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A-1140 Return to work after hand and wrist injury
Joseph J. Dias, University Hospitals of Leicester NHS Trust, UK
Thursday, June 14, 2018 · 11:13 a.m. · 17m 16s
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which is what i thanks um two excellent thoughts one from jane um
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looking at um well um has causing a problem and um and um
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one from kevin from um michigan that talking about the impact of
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compensation on outcomes have my brief is a little bit different which i'm
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pleased yeah but i think both those areas uh so fraught
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that's difficult to come out but uh mechanisms that we can use as as handset
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so what what are hard to do was to talk to
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you about return to work after hand and wrist injury
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and this is not about that i'm just occupational injury or people that are compensated for the injuries
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now the but enough of um um hand injuries is huge and these
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account for between seven to twenty nine percent of all emergency presentations
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in emergency departments and these injuries kind of guy that during an occupation or at home
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in people that employed or in traffic accidents or even in sport in people that unemployed
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and all these people then at the end need to go back to work
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and we do know that hand injuries are the leading cause of occupational injury
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and um the this is again a european paper which shows that that rate is highest
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in manufacturing and you can also get it in construction industries the the highest numbers
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now that's paper from a doctor than lots of that stuff comes from that
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including stephen obvious and good service them and they put a published this paper
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but shows that hand and wrist injuries account for twenty eight percent
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all injuries in that system and they account for seventeen percent of all the cost
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so these are important things that that if you keep people out of work there's
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a button on your whole economy and the impact all this is quite huge
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so on average regardless of what type of hand injury that you get if you look at
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all your hand injuries to get that the mean time off work is forty five days
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okay across everything and it depends upon lots of stuff and there's very very good
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literature now that point says two words what we might be able to change
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and the the two papers one is from s. the steam esteban bernstein uh if yeah
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in in europe and the second one is from
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canada uh from london uh in ontario joy
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maternity andrew big rebel and the board come up with some of the things that
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yeah the does single factor that impacts opponent return to work the
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time of return to work is the severity of the injury
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if it is open or that is a tendon or scan last or
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it's complex tissue then it lincoln's the time to return to work
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immediately if we have got to do more than one operation that lincoln's the time of return to work
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older people take longer to return to work and the well the mountains
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all to is how how some um occupations return to work visa b. v. of is
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and we know some of that that is an address by jane uh yeah
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but uh pick it would be a problem is not just about compensation is also that the low uh
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pretty injury income predicts the return to work it langdon is the time to return to but
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we do not quite understand that and you can have a position in your head about
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how this might work but no one has yet fully explain how that affects it
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one of the ways that you can assess injury severity in your systems
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is to use a hand injury severity score which is from leeds
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by uh simon k. and up campbell and this looks at the five digits and
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looks at the tissues that's been tagged human skeleton the more to the nerve
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and then you generate a total i don't want to to read all the detail here just to say that the scoring mechanism
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and you go down and you come up but uh talk to school of the severity of the injury
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and that's about it be predicts the time to return to work
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so bad that the minds of factor that you bought no control over is the severity of the injury
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now the second thing for us to relies as clinicians is that patients go
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through these faces and we've seen bowed on the lawn and and you
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will hear hear later from my kate and how you can encourage patients in
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this journey of going from red being unable to use that hand
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too green to being able to restore the function in their own environment
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and the last steps that we take them through we take them for instance to um be our members
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of exercise but not use and you've seen don't emphasise that in the stock earlier earlier today
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we can also but fractures and you say use your uh use with k.
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but do not all we use because the healing is not complete yet
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and then regardless of what we do patients wind up with an impairment and the two
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impairments that have the biggest impact on return to work up pain and weakness
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it does not loss of apart it does not stiffness and surprisingly it's not human numbness
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but if you leave them having pain in an index finger they would transfer
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to the middle finger and the strength will go down by half
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so suddenly you had an impact on the person's ability to return to work
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and this of course then leads to handicap that they can't be
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that bad they can't on the money they can't keep
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the family the can't keep the house they can't keep a
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job and there's a huge knock on impact of handicap
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no one of the things that we did in one of the studies that that be reporting on on saturday is looked at
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from interviews look that uh what patients can say that was important and interesting thing is this
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that most patients to get hand injuries things it i think it is quite minor
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it's a small part it's not huge it's no big unless you're looking at amputations
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but most think it isn't mine now and then in the process of healing
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they identify the practical difficulties they can't do there's a pop icon of
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the pants up you know they can't reach the confident that child
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you know and all that and back then has an impact which is both psychological and social
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and it is that that we do not understand as as surgeons and that is what we need to get to grips but
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the psychological impact this is um uh so cock was a bit but taken from that
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another european paper and you can see the patient goes to these phases
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you know that uh there's the worry about fine and have running and the finances
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they become dependent upon their family members the become uncertain about how
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long it's going to take for them to start functioning
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dick start catastrophe rising and worrying about this and this self image
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takes a a big knock when they suddenly find that that purpose
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in life may suddenly change and may change for ever
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based upon what we do so that has a huge impact now when you look at return
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to work in most of the literature to use as a non return to but
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but underneath that no there is a whole host and we've seen some of
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jane's work um on this uh yeah that and this is some of the
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data taken from skateboard fact is one of the only uh papers
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um that it published maybe looked at return to work but in fact
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underneath that we bought on the left hand side a whole
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bunch of occupations that you can return to work even in the
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plus the cost and then the ones that are drivers
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here they can't return to work for legal reasons even and then finally these the heavy ones may
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take a long long time to return to work if you treat them in a cost
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same thing with return to spot and that depends upon what you do you can start
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playing chess while someone is operating on you but you cannot play rugby or football
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um uh a lot of tennis if your wrist is injured until it's all set and
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you and you know several of up is um who have wrist problems going for
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so the factors that affect return to work we've got about the into the fact is that we cannot alter
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yeah but there are other factors that we need to be aware of the first we've talked about patient
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it's that attitude about to return to work and that is one of
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the ones back compensation becomes a ball and chain stopping and slowing
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a bad recovery of a um back to sleep recovery of of function
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um and and we've had an excellent talk haven't pants fall back that that
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is the other side about bark and each person's work is independent
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there is that the mound on their hands and how they function with their hands both with
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regard to not just repetition enforced but also dexterity
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and how long you do that task
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so the duration of exposure and the ability to perform the box safely if you're a rule for
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and you are having coupling on certainly then you will be on safe
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on the lad uh oh you on save on the roof
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where you'd be perfectly fine if you will yeah i i'm on the ground so that changes
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there's a huge problem about employers but to clean the in the
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u. k. and depending upon the size of the file um
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um all the business pressure um they will change that attitude of
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how they deal with people but injuries begin law is
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to to uh on you know but um martin's uh uh spend says
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but encourage n. have systems or proper it and to work but small employers less than a hundred
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um staff and they suddenly have a different attitude and that really
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small ones less than twenty bucks trouble to the labour
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they bought targets if one member goes off it so did not have the capacity uh to deal with it
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but be a part of that and our part is mainly ignorance
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that be the not advise our patients properly right from the outset
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and it is the inadequate advice can also delay the time to
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return to work and all of these factors come together
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to pause an impact upon return to work now one of the studies that i'll be reporting
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on the idea that um on saturday morning is
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the prospective randomised study on skateboard fractures
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and you would see older to job to now says that if you
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fix escape for it then you'll likely to return to work
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nine to thirteen weeks uh the uh then you p. p. them and in
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the cost for instance margaret map means study from edinburgh but um uh
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the the one but that i want to share with you is this that firstly be looked at all
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these data and many of them went full time occupation now for these foreign thirty nine patients
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and you had a whole full stop different types of of activities but the
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surprising finding was that's a that when you compare had surgery but cost
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sorry my circle the bond slightly off than um but then when you compress
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surgery but cost then so did he say less than one day
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all work time compared to cost which is surprising
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what is even more surprising is that the median time off work
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for those treated the not cost was five days compared to
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nine days for those treated in but uh the surgery
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and finally the the proportions of those um reporting zero days off work
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is twenty eight percent for those didn't not cost compared to thirteen percent
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in um of those speeded up and it's um thirteen percent of those treated a and uh but surgery
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everything is topsy turvy and what we don't know is
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what made these people go back to but this
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is a multi centre is not a single sent a study it's right across the you pay
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so be didn't have assistant of advising now operations
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so patients do more patients do best which is they decide what helps them
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and if they think that going back to work and functioning helps them recover
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overall then they will go back to what so when you actually look at good data
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then you find some things that be the not even begin to comprehend
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of why a person in a cost returned to work within two
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weeks when the remainder not cost for eight to twelve weeks
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and the continued to work when they were already in the cost and
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that is really surprising you know so what should be changed
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um that the first bit um after into these a lot of
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things that we cannot implants we cannot implants injury severity
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we cannot influence the person's work and their life for all
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and we cannot influence legislation around the system all the companies
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in which there but we can't change any of that
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but that up three things that we can change as as surgeons the first
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is that at the outset when b. c. the fracture b.
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c. the injury of easy letterman problem or no problem
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or attendant problem we don't think of it in the
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narrow confines of ah speciality but think of it
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in the context of the patient so what the patient needs from me from as as
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surgeons is there an milestones and the milestones needs to be personalised to the person
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so you need to tell them but can they get dressed bank and
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they watch when can they drive when can they do housework
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you know when can they return to work and do they need the phase returned
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to work or can they going pop on the life rule quite quickly
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the second thing that we need to do that it's predict an impediment to be a note that at the
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fingers badly damaged may revise rise it but we know that thing that is going to be stiff
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and maybe painful remember that two factors that have an
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influence on but i'll hop pain and weakness
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so just bear that in mind and we need to put they be impairment from the injury that b. c.
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on day one and top of the patient about what the likely outcome is going to be in that
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uh injury and in that context will they get back to being being a concert pianist
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and you but to say them to the to them node pick up drums
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you know so you got to get them to start recognising
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what the final outcome is going to be and what to do that quite a bit
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the second thing that we need to do and we all quite for that this uh because uh systems don't support it
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and we don't work very closely with a bit bit occupational health
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beans and that is to coordinate right at the very outset
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between the treatment team ah is that it was out that at best started is et cetera
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the the patients workplace and the insurance carrier
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so we need to be coordinating that and they used to be a time in the nineties and eighties
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but it was better that you could do it better and a lot lot less good right now
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that we all were dismembered be all in all that would silos behind
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our hospitals and in our little bit meeting off let's attendant patients
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you know with the north seen them as patients needing to go back and start working
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and the third thing of course is to continuously feedback
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if we're seeing seeing a system of um
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injury in one occupation and one area of pop county or
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up country then we need to be flagging that now
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two teams like you was doing to make sure that they're not injury
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prevention mechanisms put in place and that is our role three things
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discuss with the patient that milestones
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improve coordination to help them determine to work
