (sugar tong or long arm cast). This locks the elbow and hand, preventing rotation of the radius and possible displacement of the fracture.

If the fracture is unstable, metal hardware, most often plates and screws may be used to hold the fragments in position during healing. This hardware may be inserted directly into the fragments during surgery (open reduction, internal fixation [ORIF]).

Traction fixation may be accomplished with attached long pins passing through the skin into bone from the mid forearm, across the fractured wrist, and into a set of pins in the hand. These devices, called external fixators, maintain reduction of the fracture with traction. Some individuals require use of a sling, but elevation of the wrist and forearm during the early stages of healing is important to prevent complications.

Motion of the fingers and shoulder is encouraged. Medications for pain and swelling will be needed. Ice packs over the cast or splint can be helpful in reducing swelling and pain. Early motion of the wrist helps prevent stiffness and arthritis. Sometimes a removable splint can be used during the late stages of healing to encourage motion exercises.

Referral to a hand therapist can be invaluable, even early in treatment. In very severe cases in which a wrist fracture has not healed after 4 months or when the bones have been so displaced and fragmented that they cannot be repaired, wrist replacement surgery (wrist arthroplasty) or wrist fusion, partial or total, may be indicated.

Return to Work

If the fracture is unstable, the arm should not be used for several weeks except for finger range of motion exercises without resistance. The wrist should not be rotated until the fracture is healed.

Lifting, carrying, pulling, and pushing should be limited. Use of a cast, splint, external fixation, and/or sling will affect dexterity; therefore, if the dominant side is injured, work restrictions may be more extensive (e.g., if an individual is right-handed and must write or perform fine motor skills with the dominant hand, he or she will experience more work limitations than if the nondominant left hand were injured).

In some cases, alternatives to a standard keyboard such as speech recognition software or one-handed keyboards may be appropriate accommodations. Some individuals may find ergonomically adjusted or pneumatic tools useful during the healing period.

Rest periods for elevation of the hand and forearm may be necessary during the initial stage of recovery. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Find Out More

To read more about wrists fractures, including treatment, rehabilitation, complicating factors, recovery times and return-to-work durations, go to www.mdguidelines.com.

Clinical Guidelines & the Ethics of Comparative Effectiveness

In today’s post to his always-excellent blog Managed Care Matters, Joe Paduda writes about the ethics of clinical guidelines and the dilemma of comparative effectiveness.

He rightly says that… “If we are to solve the access and cost problem, payers, providers, and patients must be comfortable with the decision process and methodology.”

And he goes on to talk about the challenges among all stakeholders of using treatment guidelines, when each case is different. Read his post here.

Here is a copy of my response, which I posted on Joe’s blog today…

Joe, I’m president of guidelines for Reed Group (www.reedgroup.com), a leader in the field of absence management. We develop and publish the industry-standard return-to-work guidelines, and have a partnership with the American College of Occupational and Environmental Medicine to integrate evidence-based treatment guidelines. (www.mdguidelines.com)

You talk about one of the classic issues in medical publishing, which is the apparent conflict between the “art” and “science” of practicing. Presumably, if enough quality information were available (and in a usable format), the “art” could be displaced in favor of the “science”. Making that practical, while aligning with the incentives that drive physician behavior, is obviously an immense challenge.

At MDGuidelines, we have taken a huge step by making outcomes (statistics) the fundamental basis for our recommendations. We believe that data speaks louder than experts, and we put this into practice via some very innovative tools. Our predictive model actually allows physicians to “drill down” into the outcomes data to see what effect co-morbidities are likely to have on recovery times. At the same time, our world-class Medical Advisory Board layers clinical wisdom on top of the data to provide appropriate insight and corroboration.

We also have a vibrant integration model in our business. We realize that the best way for content to be utilized is via “decision support” — meaning that the information is available in the physician’s workflow in an unobtrusive but persistent way. We are working with major electronic medical records providers in anticipation that this is the way most medical content will be utilized in the future. Importantly, too, our integration relationships allow us to collect outcomes for ongoing development of the guidelines.

We believe that occupational health is dramatically outside the mainstream in modern medical practice. Physicians are very poorly trained in the “work” part of the work/life balance and as such, often fail to consider the critical importance of the patient’s productivity to their health. At MDGuidelines, we consider return-to-work to be a proxy for quality health care delivery in general. When a patient is too sick to work, that is the beginning of a health care episode. When she is healthy enough to return to work, then there is a positive outcome marking the end of the episode. Anyone interested in the “big picture” of measuring outcomes in health care should take a strong interest in return-to-work data.

Finally, the ethical issues around use of clinical guidelines can only be resolved with the understanding that all of the stakeholders need to have access to the same information. We believe this leads to more consistent and responsible care and better outcomes. We continuously promote the notion that our guidelines should be used as a communication tool between physician, employer, insurer, and patient. This allows for a more transparent and better-planned recovery process where “hidden agendas” and one-sided interests and incentives can be minimized, and the physician-patient relationship can be emphasized. In the era of the internet, this collaborative approach to outcomes-driven medicine is realistically within reach.

– Jon Seymour, M.D., Reed Group President, Guidelines