Carpal Trauma

Occupational illness and injury187 cost 30-40 billion dollars/yr in the United States.188 In 1994 there were 6.8 million injuries and illnesses in private industry, amounting to 8.4 cases per 100 workers. Nearly two-thirds were disorders associated with repeated trauma, such as carpal tunnel syndrome.189 The Occupational Safety and Health Act of 1970 set up the National Institute Safety and Health (NIOSH) to study the problem and the Occupational Safety and Health Administration (OSHA) to deal with it through inspections and regulations. Both have received so much criticism of their effectiveness that they are struggling to find more effective ways to deal with the problem.190 NIOSH is searching for practical ways to protect workers, especially those in small businesses from methylene chloride, tetrachloroethylene, diesel exhaust in coal mines, isocyanates, 2-methoxyethanol, and others. OSHA is about to expand a plan that worked well in Maine, a state that used to have one of the worst accident and illness records in the United States.191 The 200 firms with the worst records were asked to look for deficiencies and to correct them. They were also inspected. These measures cut injuries and illnesses over a 2-year period. 

According to the U.S. Department of Labor, Occupational Safety and Health Administration (OSHA), repetitive strain injuries are the most common and costly occupational health problem, affecting hundreds of thousands of American workers, and costing more than 20 billion a year in workers compensation. According to the U.S. Bureau of Labor Statistics, nearly two-thirds of aU occupational illnesses reported were caused by exposure to repeated trauma to workers upper body (the wrist, elbow, or shoulder). One common example of such an injury is carpal tunnel syndrome. Replacement Air... 

By 1991, that percentage had increased to over 60 percent. A conservative estimate of the medical costs of treating one industrial case of carpal tunnel syndrome, a type of cumulative trauma disorder affecting the wrists and hands, is about 20,000 a year. This cost estimate does not take into consideration the costs involved with lost work time, replacement workers, and lower productivity. Only the common cold and the flu cause workers to miss more work annually. Additional expenses to the employer resulting from ergonomic hazards in the workplace are administrative expenses associated with flling insurance claims and recordkeeping. 

Fractures and dislocations of the carpal bones are rare, and a child with a painful wrist following trauma is much more likely to have injured the distal radius (Fig. 19.33). Carpal bone fractures are uncom-... 

The ossific nucleus of the scaphoid appears around 4-6 years of age, and ossification is complete at 13-15 years. As in adults, the scaphoid is the most frequently injured carpal hone. The incidence of fractures is extremely low in the first decade, thereafter rising to a peak in the late teens to mid twenties (Grad 1986). Unlike adults, fractures of the distal pole are more common than of the waist (Fig. 19.34). These fractures represent ligamentous avulsion injuries, with failure through the bone rather than the stronger soft tissues. Middle third fractures occur in older children and adolescents, whilst proximal pole fractures are rare. Many fractures are the result of direct trauma to the wrist rather than a fall on the outstretched hand (Vahvanen and Westerlund 1980). 

Vahvanen V, Westerlund M (1980) Fracture of the carpal scaphoid in children. A clinical and roentgenological study of 108 cases. Acta Orthop Scand 51 909-913 Valencia J, Leyva F, Gomez-Bajo GJ (2005) Pediatric hand trauma. Clin Orthop Relat Res (432) 77-86 Waters PM (2001) Fractures and dislocations of the hand and carpus in children. In Beaty JH, Kasser JR (eds) Rock-wood and Wilkins Fractures in children, 5th edn. Lippincott Williams and Wilkins, Philadelphia, pp 381-442 Weiss AP, Hastings H (1993) Distal unicondylar fractures of the proximal phalanx. J Hand Surg [Am] 18 594-599 Wyatt JP, Beattie TF (1995) Paediatric injuries on an artificial ski slope. Injury 26 87-88... 

Cumulative trauma disorders (CTDs), also referred to as repetitive-motion injuries, result from excessive use of the hand, wrist, or forearm. As with overexertion injuries, the frequency and costs of CTDs are growing to epidemic proportions. Some of the most common cumulative trauma disorders are carpal tunnel syndrome, cubital tunnel syndrome, tendinitis, and tenosynovitis. 

The Carpal Tunnel Syndrome Book Preventing and Treating CTSs, Tendinitis and Related Cumulative Trauma Disorders. (1993). M. Pinsky. New York Warner... 

Carpal T mnel Syndrome A cumulative trauma disorder (CTD) often associated with activities involving flexing or extending the wrists or repeated force on the base of the palm and wrist. The carpal tunnel is an opening in the wrist under the... 

The wrist and hand joints should be palpated for swelling, asymmetries, and tenderness. The skin of the wrist and hand shonld be evalnated for temperature and moisture changes. Tendons or joints may be tender. The anatomic snuffbox should be palpated. In case of trauma, any tenderness in this area should be noted, because the navicular is the most commonly fractured of the carpal bones. 

The 249,000 occupational illnesses included repeat trauma such as carpal tunnel syndrome, noise-induced hearing loss, and poisonings. It is my professional opinion that many occupational illnesses go unreported when the employer or worker is not able to link exposure with the symptoms the employees exhibit. In addition, physicians fail to ask the right questions regarding the patient s employment history, which can lead to the commonest diagnosis of a cold or flu. This has become very apparent with the recent occupational exposure to anthrax where a physician sent a worker home with anthrax without addressing potential occupational exposure hazards. Unless the physician is trained in occupational medicine, he or she seldom addresses work as the potential exposure source. 

Another way to solve the problem is to eliminate constraints. Tools, equipment, and time might be in this category since these constraints can take many forms. Ergonomic considerations in job design is a potential constraint. Employees who are forced to stoop, bend, twisf turn, stretch, lean, reach, or assume unnatural postures to perform routine tasks are subject to discomfort and fatigue. Discomfort and fatigue may distract fiom immediate hazards, and chronic physical stresses may make employees prime candidates for such cumulative trauma disorders as carpal tuimel syndrome and tendinitis. 

An illustrative case study. Several years ago, I consulted with the managers and safety leaders of a large work group who were genuinely concerned about the work pace of titeir line employees. The probability of a cumulative trauma disorder, especially carpal tunnel syndrome, was certainly a direct function of the work pace (Silverstein et al., 1987). Their question was, "How can we reduce the work pace " They essentially wanted my advice on an education or incentive program that would decrease the work pace and lessen the occurrence of cumulative trauma disorders (CTDs). 

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