Clinical case study: Painful wrist

Scenario

De Quervain's Tenosynovitis

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Samantha, a 48 year old right handed community physiotherapy assistant, attends your GP practice. She complains of a 2 week history of right wrist pain. On further consultation she indicates that she had just put together a large number of information packs at work with repeated use of a stapler and feels this caused her wrist pain. Her job usually involves assisting patients undergoing physiotherapy and she says that this does not involve such repetitive use of her wrist.

The GP consultation

What are the possible diagnoses?

De Quervain's Tenosynovitis
Osteoarthritis of the first carpo-metacarpal joint.

On assessment you note that she has a positive Finklestein's test.

How would you perform this test and what is the diagnosis?

The Finklestein's test is performed as follows:

Pull the thumb in ulnar deviation and longitudinal traction. If there is an increased pain in the radial styloid process and along the length of the extensor pollicis brevis and abductor pollicis longus tendons, then the test is positive.

The diagnosis is: De Quervain's Tenosynovitis.

What other test(s) can you use in order to exclude other conditions that you have listed as a differential diagnosis?

Osteoarthritis of the first carpo-metacarpal joint can be tested for using the 'grind test'. This is performed by compressing and rotating the proximal phalanx and metacarpal of the thumb on the trapezium. Pain is noted at the CMC joint.

What management would you initially advise?

Rest (by signing her as unfit for work using the fit note) and also prescribing anti-inflammatory agents.

You review her 3 weeks later. She is much better and assessment reveals normal right hand and wrist function with no tenderness or ongoing signs. You advise her that she can return to work. However, she is reluctant to return to work and has concerns about the same issue happening again.

What would you do to enable her to return to work while also managing her concerns?

Complete a fit note indicating that she is fit to return to work but with restriction on repeated activities (e.g. stapling)
Advise a referral by the employer to a local Occupational Health service for further assessment and guidance on adjustments at work.

She has also heard of legislation from her union representative and asks you whether her case needs to be reported via RIDDOR.

Where would a GP find information about RIDDOR and RIDDOR reporting?

RIDDOR refers to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013. The Regulations put duties on employers, the self-employed and people in control of work premises (the Responsible Person) to report certain serious workplace accidents, occupational diseases and specified dangerous occurrences (near misses). Accident reporting under RIDDOR is different to disease reporting (i.e. reporting of an accident does not need to go through the requirement of being diagnosed by a doctor before it can be reported).

You advise Samantha that RIDDOR reporting (if appropriate) is the responsibility of her employer and that seeking advice/assistance from her union representative about how to take this forward is appropriate.

Her employer facilitates a referral to a local Occupational Health service.

The Occupational Health Service consultation

A GP with a special interest (GPwSI) in Occupational Medicine who undertakes sessions at your local hospital's Occupational Health service assesses her. The GPwSI receives the following referral letter from her employer:

Samantha has been recently struggling with pain and difficulty moving her right wrist. This followed a period when she spent four consecutive days assembling some information sheets and stapling them together. She has seen her GP who feels it is work-related repetitive strain injury (RSI). She was off sick for 3 weeks with this and she is worried that the pain may recur and cause problems carrying out some of her duties.

Can you please advise on her fitness for work and whether she needs reasonable adjustments?

Could you also provide advice on whether what has happened to Samantha is RIDDOR reportable?

What information would the occupational physician expect to find in the manager's referral letter?

Demographic details (Name, address, DOB)
Job title
Patient information (email address if available; contact telephone numbers)
Job description/duties, if not explicit from job title
Background information (history of the issue)
Reasons for referral; any specific questions to answer
Sickness absence record
Details of employment-related concerns
Contact details of the Manager and designated Human Resource Officer (e.g. secure email addresses)
Information confirming that the manager had informed the lady about the referral to the occupational physician and that the lady had consented to the referral.

The GPwSI takes an occupational history. Samantha reports that she is based in a Health Centre and as part of a recent health promotion campaign she had to put together multiple information packs using a stapler. After a few days she developed right wrist pain and visited her GP (you), who had advised a period of rest (away from work) and that she should use an anti-inflammatory gel.

She was away from work on sick leave for a total period of 3 weeks, as instructed by you. She had also been using a wrist splint, which she was given by one of her work colleagues, but is no longer using this. Her pain has now fully resolved.

What information would the GPwSI need to obtain from Samantha about her job?

Hours of work
How her work tasks are structured throughout the day
What time pressures and deadlines she is required to work to
Whether there had been any recent change(s) to her work duties recently, including details about producing the health promotion information packs
Details about work tasks and what she does at work
In addition to physical factors, perceived workload, job stressors and job satisfaction should be explored
Have any other colleagues had similar problems?
Were her symptoms better when away from work, e.g. over weekends or rest days?
Has she got another job as well as being a physiotherapy assistant?

The repeated stapling task takes place in a specific month each year. During this month staff members would need to manually staple several thousand packs over a period of a few days and move heavy boxes containing printed materials from various floors of the building.

What additional non-work related issues could the GPwSI ask about during the consultation?

Whether there had been any local trauma
Whether she had been undertaking "unusual" tasks at home, e.g. DIY tasks such as painting/decorating
Information on the patient's sporting activities
Information about hobbies.

There were no other obvious triggers or injuries that might have caused Samantha's symptoms.

After examining Samantha, the GPwSI confirms that she is symptom free. The GPwSI writes to inform the manager that the medical problem has resolved and that Samantha is fit to return to work. The GPwSI also provides the manager with advice about further measures that should be taken.

What additional actions would the GPwSI advise the manager to take at this stage?

A risk assessment needs to be performed for this lady's job duties
To extend the risk assessment to her colleagues
Postural/ergonomic adjustments could provide a solution*
Task modification/job rotation needs to be considered to prevent recurrence.

*Some people might question this action, but an electric stapler could be considered to be an 'ergonomic' adjustment.

What advice should the GPwSI give the patient and manager on work-related issues?

In Samantha's case the temporal factors indicate that a work-related activity may have caused/aggravated her symptoms.
A risk assessment would be helpful to look at her range of tasks and therefore identify operationally feasible control measures. Reassure the manager that the process can identify useful changes in practice to help Samantha fulfil her role (long term).
Modification to her job may be required for her to be in work and remain symptom free. This might include alteration of workload, modification of workstation (i.e. where the work is undertaken), use of automation (e.g. an electric stapler), extending the stapling task over a more extended period, task rotation to prevent over use of the wrist.
Manual handling tasks should also be assessed in terms of risk, as Samantha described moving heavy boxes containing printed materials from various floors of the building. What "tools" are available for this task (e.g. trolleys) and what could/should be provided to reduce the manual handling component (e.g. printed materials being stored on one floor with easy access and space for the related task).
The manager and the employee should discuss any psychobiosocial issues (e.g. lone working, isolation, etc.) associated with the job and explore the employee's perception of the workload and any job stressors.
The GPwSI will advise her and her manager of a return to work programme. [Note: Any GPwSI recommendations need to be agreed with the manager].
Samantha needs to inform the occupational physician and her manager if she experiences any difficulties with the rehabilitation programme.
There is legislation relating to her employment and work tasks (Health and Safety at Work etc Act 1974, Management of Health and Safety at Work Regulations 1999).

The RIDDOR issue

The GPwSI should also provide advice on whether Samantha's wrist pain episode needs reporting under RIDDOR, and therefore review the guidance in RIDDOR on work-related upper limb disorders (WRULDs).

What is the specific guidance on RIDDOR reporting for work related upper limb disorders, and if applicable who should submit a RIDDOR report?

Work related upper limb disorders are reportable if there is tendonitis or tenosynovitis of the hand or forearm where work is physically demanding and involves frequent repetitive movements.
A reportable disease must be diagnosed by a doctor. Diagnosis includes identifying any new symptoms, or any significant worsening of existing symptoms. For employees, they need to provide the diagnosis in writing to their employer. Doctors are encouraged to use standard wording when describing reportable diseases on written statements they make out for their patients.
Reporting is done online and reported by the employer or anyone in control of premises (i.e. a Responsible Person).

What clinical, ethical and legal factors should the GPwSI consider when advising on RIDDOR reporting?

To carefully consider the chronology of events when considering/advising on RIDDOR reporting
The importance of not making a knee-jerk judgement when reporting under RIDDOR - the physician must consider the criteria carefully in the context of the occupational demands
The importance of considering a potential hidden agenda for compensation/industrial injury claims
The need to remain objective and impartial when formulating an opinion.

Summary

From your clinical practice you will be well aware of having to use a multifaceted approach to dealing with similar cases to this one.

Clinical treatment and ergonomic considerations may play relatively small parts in the long term outcome. However, modifications of working practices, task rotation and taking into account the impact of behavioural and interpersonal relationships between employers and employees may be highly relevant in a successful rehabilitation.