Injuries involving the hand, wrist, and forearm are addressed in the guidelines set forth by the New York State Workers Compensation Board. These guidelines offer foundational principles for carrying out therapeutic procedures, specifically operative interventions. They are crafted to assist healthcare professionals in determining suitable therapeutic approaches as part of a comprehensive assessment.
Healthcare professionals specializing in operative therapeutic procedures can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most appropriate methods for their patients.
It is essential to underscore that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding operative therapeutic procedures should involve collaboration between the patient and their healthcare provider.
History Taking and Physical Exam
History taking and physical examination form the foundation for subsequent stages of diagnostic and therapeutic procedures. In cases where clinical evaluations and other diagnostic findings are inconsistent, priority should be given to objective clinical findings. The medical records should thoroughly document the following:
Age, hand dominance, and gender.
Mechanism of injury, including details of symptom onset (date), progression, triggering event (if present) versus gradual onset, and activity at or before symptom onset.
Prior occupational and non-occupational injuries to the same area, including specific prior treatments.
Location of symptoms.
Nature of symptoms, including pain, numbness, tingling, weakness, swelling, stiffness, limited movement, temperature change, moisture change, and color change.
Factors that exacerbate or alleviate symptoms, with identification of specific physical factors influencing the problem.
Timing of symptoms throughout the day, noting when they are at their best and worst (e.g., upon awakening, after work).
Evaluation of symptom improvement during periods away from work (weekends, vacations).
For traumatic injuries, documentation of whether the area was swollen and, if so, the speed of swelling occurrence (immediate or delayed).
Observation of hand/finger deformity.
Utilization of comprehensive pain diagrams to enhance the localization of pain symptoms.
Assessment of sleep disturbances.
Identification of other associated signs and symptoms reported by the patient.
Evaluation of the ability to perform work activities and activities of daily living (ADLs), assessing the overall degree of restriction or combination of restrictions.
Discussion of any symptoms present in the uninjured extremity.
Exploration of the relationship to work, including a statement about the likelihood that the illness or injury is work-related.
Inquiry about treatments used for current symptoms, such as medications, splints, ice/heat, rest, surgery, and others. Assessment of the effectiveness of these treatments and identification of any that were not helpful.
Past History
Past medical history includes, but is not limited to, neoplasm, gout, arthritis, diabetes, overweight/obesity, hypothyroidism, other endocrinopathy, pregnancy, osteoarthrosis, rheumatoid arthritis, other arthritides, renal disease, systemic lupus erythematosus, and spondyloarthropathy. The review of systems includes, but is not limited to, symptoms of rheumatologic, neurologic, endocrine, neoplastic, and other systemic diseases. Additionally, the past medical history should cover the patient’s smoking history, vocational and recreational pursuits, previous testing, imaging or diagnostic studies, treatment outcomes, past surgical history, and psychosocial history.
Physical Examination
Examination should cover the joint above and below the affected area, with consideration for the opposite side for comparison. The physical examination should encompass accepted tests and exam techniques relevant to the joint or area under examination:
Visual Inspection
- Examine both hands, wrists, and forearms, noting asymmetries and looking for deformities indicative of degeneration, malformation, fracture, or dislocations. Observe for signs of serious injuries such as degloving injuries, lacerations, puncture wounds, open wounds, and crush injuries. Evaluate the neurologic and vascular status of the hand, wrist, forearm, and upper limb, including peripheral pulses, motor function, reflexes, sensory status, and any dystrophic changes or variations in skin color or turgor. Examining the neck and cervical nerve root function is also recommended for most patients.
Palpation
Range of Motion/Quality of Motion (Active and Passive)
- Determine the range of motion (ROM) of the hand, wrist, and forearm both actively and passively. Compare the mobility of the affected and unaffected sides.
Strength (Weakness/Atrophy)
Joint Integrity/Stability
- Stress the ligaments to assess stability and compare to the contralateral unaffected side.
Examination for Deformity, Displacement, Swelling
Assess Neurologic (Motor, Sensory, and Reflexes) and Vascular Status
- Evaluate the integrity of distal circulation, peripheral pulses, skin temperature of the foot and ankle, as clinically indicated. Examining the neck and cervical nerve root function is also recommended for most patients. Observe for signs of serious injuries, such as degloving injuries, lac
Red Flags
- Certain findings, termed “red flags,” raise suspicion of potentially serious and urgent medical conditions. Assessment (history and physical examination) should include an evaluation for red flags that require urgent/emergent assessment and treatment, as clinically indicated. The Hand Wrist and Forearm MTG incorporate changes in clinical management triggered by “red flags.”
Assessing Red Flags
- Early consultation by a hand or upper limb specialist, rheumatologist, or other relevant specialist is recommended based on the provider’s training and experience in dealing with the particular disorder.
Rehabilitation Principles
Rehabilitation (supervised formal therapy) necessitated by a work-related injury should concentrate on reinstating the functional ability essential for the patient’s daily and work activities, ultimately aiming for a return to work and endeavoring to restore the injured worker to their pre-injury state to the extent feasible.
Active therapy involves the patient’s internal effort to carry out specific exercises or tasks. In contrast, passive therapy encompasses interventions not demanding exertion from the patient but relying on modalities administered by a therapist. Generally, passive interventions are considered a means to enhance progress in an active therapy program, concurrently achieving objective functional improvements. Emphasis should be placed on active interventions over passive ones.
Patients should receive guidance to continue both active and passive therapies at home as an extension of the treatment process to sustain the achieved improvement levels. Assistive devices may be incorporated as a supplementary measure into the rehabilitation plan to facilitate functional gains.
