![](media/image1.png){width="5.96875in" height="0.41944444444444445in"}

Top of Form

## Complete Summary

#### GUIDELINE TITLE

Forearm, wrist, & hand (acute & chronic), not including carpal tunnel
syndrome.

#### BIBLIOGRAPHIC SOURCE(S)

Work Loss Data Institute. Forearm, wrist, and hand (acute & chronic),
not including carpal tunnel syndrome. Corpus Christi (TX): Work Loss
Data Institute; 2007 May 16. 113 p. \[138 references\]

#### GUIDELINE STATUS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released.

-   [June 15, 2005, Non-Steroidal Anti-Inflammatory Drugs
    (NSAIDs)](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#NSAID):
    U.S. Food and Drug Administration (FDA) recommended proposed
    labeling for both the prescription and over the counter (OTC) NSAIDs
    and a medication guide for the entire class of prescription
    products.

-   [April 7, 2005, Non-steroidal anti-inflammatory drugs (NSAIDS)
    (prescription and OTC, including ibuprofen and
    naproxen)](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#BEXTRA):
    FDA asked manufacturers of prescription and non-prescription (OTC)
    non-steroidal anti-inflammatory drugs (NSAIDs) to revise their
    labeling to include more specific information about potential
    gastrointestinal (GI) and cardiovascular (CV) risks.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Work-related injuries of forearm, wrist, and hand, not including carpal
tunnel syndrome

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Orthopedic Surgery\
Physical Medicine and Rehabilitation

#### INTENDED USERS

Advanced Practice Nurses\
Health Care Providers\
Health Plans\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To offer evidence-based step-by-step decision protocols for the
assessment and treatment of workers\' compensation conditions

#### TARGET POPULATION

Workers with occupational injuries of the forearm, wrist, and hand
(excluding carpal tunnel syndrome)

#### INTERVENTIONS AND PRACTICES CONSIDERED

The following interventions/procedures were considered and recommended
as indicated in the original guideline document:

1.  Activity restrictions/work modifications

2.  Anesthesia, transdermal (for percutaneous trigger finger release)

3.  Arthrodesis (fusion)

4.  Arthroplasty, finger and/or thumb (joint replacement)

5.  Bone-growth stimulators in selected long bone fractures

6.  Casting, fiberglass and plaster

7.  Cold/heat packs

8.  Computed tomography (CT) (see original guideline document for
    specific indications)

9.  Continuous passive motion (CPM)

10. De Quervain\'s tenosynovitis surgery

11. Dupuytren\'s release (fasciectomy or fasciotomy)

12. Early mobilization (after tendon repair)

13. Exercises

14. Steroid injection for de Quervain\'s tenosynovitis and trigger
    finger

15. Magnetic resonance imaging (MRI) (see original guideline document
    for specific indications)

16. Mallet finger splinting

17. Mallet finger surgery

18. Nonprescription medication: acetaminophen, non-steroidal
    anti-inflammatory drugs (NSAIDs)

19. Occupational therapy/physical therapy

20. Percutaneous release (of trigger finger or trigger thumb)

21. Radiography

22. Return to work

23. Splints

24. Tendon repairs

25. Trapeziectomy

26. Triangular fibrocartilage complex (TFCC) reconstruction

27. Ultrasound (diagnostic)

28. Ultrasound fracture healing (bone-growth stimulators)

29. Vitamin C

30. Work

31. Yoga

The following interventions/procedures are under study and are not
specifically recommended:

1.  Casting versus splinting

2.  Ergonomic interventions

3.  Iontophoresis

4.  Pulsed electromagnetic field

The following interventions/procedures were considered, but are not
recommended:

1.  Acupuncture

2.  Arthroplasty, wrist (joint replacement)

3.  Chiropractic/manipulation

4.  Immobilization/rest as primary treatment

5.  Surgery for broken wrist (in the absence of displacement or delayed
    healing)

6.  Transcutaneous electrical neurostimulation (TENS)

7.  Ultrasound (therapeutic)

#### MAJOR OUTCOMES CONSIDERED

Effectiveness of treatments in relieving pain, improving stability, and
restoring normal function

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Work Loss Data Institute (WLDI) conducted a comprehensive medical
literature review (now ongoing) with preference given to high quality
systematic reviews, meta-analyses, and clinical trials published since
1993, plus existing nationally recognized treatment guidelines from the
leading specialty societies. WLDI primarily searched MEDLINE and the
Cochrane Library. In addition, WLDI also reviewed other relevant
treatment guidelines, including those in the National Guideline
Clearinghouse, as well as state guidelines and proprietary guidelines
maintained in the WLDI guideline library. These guidelines were also
used to suggest references or search terms that may otherwise have been
missed. In addition, WLDI also searched other databases, including MD
Consult, eMedicine, CINAHL, and conference proceedings in occupational
health (i.e. American College of Occupational and Environmental medicine
\[ACOEM\]) and disability evaluation (i.e. American Academy of
Disability Evaluating Physicians \[AADEP\], American Board of
Independent Medical Examiners \[ABIME\]). Search terms and questions
were diagnosis, treatment, symptom, sign, and/or body-part driven,
generated based on new or previously indexed existing evidence,
treatment parameters and experience.

In searching the medical literature, answers to the following questions
were sought: (1) If the diagnostic criteria for a given condition have
changed since 1993, what are the new diagnostic criteria? (2) What
occupational exposures or activities are associated causally with the
condition? (3) What are the most effective methods and approaches for
the early identification and diagnosis of the condition? (4) What
historical information, clinical examination findings or ancillary test
results (such as laboratory or x-ray studies) are of value in
determining whether a condition was caused by the patient\'s employment?
(5) What are the most effective methods and approaches for treating the
condition? (6) What are the specific indications, if any, for surgery as
a means of treating the condition? (7) What are the relative benefits
and harms of the various surgical and non-surgical interventions that
may be used to treat the condition? (8) What is the relationship, if
any, between a patient\'s age, gender, socioeconomic status and/or
racial or ethnic grouping and specific treatment outcomes for the
condition? (9) What instruments or techniques, if any, accurately assess
functional limitations in an individual with the condition? (10) What is
the natural history of the disorder? (11) Prior to treatment, what are
the typical functional limitations for an individual with the condition?
(12) Following treatment, what are the typical functional limitations
for an individual with the condition? (13) Following treatment, what are
the most cost-effective methods for preventing the recurrence of signs
or symptoms of the condition, and how does this vary depending upon
patient-specific matters such as underlying health problems?

**Criteria for Selecting the Evidence**

Preference was given to evidence that met the following criteria: (1)
The article was written in the English language, and the article had any
of the following attributes: (2) It was a systematic review of the
relevant medical literature, or (3) The article reported a controlled
trial -- randomized or controlled, or (4) The article reports a cohort
study, whether prospective or retrospective, or (5) The article reports
a case control series involving at least 25 subjects, in which the
assessment of outcome was determined by a person or entity independent
from the persons or institution that performed the intervention the
outcome of which is being assessed.

More information about the selection of evidence is available in
\"Appendix. ODG Treatment in Workers\' Comp. Methodology description
using the AGREE instrument\" (see \"Availability of Companion
Documents\" field).

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Ranking by Type of Evidence**

1.  Systematic Review/Meta-Analysis

2.  Controlled Trial-Randomized (RCT) or Controlled

3.  Cohort Study-Prospective or Retrospective

4.  Case Control Series

5.  Unstructured Review

6.  Nationally Recognized Treatment Guideline (from
    [www.guideline.gov](http://www.guideline.gov/))

7.  State Treatment Guideline

8.  Other Treatment Guideline

9.  Textbook

10. Conference Proceedings/Presentation Slides

**Ranking by Quality within Type of Evidence**

a.  High Quality

b.  Medium Quality

c.  Low Quality

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The Work Loss Data Institute (WLDI) reviewed each article that was
relevant to answering the question at issue, with priority given to
those that met the following criteria: (1) The article was written in
the English language, and the article had any of the following
attributes: (2) It was a systematic review of the relevant medical
literature, or (3) The article reported a controlled trial -- randomized
or controlled, or (4) The article reported a cohort study, whether
prospective or retrospective, or (5) The article reported a case control
series involving at least 25 subjects, in which the assessment of
outcome was determined by a person or entity independent from the
persons or institution that performed the intervention the outcome of
which is being assessed.

Especially when articles on a specific topic that met the above criteria
were limited in number and quality, WLDI also reviewed other articles
that did not meet the above criteria, but all evidence was ranked
alphanumerically (see the Rating Scheme of the Strength of Evidence
field) so that the quality of evidence could be clearly determined when
making decisions about what to recommend in the Guidelines. Articles
with a Ranking by Type of Evidence of Case Reports and Case Series were
not used in the evidence base for the Guidelines. These articles were
not included because of their low quality (i.e., they tend to be
anecdotal descriptions of what happened with no attempt to control for
variables that might effect outcome). Not all the evidence provided by
WLDI was eventually listed in the bibliography of the published
Guidelines. Only the higher quality references were listed. The criteria
for inclusion was a final ranking of 1a to 4b (the original inclusion
criteria suggested the methodology subgroup), or if the Ranking by Type
of Evidence was 5 to 10, the quality ranking should be an \"a.\"

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

Guideline developers reviewed published cost analyses.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Prior to publication, select organizations and individuals making up a
cross-section of medical specialties and typical end-users externally
reviewed the guideline.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary. The
recommendations that follow are based on the previous version of the
guideline.

**Initial Diagnosis**

1.  Determine the type of injury or contributing factors (direct trauma,
    fall, repetitive motion, twisting incident, animal bite, etc.)

2.  Determine whether the problem is acute, subacute, chronic, or of
    insidious onset.

3.  Record the severity and specific anatomic location of the pain
    asserted.

4.  Assess the ability of the patient to use the fingers, forearm,
    wrist, or hand, from no to full ability.

5.  Search for any evidence of an open or penetrating wound.

6.  Search for any evidence of deformity (anterior/posterior or
    lateral/medial) of the wrist or phalanges.

7.  Test the range-of-motion of the joint (normal, mild restriction,
    severe restriction, or complete restriction).

8.  Record any present medication.

9.  Elicit any previous medical history, history of systemic disease, or
    previous wrist or hand injury or disability.

**Presumptive Diagnosis**

-   **Fracture or Dislocation** (see original guideline document for
    International Classification of Diseases, Ninth Revision \[ICD-9\]
    codes for this and other diagnoses)

-   **Other diagnoses**:

    -   Sprain, sprain-fracture or contusion, excluding carpal tunnel
        syndrome (see separate chapter)

    -   Laceration

    -   Tenosynovitis

    -   Hand tendon injuries

    -   Superficial injury

**Fracture or Dislocation of Wrist**

A.  **Definitive Evaluation**

    -   Record a history of the cause of injury.

    -   Search for any evidence of an open wound in the vicinity of the
        injury.

    -   Perform a clinical examination for deformity, tenderness, or
        ecchymosis, or associated nerve, neurovascular, or tendon
        injury.

    -   Check for snuff box tenderness.

    -   Search for any evidence of dislocation or arterial vascular
        compromise (cold, dusky hand with loss of sensation). If found,
        an immediate reduction should take place (prior to x-rays, if
        necessary, or proper consultations).

    -   Perform an evaluation for an associated injury of the wrist or
        fingers.

    -   X-ray the wrist. Include a scaphoid view.

    -   Consider the easily missed scapholunate dissociation, or
        scaphoid fracture.

```{=html}
<!-- -->
```
B.  **Initial Therapy**

    1.  Simple, undisplaced, stable fractures of the wrist can be
        treated by the primary care physician.

        a.  Place the wrist in a plaster or sugar tong splint for seven
            to ten days, and then change to a short arm cast.

        b.  Ice prior to application of cast, if applicable, and elevate
            for 4 to 7 days to prevent or reduce swelling (Hand Higher
            than Heart - HHH).

        c.  Give the patient instructions to prevent tight cast
            problems.

        d.  Analgesics and/or nonsteroidal anti-inflammatory drugs for
            up to two weeks may be appropriate.

        e.  Recheck at seven days and then at two-week intervals until
            healed. Repeat x-rays at seven days and at two weeks to
            assure that the fracture has not slipped. X-ray again at
            five weeks; in most cases, the cast can be removed at that
            time.

        f.  Estimate a return-to-work date for temporary transitional
            and regular work at each visit.

        g.  Prescribe temporary transitional and job modifications at
            each visit.

    ```{=html}
    <!-- -->
    ```
    2.  Undisplaced scaphoid fractures can be treated by the primary
        care physician.

        a.  With a negative x-ray but clinical suspicion of a scaphoid
            fracture (i.e., localized pain at snuff box following
            fall/trauma), a short arm thumb spica cast is used for seven
            to ten days. Then a repeat x-ray out of plaster is obtained
            to clarify the diagnosis. Rarely is a bone scan useful to
            confirm a suspected diagnosis of scaphoid fracture.

        b.  Confirmed scaphoid fractures should be immobilized in a
            short arm thumb spica cast for 10 to 12 weeks until healed
            by x-ray examination.

        c.  Analgesics and/or nonsteroidal anti-inflammatory drugs for
            up to two weeks may be appropriate.

        d.  Recheck at seven days and then at two-week intervals until
            healed. Treatment may be as long as 12 to 36 weeks.

        e.  Wrist x-rays should be taken at four to six weeks. It is
            often necessary to remove the cast to obtain the quality of
            x-rays necessary to determine healing status. Persistent
            fracture line on the x-ray and continued clinical tenderness
            over the scaphoid suggest delayed union that should prompt
            referral.

        f.  Estimate a return-to-work date for temporary transitional
            and regular work at each visit.

        g.  Prescribe temporary transitional and job modifications at
            each visit, and maybe a brace to prevent re-injury.

    ```{=html}
    <!-- -->
    ```
    3.  Minimally displaced fractures can be reduced and treated by a
        primary care physician with proper training.

        a.  Patients with minimally displaced fractures and no loss of
            length can have local anesthesia injected into the fracture;
            then the physician can perform a reduction. Parenteral
            analgesic will facilitate the reduction.

        b.  Ice prior to application of cast, if applicable, and elevate
            for up to seven days is appropriate to prevent or reduce
            swelling.

        c.  Apply a sugar tong splint with an ace bandage. Replace with
            a short arm cast after seven days or when swelling has
            subsided.

        d.  Give the patient instructions to prevent tight cast
            problems.

        e.  Analgesics and/or nonsteroidal anti-inflammatory drugs for
            up to two weeks may be appropriate.

        f.  Recheck at seven days and then at two-week intervals until
            healed.

        g.  Obtain x-rays after reduction, seven to ten days, and at
            four weeks.

        h.  Physical therapy (three to four visits) to teach patient
            range-of-motion and muscle-strengthening exercises is
            appropriate following removal of cast.

        i.  Estimate a return-to-work date for temporary transitional
            and regular work at each visit.

        j.  Prescribe temporary transitional and job modifications at
            each visit.

> Wrist fractures with any question of non-union and all other wrist
> fractures not described above should be referred to an orthopedic
> surgeon for care.
>
> Evaluate for delayed union, malalignment, or signs of associated
> tendon or nerve injury.
>
> Promptly refer to an orthopedic surgeon if one of these conditions is
> found, otherwise continue therapy.

+-----------------------------------------------------------------------+
| **Official Disability Guidelines (ODG) Return-To-Work Pathways -      |
| Fracture of Carpal Bone(s)**                                          |
|                                                                       |
| Stable, clerical/modified work: 1 day                                 |
|                                                                       |
| Stable, manual work: 7 days                                           |
|                                                                       |
| Reduction/manipulation, clerical/modified work: 7 days                |
|                                                                       |
| Reduction/manipulation, manual work: 21 days                          |
|                                                                       |
| Reduction/manipulation, heavy manual work: 56 days                    |
|                                                                       |
| **ODG Return-To-Work Pathways - Fracture of Radius and Ulna**         |
|                                                                       |
| Stable, clerical/modified work: 2 days                                |
|                                                                       |
| Stable, manual work: 14 days                                          |
|                                                                       |
| Reduction/manipulation, clerical/modified work: 14 days               |
|                                                                       |
| Reduction/manipulation, manual work: 28 days                          |
|                                                                       |
| Reduction/manipulation, heavy manual work: 42 days                    |
|                                                                       |
| Open surgery, clerical/modified work: 21 days                         |
|                                                                       |
| Open surgery, manual work: 56 days                                    |
|                                                                       |
| Open surgery, heavy manual work: 112 days                             |
|                                                                       |
| **ODG Return-To-Work Pathways - Dislocation of Wrist**                |
|                                                                       |
| Non-dominant arm, clerical/modified work: 0 days                      |
|                                                                       |
| Non-dominant arm, manual work: 14 days                                |
|                                                                       |
| Non-dominant arm, heavy manual work: 35 days                          |
|                                                                       |
| Dominant arm, clerical/modified work: 7 days                          |
|                                                                       |
| Dominant arm, manual work: 42 days                                    |
|                                                                       |
| Dominant arm, heavy manual work: 63 days                              |
|                                                                       |
| (See *ODG Capabilities & Activity Modifications for Restricted Work*  |
| under \"Work\" in the Procedure Summary of the original guideline     |
| document)                                                             |
+-----------------------------------------------------------------------+

**Other Diagnoses**

Record a history including the onset of symptoms, limitations of present
activity, and history of previous episodes, including type of treatment
and results.

The history should include the nature of symptoms (numbness, pain,
tingling), the time of day symptoms are experienced, and how the pain is
relieved.

Separate cases of true nerve root impairment from those that mimic
carpal tunnel syndrome (CTS). These include sprains, tenosynovitis,
contusions, and hand arm vibration syndrome (HAV).

X-rays are not usually needed, unless local pathology or referred pain
in the wrist from cervical spine pathology is suspected or the case is
persistent. In such cases, wrist or cervical spine x-rays are
appropriate.

Order laboratory studies including glycohemoglobin, sedimentation rate,
thyroid-stimulating hormone (TSH), and a Rheumatoid Factor, if
appropriate.

-   The initial evaluation of the wrist needs to include a careful
    history for type of injury and the possibility of both repetitive
    and vibration type injuries. It is extremely important to make sure
    that any painful injury of the wrist does not have its origin in the
    upper extremity or the neck. It is also important to evaluate the
    patient\'s history for avocational activities that may be the cause
    of or be aggravating the problem, as it is necessary to have the
    patient modify these activities if one is to successfully treat the
    problem.

-   The presumptive diagnosis is used to classify the type of problem
    prior to a thorough evaluation. Subsequent to a thorough evaluation,
    the diagnosis may change (e.g., if the physician classifies a
    patient with a sprain and the x-rays subsequently show a fracture).
    In such a case, therapy should follow the subsequent rather than the
    initial diagnosis.

-   An open wound in the vicinity of a fracture makes it a compound
    fracture, even if no clear connection to the fracture site is
    apparent. All compound fractures should be referred to an orthopedic
    surgeon for care.

-   Snuff box tenderness is often a sign of injury to the scaphoid bone.
    If symptoms persist for seven days or longer, repeated scaphoid view
    x-rays should be taken.

-   Trans-scaphoid perilunar dislocation is a rare, severe injury which
    should be referred to an orthopedic surgeon.

-   Scapholunate dissociation is the most frequent serious ligamentous
    injury of the wrist and is diagnosed by the \"Terry Thomas sign\" on
    wrist x-rays. There is a widening of the space between the lunate
    and the scaphoid on the anteroposterior view.

-   Magnetic resonance imaging (MRI) of the wrist shows:

    -   82% of triangular fibrocartilage (TFC) tears confirmed by
        arthroscopy (Injuries to the triangular fibrocartilage complex
        are a frequent cause of ulnar-sided wrist pain. The TFC is a
        complex structure that involves the central fibrocartilage
        articular disc, merging with the volar edge of the ulnocarpal
        ligaments and, at its dorsal edge, with the floors of the
        extensor carpi ulnaris and extensor digiti minimi.)

    -   50% of scapholunate ligament tears

    -   40% of intercarpal dorsal ligament tears

-   Arthroscopy is thought to be superior to arthrograms in delineating
    ligament tears.

-   Fluoroscopy exam is helpful in diagnosing tears and abnormal motion.

-   Undisplaced scaphoid fractures can be treated by the primary care
    physician. Those scaphoid fractures that are displaced or have a
    wide gap between the fragments should be immediately referred to an
    orthopedic surgeon, as they have a significant increased incidence
    of nonunion.

-   Wrist sprains are common industrial injuries, and must be
    differentiated from carpal tunnel syndrome and tendonitis.

-   Tendon injuries are not common with sprains, but it is important to
    check for such injuries as they require different therapy than a
    simple sprain.

-   Grade III sprains involve tears of the carpal ligaments and are
    impairing injuries. Clinically they have significant swelling,
    ecchymosis, and an unstable joint. These are the sprains that are
    more likely to have associated injury of tendons or nerves. Injuries
    to the triangular fibrocartilage complex (TFCC) may have pain and
    stiffness as the only relevant findings. These injuries should be
    referred to an orthopedic surgeon or hand surgeon for evaluation and
    treatment.

-   A wrist splint or short arm cast is sometimes necessary for the
    initial treatment of sprains which are very tender, swollen, and
    painful with motion. Splinting is continued until symptoms abate. An
    early nonresisted exercise program is indicated.

-   The Terry Thomas sign refers to the x-ray appearance of a widening
    gap between the two carpal bones of the wrist in patients with
    scapholunate dissociation. (Terry Thomas\'s teeth were apart when he
    smiled).

-   Imaging procedures are appropriate for sprains that have been
    treated for six weeks with little or no improvement in the
    patient\'s complaints or physical findings. Repeat x-rays with
    scaphoid views are indicated, since routine anteroposterior and
    lateral x-rays generally fail to demonstrate scaphoid fractures.
    Additionally, an arthrogram may be of value to demonstrate carpal
    ligament tears and help determine the necessity of surgical therapy,
    but should be obtained only after a consultation with an orthopedic
    surgeon.

-   A laceration produced by crush injury needs an x-ray to rule out any
    underlying fracture and to answer any question of penetration of the
    joint or a foreign body in the wound.

-   Neurovascular and tendon function need evaluation with any
    laceration around a joint. No anesthesia should be used in the wound
    until the sensation has been checked distal to the laceration and
    the function of the tendons has been identified as intact.

-   Antibiotic therapy for contaminated lacerations should include both
    anti-staphylococcal and broad-spectrum coverage.

-   Tenosynovitis is a common enthesopathy of the tendon of the wrist.
    It is most important to rule out infection, for this is an emergent
    problem that requires prompt referral. Infectious tenosynovitis will
    usually demonstrate marked tenderness and more pain than
    noninfectious tenosynovitis. The patient with septic tenosynovitis
    will frequently have an elevated temperature, lymphangitis,
    erythematous swelling, and severe pain with attempted motion along
    with an elevated white blood count.

-   Ganglions of the wrist are benign synovial cysts and usually do not
    require treatment. An initial aspiration with injection of
    corticosteroids is acceptable. There is a 50% recurrence rate. With
    an accurate diagnosis, no further treatment is necessary. Surgery,
    though commonly done, has a significant recurrence rate and is only
    indicated in unusually symptomatic wrists.

-   Placing the wrist in a splint post injection for a short time is
    often helpful.

-   Hand arm vibration syndrome (HAV) is a relatively common industrial
    injury in workers whose job involves work with frequent and
    sustained vibrations. Sensory impairment of the fingers and
    Raynaud\'s phenomenon are the common complaints. It must be
    differentiated from carpal tunnel syndrome, as the treatment is
    never surgical for HAV. The treatment is primarily reduction of
    vibration exposure and taking a slow release calcium channel blocker
    (e.g., nifedipine).

-   Acute carpal tunnel syndrome (CTS) occasionally occurs with acute
    trauma to the wrist, most commonly with severe sprains. It can occur
    in fractures and with a direct blow to the volar aspect of the
    wrist. There is rapid and intense development of symptoms with
    paresthesias, pain, and numbness in the distribution of the median
    nerve. This is an urgent (four to eight hours) surgical problem. It
    can be differentiated from other problems by the measurement of the
    pressure in the carpal tunnel.

-   Acute episodes of traumatic arthritis frequently follow minor wrist
    fractures and severe sprains. One of the common sites of traumatic
    arthritis of the wrist is the trapezio-metacarpal joint at the base
    of the first metacarpal. Persistent and increasing impairment of
    this joint from arthritis often requires surgical treatment.

+-----------------------------------------------------------------------+
| **ODG Return-To-Work Pathways - Sprains and Strains of Wrist and      |
| Hand**                                                                |
|                                                                       |
| Mild, clerical/modified work: 0 days                                  |
|                                                                       |
| Mild, manual work: 5 days                                             |
|                                                                       |
| Moderate, clerical/modified work: 7 days                              |
|                                                                       |
| Moderate, manual work: 21 days                                        |
|                                                                       |
| Severe, clerical/modified work: 10 days                               |
|                                                                       |
| Severe, manual work: 35 days                                          |
|                                                                       |
| **Return-To-Work Pathways - Dislocation of wrist**                    |
|                                                                       |
| Non-dominant arm, clerical/modified work: 0 days                      |
|                                                                       |
| Non-dominant arm, manual work: 14 days                                |
|                                                                       |
| Non-dominant arm, heavy manual work: 35 days                          |
|                                                                       |
| Dominant arm, clerical/modified work: 7 days                          |
|                                                                       |
| Dominant arm, manual work: 42 days                                    |
|                                                                       |
| Dominant arm, heavy manual work: 63 days                              |
|                                                                       |
| Triangular fibrocartilage complex (TFCC) reconstruction,              |
| clerical/modified work: 42 days                                       |
|                                                                       |
| TFCC reconstruction, heavy manual work: 180 days                      |
|                                                                       |
| **ODG Return-To-Work Pathways - Dislocation of finger**               |
|                                                                       |
| Non-dominant hand, clerical/modified work: 0 days                     |
|                                                                       |
| Non-dominant hand, manual work: 4 days                                |
|                                                                       |
| Dominant hand, clerical/modified work: 7 days                         |
|                                                                       |
| Dominant hand, manual work: 14                                        |
|                                                                       |
| **ODG Return-To-Work Pathways - Contusion of Upper Limb**             |
|                                                                       |
| Superficial contusions: 0 days                                        |
|                                                                       |
| Deep contusions, clerical/modified work: 5 days                       |
|                                                                       |
| Deep contusions, manual work: 21 days                                 |
|                                                                       |
| **ODG Return-To-Work Pathways - Open Wound of Elbow, Forearm, and     |
| Wrist**                                                               |
|                                                                       |
| Minor: 0 days                                                         |
|                                                                       |
| Major, clerical/modified work: 3 days                                 |
|                                                                       |
| Major, manual work: 8 days                                            |
|                                                                       |
| Tendon repair, clerical/modified work: 14 days                        |
|                                                                       |
| Tendon repair, manual work: 91 days                                   |
|                                                                       |
| **ODG Return-to-Work Pathways - Open wound of finger**                |
|                                                                       |
| Minor, clerical/modified work: 0 days                                 |
|                                                                       |
| Minor, heavy manual work: 10 days                                     |
|                                                                       |
| Major, clerical/modified work: 3 days                                 |
|                                                                       |
| Major, heavy manual work: 21 days                                     |
|                                                                       |
| With tendon involvement, clerical/modified work: 14 days              |
|                                                                       |
| With tendon involvement, heavy manual work: 49 days                   |
|                                                                       |
| **ODG Return-To-Work Pathways - Trigger Finger**                      |
|                                                                       |
| Medical treatment: 0 days                                             |
|                                                                       |
| Surgical release, clerical/modified work: 14 days                     |
|                                                                       |
| Surgical release, manual work: 28 days                                |
|                                                                       |
| **ODG Return-To-Work Pathways -- de Quervain\'s Tenosynovitis**       |
|                                                                       |
| Medical treatment, clerical/modified work: 0 to 1 days                |
|                                                                       |
| Medical treatment, manual work: 10 days                               |
|                                                                       |
| Medical treatment, regular work if cause of disability: 42 days       |
|                                                                       |
| Medical treatment, heavy manual work: 56 days                         |
|                                                                       |
| Surgical release, clerical/modified work: 14 days                     |
|                                                                       |
| Surgical release, manual work: 42 days                                |
|                                                                       |
| **ODG Return-To-Work Pathways - Radial Styloid Tenosynovitis**        |
|                                                                       |
| Medical treatment, clerical/modified work: 0 to 1 days                |
|                                                                       |
| Medical treatment, manual work: 10 days                               |
|                                                                       |
| Medical treatment, regular work if cause of disability: 42 days       |
|                                                                       |
| Medical treatment, heavy manual work: 56 days                         |
|                                                                       |
| Surgical release, clerical/modified work: 14 days                     |
|                                                                       |
| Surgical release, manual work: 42 days                                |
|                                                                       |
| **ODG Return-To-Work Pathways - Other Tenosynovitis or Hand and       |
| Wrist**                                                               |
|                                                                       |
| Medical treatment, clerical/modified work: 0 days                     |
|                                                                       |
| Medical treatment, manual work: 21 days                               |
|                                                                       |
| Medical treatment, heavy manual work: 35 days                         |
|                                                                       |
| Surgical treatment, clerical/modified work: 7 days                    |
|                                                                       |
| Surgical treatment, manual work: 21 days                              |
|                                                                       |
| **ODG Return-To-Work Pathways - Ganglion and Cyst of Synovium,        |
| Tendon, and Bursa**                                                   |
|                                                                       |
| Asymptomatic: 0 days                                                  |
|                                                                       |
| Aspiration, clerical/modified work: 0 days                            |
|                                                                       |
| Aspiration, manual work: 3 days                                       |
|                                                                       |
| Excision of wrist ganglion, clerical/modified work: 7 days            |
|                                                                       |
| Excision of wrist ganglion, manual work: 14 days                      |
|                                                                       |
| Excision of wrist ganglion, manual work, dominant arm: 14 to 21 days  |
+-----------------------------------------------------------------------+

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

During the comprehensive medical literature review, preference was given
to high quality systematic reviews, meta-analyses, and clinical trials
over the past ten years, plus existing nationally recognized treatment
guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure
Summary (see the original guideline document), which provides a concise
synopsis of effectiveness, if any, of each treatment method based on
existing medical evidence. Each summary and subsequent recommendation is
hyper-linked into the studies on which they are based, in abstract form,
which have been ranked, highlighted and indexed.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

These guidelines unite evidence-based protocols for medical treatment
with normative expectations for disability duration. They also bridge
the interests of the many professional groups involved in diagnosing and
treating work-related injuries of the forearm, wrist, and hand.

#### POTENTIAL HARMS

-   Participants who underwent trapeziectomy with ligament
    reconstruction and tendon interposition had 11% more adverse effects
    (including scar tenderness, tendon adhesion or rupture, sensory
    change, or Complex Regional Pain Syndrome Type 1).

-   There is a risk of troublesome complications after trigger finger
    surgery.

-   The overall complication rate in patients who underwent Dupuytren\'s
    release (fasciectomy or fasciotomy) was 26%. Nerve lesions occurred
    in 7.7%.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Contraindications to arthroplasty of the finger and/or thumb (joint
replacement) include:

-   Lack of stability (e.g., as a result of rheumatoid arthritis or
    destruction of the ligaments caused by an accident)

-   Nonreconstructable extensor tendons

-   Florid or chronic infection

-   Lack of patient compliance

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The Treatment Planning sections outline the most common pathways to
recovery, but there is no single approach that is right for every
patient and these protocols do not mention every treatment that may be
recommended. See the Procedure Summaries (in the original guideline
document) for complete lists of the various options that may be
available, along with links to the medical evidence.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Patient Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Work Loss Data Institute. Forearm, wrist, and hand (acute & chronic),
not including carpal tunnel syndrome. Corpus Christi (TX): Work Loss
Data Institute; 2007 May 16. 113 p. \[138 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 (revised 2007 May 16)

#### GUIDELINE DEVELOPER(S)

Work Loss Data Institute - Public For Profit Organization

#### SOURCE(S) OF FUNDING

Not stated

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Editor-in-Chief, Philip L. Denniston, Jr. and Senior Medical Editor,
Charles W. Kennedy, MD, together pilot the group of approximately 80
members. See the ODG *Treatment in Workers Comp* [Editorial Advisory
Board](http://www.disabilitydurations.com/advisoryboard.htm).

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

There are no conflicts of interest among the guideline development
members.

#### GUIDELINE STATUS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary.

#### GUIDELINE AVAILABILITY

Electronic copies of the updated guideline: Available to subscribers
from the [Work Loss Data Institute Web
site](http://www.odg-disability.com/).

Print copies: Available from the Work Loss Data Institute, 169 Saxony
Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992,
Fax: 760-753-9995; [www.worklossdata.com](http://www.worklossdata.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Background information on the development of the Official Disability
    Guidelines of the Work Loss Data Institute is available from the
    [Work Loss Data Institute Web
    site](http://www.disabilitydurations.com/ODG Treatment in Workers.htm).

-   Appendix. ODG Treatment in Workers\' Comp. Methodology description
    using the AGREE instrument. Available to subscribers from the [Work
    Loss Data Institute Web site](http://www.odg-disability.com/).

#### PATIENT RESOURCES

The following is available:

-   Appendix B. ODG Treatment in Workers\' Comp. Patient information
    resources. 2006.

Electronic copies: Available to subscribers from the [Work Loss Data
Institute Web site](http://www.odg-disability.com/).

Print copies: Available from the Work Loss Data Institute, 169 Saxony
Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992,
Fax: 760-753-9995; [www.worklossdata.com](http://www.worklossdata.com/).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on April 4, 2005. This NGC
summary was updated by ECRI on January 18, 2006, April 11, 2006,
November 9, 2006, March 29, 2007, and August 17, 2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

Bottom of Form

© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008