Carpal Tunnel Syndrome and Work

Occupational Carpal Tunnel Syndrome: a scoping review of causes, mechanisms, diagnosis, and intervention strategies

Carpal Tunnel Syndrome (CTS) has traditionally been viewed as a specialized medical condition. However, its escalating prevalence among professionals across a multitude of industries has sparked substantial interest in recent years. This review aims to delve into CTS as an occupational disease, focusing on its epidemiological patterns, risk factors, symptoms, and management options, particularly emphasizing its relevance in professional environments. The complex interaction of anatomical, biomechanical, and pathophysiological factors that contribute to the development of CTS in different work settings underlines the critical role of ergonomic measures, prompt clinical identification, and tailored treatment plans in reducing its effects. Nevertheless, the challenges presented by existing research, including diverse methodologies and definitions, highlight the need for more unified protocols to thoroughly understand and tackle this issue. There's a pressing demand for more in-depth research into the epidemiology of CTS, its injury mechanisms, and the potential role of targeted medicine. Moreover, recognizing CTS's wider ramifications beyond personal health is essential. The economic burden associated with CTS-related healthcare costs, productivity losses, and compensation claims can significantly impact both businesses and the broader society. Therefore, initiatives aimed at preventing CTS through workplace interventions, education, and early intervention programs not only benefit the affected individuals but also contribute to the overall well-being of the workforce and economic productivity. By fostering a collaborative approach among healthcare professionals, employers, policymakers, and other stakeholders, we can strive towards creating safer and healthier work environments while effectively managing the challenges posed by CTS in occupational settings.

Platelet-rich plasma in non-operative management of mild to moderate carpal tunnel syndrome - A systematic review & meta-analysis of short-term outcomes

Background

To perform an updated systematic review with meta-analysis on trials focusing on patient-reported outcome measures (PROMs), nerve conduction studies (NCS) result and cross sectional area (CSA) measurements of those who underwent PRP injection for mild to moderate CTS, versus a control.

Conclusion

This study indicates that there may be a potential role for the use of PRP in the non-operative management of mild to moderate CTS results in improvements in pain scores, functional outcomes as well as CSA measurements of the MN at short-term follow-up. However, PRP does not result in improvements in NCS.

Level of evidence

II; Systematic Review & Meta-Analysis of Prospective Trials;

A pilot study: Exploring the musculoskeletal risk exposure associated with drying laundry using the public housing pipe-socket system amongst women in Singapore

BACKGROUND

The biomechanics of homemakers has been minimally studied. The way laundry-drying is performed in Singapore public-housing, using the pipe-socket-system (PSS), could expose the homemakers to musculoskeletal disorder risk.

OBJECTIVE

This study aims to quantify the musculoskeletal risk exposure (MRE) associated with laundry-drying amongst female homemakers using the PSS in Singapore public-housing.

METHODS

Using snowball sampling approach, five female homemakers familiar with the described laundry-drying method were recruited. The postures of the participants were analysed from video-recorded data and scored using the Rapid Entire Body Assessment (REBA).

RESULTS

This pilot study revealed very strong evidence (p = 0.001) that the participants were exposed to medium risk (REBA score 4.3) when performing this housework task.

CONCLUSIONS

Extreme awkward postures and repetitive motions were observed from the participants during the analysis. High REBA scores were frequently associated with the awkward postures adopted due to constraints of physical work space.

Ultrasound as a diagnostic tool in the investigation of patients with carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is reveled to be the most common peripheral nerve entrapment syndrome, estimating for 90% of all compressive. The diagnosis of CTS is based on the use of clinical criteria and imaging technique tests such as ultrasonography (US) and magnetic resonance imaging (MRI). US is a time-saving method in the diagnosis of CTS, which induces less discomfort to the patient and may be a more cost-effective approach to confirm clinical suspicion of this syndrome .The current study was aimed to evaluate the value of US and physical examinations in the diagnosis of CTS. This cross-sectional and cross-sectional prospective case study was conducted to evaluate the usefulness of wrist ultrasonography in diagnosing CTS. Twenty one patients (21 wrists) were invited to participate in the study along with an age- and sex-matched group of participant controls. Physical examination included Phalen, Tinel, Durkan, Tourniquet test. Anteroposterior and mediolateral dimension of carpal tunnel, and the median nerve area at the tunnel were also measured. All the patients underwent the open surgical release of the flexor retinaculum. There was a significant statistical relationship (p=0.05) between anteroposterior diameter of the carpal tunnel and clinical and electro physiologic nerve involvement. Furthermore, some qualitative findings was achieved such as median nerve splitting, hypo echogenicity of the involved nerve, thickening of flexor retinaculum and disappearance of median nerve areas (especially mediolateral direction). In conclusion, ultrasonographic examination of the wrists in the patients with suspected clinical symptoms can improve the diagnostic ability of CTS, especially by improving technology and experience. US can be applied for the median nerve area (MNA) measurement as a first line technique in patients with CTS.

Impact of keyboard typing on the morphological changes of the median nerve

Objectives:

The primary objective was to investigate the effects of continuous typing on median nerve changes at the carpal tunnel region at two different keyboard slopes (0° and 20°). The secondary objective was to investigate the differences in wrist kinematics and the changes in wrist anthropometric measurements when typing at the two different keyboard slopes.

Methods:

Fifteen healthy right-handed young men were recruited. A randomized sequence of the conditions (control, typing I, and typing II) was assigned to each participant. Wrist anthropometric measurements, wrist kinematics data collection and ultrasound examination to the median nerve was performed at designated time block.

Results:

Typing activity and time block do not cause significant changes to the wrist anthropometric measurements. The wrist measurements remained similar across all the time blocks in the three conditions. Subsequently, the wrist extensions and ulnar deviations were significantly higher in both the typing I and typing II conditions than in the control condition for both wrists (p<0.05). Additionally, the median nerve cross-sectional area (MNCSA) significantly increased in both the typing I and typing II conditions after the typing task than before the typing task. The MNCSA significantly decreased in the recovery phase after the typing task.

Conclusions:

This study demonstrated the immediate changes in the median nerve after continuous keyboard typing. Changes in the median nerve were greater during typing using a keyboard tilted at 20° than during typing using a keyboard tilted at 0°. The main findings suggest wrist posture near to neutral position caused lower changes of the median nerve.

Prognostic Variables for Patient Return-to-Work Interval Following Carpal Tunnel Release in a Workers' Compensation Population

BACKGROUND

We hypothesize that depressive and anxiety disorders, chronic pain conditions, and work-related factors are significant determinants of the time interval for return to work (RTW) in the workers' compensation (WC) population following carpal tunnel release (CTR) surgery.

METHODS

We retrospectively reviewed records of all WC patients who underwent open CTR surgery over a 5-year period by 1 of 3 fellowship-trained hand surgeons. One hundred fifty-two wrists in 108 patients (64 unilateral, 44 bilateral) met the inclusion criteria. Demographic, medical, and surgical data were obtained from patient records. Bivariate and multivariate analyses were performed to assess predictors of RTW.

RESULTS

Eighty-nine percent of all patients returned to work full-duty. Average RTW duration in all wrists was 12.5 ± 11.3 weeks. Predictors of delayed RTW in bivariate and multivariate analyses were depression with or without anxiety, chronic pain disorders including fibromyalgia, preoperative opioid use, and modified preoperative work status. Job type, motor nerve conduction velocity, and bilateral surgery were not predictive of delayed RTW interval.

CONCLUSIONS

WC patients with depression, anxiety, or fibromyalgia and other chronic pain disorders were significantly more likely to have delayed RTW following CTR than were WC patients without these conditions. In addition, those who use opioid medications preoperatively and those with preoperative work restrictions were also found to have a significantly delayed RTW after CTR. Knowledge of these risk factors may help care providers and employers identify those WC patients who are most likely to have a protracted postoperative recovery period.

Association between work-related biomechanical risk factors and the occurrence of carpal tunnel syndrome: an overview of systematic reviews and a meta-analysis of current research

BACKGROUND

Occupational risks for carpal tunnel syndrome (CTS) have been examined in various occupations, and several systematic reviews (SRs) have been published on this topic. There has been no critical appraisal or synthesis of the evidence in the SRs. The aims of this study are (1) to synthesise the observational evidence and evaluate the methodological quality of SRs that assess the effect of biomechanical risk factors on the development of CTS in workers, (2) to provide an update of current primary research on this association, (3) to assess a potential dose-response relationship.

METHODS

We searched MEDLINE, EMBASE, CINAHL, the Cochrane Library and the reference lists of articles. The first step covered SRs (1998-2014), and the second step covered current primary studies (2011-2014). The methodological quality of the SRs was evaluated by using the AMSTAR-R tool; primary studies were assessed using a list of 20 items. A qualitative approach was used for synthesising evidence. In addition, we undertook a meta-analysis of the primary studies to determine risk ratios in the dose-response relationship.

RESULTS

We identified ten SRs that covered a total of 143 original studies. Seven primary studies met the criteria for inclusion, of which four provided longitudinal data. We found high quality of evidence for risk factors such as repetition, force and combined exposures. Moderate quality of evidence was observed for vibration, and low quality of evidence was found for wrist postures. An association between computer use and CTS could not be established. Recent primary studies supported the existence of a significant relationship between CTS and repetition, force and combined exposure. The meta-analysis of current research revealed a dose-response relationship between CTS and the American Conference of Governmental Industrial Hygienists' (ACGIH) threshold limit value (TLV) for hand-activity level (HAL). Those between the action limit and TLV and above TLV had RR of 1.5 (95% CI 1.02-2.31) and RR 2.0 (95% CI 1.46-2.82), respectively.

CONCLUSIONS

Occupational biomechanical factors play a substantial role in the causation of CTS. Data from current primary studies on dose-response suggest that the risk of CTS increases with the ACGIH TLV levels.

The study of work behaviours and risks for occupational overuse syndrome

"Occupational overuse syndrome" is defined as the syndrome of work-related musculoskeletal disorders resulting from repetitive hand posture and motion. We looked at 867 employees in seven different factories to determine the groups suffering from trigger fingers, de Quervain's disease and carpal tunnel syndrome (CTS) from the period of January 2009 to November 2010. The inclusion and exclusion criteria were designated for the subjects in each group. We found the highest prevalence of the syndrome in the rate of CTS development. The differences in the hand spans and the grip strengths between the normal versus the diseased groups were statistically significant. The most common work patterns were a repetitive workload with the hand in a posture of a contracted grasping position. This accounted for 43.1% of the cases of trigger fingers, 38.1% in cases of CTS and this position with a contributing increased speed in the work pattern at 29.8% in the de Quervain's disease patients.

Carpal and cubital tunnel syndrome: who gets surgery?

BACKGROUND

Despite the prevalence of carpal and cubital tunnel syndrome, and relief of symptoms following timely surgical release, it is unclear how nonclinical patient characteristics affect disease management.

QUESTIONS/PURPOSES

We examined the effects of a variety of factors, such as age, gender, and socioeconomic status on the management of both carpal and cubital tunnel syndromes.

PATIENTS AND METHODS

We retrospectively reviewed the records of all 273 patients seen by two hand surgeons with a diagnosis of either carpal or cubital tunnel syndrome between January 2005 and January 2007. Demographic, clinical (diagnosis, treatment), and socioeconomic (insurance type, median income) information was collected. Census data (2000) were used to collect information on median household income. The average age was 52 years (range, 19-87 years), and 65% of the patients were women (n = 178). Eighteen patients had Workers Compensation. Of the 273 patients, 86 (32%) had two or more diagnoses.

RESULTS

Among patients with carpal tunnel syndrome, there was a higher proportion of female patients compared to male patients (68% versus 32%); male patients with multiple neuropathies had higher rates of surgery than their female counterparts (63% versus 41%). Only increasing age was associated with increasing likelihood of surgery. Among multiple-diagnosis patients, those with Workers Compensation (n = 6) had higher wait times for surgery than their counterparts (n = 46) (126 days versus 26 days).

CONCLUSION

Patient age was the most important predictor of surgical release, and among those with multiple neuropathies, male patients were more likely to have surgery than female patients. Patients with Workers Compensation may experience long wait times to surgery.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

A Holistic Evaluation of Risk Factors for Work-Related Musculoskeletal Distress Among Asymptomatic Sonographers Performing Neurosonology

A pilot study was conducted to gather holistic data points on female sonographers who executed neonatal neurosonography over four portable scanning sessions. The hypothesis was that specific risk factors contributed to work-related musculoskeletal distress in the hand and wrist as a result of neonatal neurosonography. A preexperimental pre-post research design was used to gather data on work demands, self-rated physical and mental health, posture/position during scanning, physiologic change, and pain scores. No statistically significant changes were detected between pre-post measures for work demands, physical and mental health, or pain scores as a result of portable scanning sessions. The physiologic changes, between scanning sessions, were recorded with the use of a hand-carried sonographic unit. Sonographic measures were less than the published criteria for carpal tunnel syndrome with a proximal cross-sectional area ≥10 mm 2 and an anterior bulge of the retinaculum of >4 mm. Sonography documented a statistically significant cross-sectional area change, within the median nerve, at the distal radius only after the first scanning session. Power and spectral Doppler was used to document perineural vascular flow within the median nerve, but it was not consistently obtained to allow for a rigorous comparison between pre- and postscanning sessions. This is the first pilot study to explore using a hand-carried sonographic unit to document change in the median nerve for an isolated sonographic examination. The results are only reflective of these particular participants, but much larger N and shorter scanning sessions are needed to confirm the hypothesis proposed.

Outcome of carpal tunnel decompression: the influence of age, gender, and occupation

The aim of this study was to investigate the effect of age, gender, and occupation on the outcome of carpal tunnel decompression. A total of 479 patients (342 females, 137 males) with a mean age of 56 years undergoing 608 carpal tunnel decompressions were prospectively studied. Outcome was assessed using the Brigham Hospital carpal tunnel questionnaire at two weeks pre-operatively and six months post-operatively. Cases were divided into four age categories (less than 40 years of age, 40-59, 60-79, and over 80 years of age) and two occupation (repetitive and non-repetitive) groups. The mean differences for both the symptom-severity and functional-status scores amongst the four age categories were similar and no significant difference was found. The mean differences for both the symptom-severity and functional-status scores between females and males and the two occupation groups were similar and no significant differences were found. The majority of the patient's symptoms improved following carpal tunnel decompression. However, we found no influence of age, gender, or occupation on the outcome of carpal tunnel decompression in our series of patients.

Comparing the outcome of a carpal tunnel decompression at 2 weeks and 6 months

PURPOSE

The purpose of the study was to evaluate if 2-week Levine score can provide an adequately responsive outcome measure in carpal tunnel decompression by comparing it with 6-month score.

METHODS

The treatment outcome of 300 patients with carpal tunnel decompression was determined by using Levine score at 2 weeks and 6 months after surgery. The mean age of patients was 56 years, 71% (214) were women, and 55% (167) of operations were performed on the right hand. All patients were scored using the Levine questionnaire preoperatively and at 2 weeks and 6 months from date of surgery. The correlation between the scores was evaluated.

RESULTS

Although statistical significance was found between the preoperative score and the scores at both 2 weeks and 6 months, no statistical difference was found between the scores at 2 weeks and 6 months after surgery. Multiple regression analysis with the 2 week-6 month score difference as the dependent variable shows a predictable outcome at 2 weeks.

CONCLUSIONS

We conclude that the Levine score at 2 weeks is a reliable, responsive, and practical instrument for outcome measure in carpal tunnel surgery. It coincides with suture removal and provides a convenient and predictive assessment of the medium-term results in a high percentage of treated patients. We conclude that the 2 time points, 2 weeks and 6 months, are equivalent in outcome because a less than 10-point difference is not clinically meaningful.

Carpal tunnel syndrome

Carpal tunnel syndrome is the most common compressive neuropathy of the upper extremity. As a result of median nerve compression, the patient reports pain, weakness, and paresthesias in the hand and digits. The etiology of this condition is multifactorial; anatomic, systemic, and occupational factors have all been implicated. The diagnosis is based on the patient history and physical examination and is confirmed by electrodiagnostic testing. Treatment methods range from observation and splinting, to cortisone injection and splinting, to surgical intervention. Both nonsurgical and surgical management provide symptom relief in most patients. The results of open and endoscopic surgery essentially are equivalent at 3 months; the superiority of one technique over the other has yet to be established.

Predictors of functional outcomes after surgical treatment of distal radius fractures

PURPOSE

Identifying predictors of outcomes is important in anticipating and treating patients with underlying factors that may affect recovery. The predictors of functional outcomes after distal radius fracture (DRF) treatment have not been well defined in the past.

METHODS

This was a prospective cohort study designed to identify predictors of hand outcomes after DRF treatment. The study included consecutive patients with inadequately reduced DRFs who had open reduction and internal fixation with volar plating. Demographic and socioeconomic data were collected at the time of the initial treatment. Outcome data were collected 3, 6, and 12 months after surgery. Outcome evaluation consisted of radiographic measurements and the Michigan Hand Outcomes Questionnaire (MHQ). We hypothesized that the following factors are important predictors of functional outcomes: (1) age, (2) socioeconomic status, (3) severity of fracture pattern, and (4) postsurgical radiographic measurements. Regression models were developed using the overall MHQ score as the outcome variable at 3 months and 1 year after surgery.

RESULTS

Sixty-six patients had data available at 3 months and 49 patients had data available at 1 year. At 3 months after surgery, radiographic incongruity (step + gap) was a significant predictor after controlling for age, fracture type, dorsal-volar tilt angulation, and income. Patients with increased incongruity reported lower MHQ scores (worse functional outcomes). At 1 year after surgery, however, only age and income were significant predictors after controlling for fracture type. Increased age and decreased income were associated with lower MHQ scores.

CONCLUSIONS

After successful surgery and hand therapy, only age and income were significantly associated with long-term outcomes 1 year after surgery. Precise anatomic reduction enhances short-term functional outcomes in DRF treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic, Level I.

Treatment of unstable distal radial fractures with the volar locking plating system

BACKGROUND

The best treatment for an inadequately reduced fracture of the distal part of the radius is not well established. We collected prospective outcomes data for patients undergoing open reduction and internal fixation of an inadequately reduced distal radial fracture with use of the volar locking plating system.

METHODS

Over a two-year period, 161 patients underwent open reduction and internal fixation of an inadequately reduced distal radial fracture with use of the volar locking plating system. Patients were enrolled in the present study three months after the fracture on the basis of strict entry criteria and were evaluated three, six, and twelve months after surgery. Outcome measures included radiographic parameters, grip strength, lateral pinch strength, the Jebsen-Taylor test, wrist range of motion, and the Michigan Hand Outcomes Questionnaire.

RESULTS

Eighty-seven patients with a distal radial fracture were enrolled. The mean age at the time of enrollment was 48.9 years. Forty percent (thirty-five) of the eighty-seven fractures were classified as AO type A, 9% (eight) were classified as type B, and 51% (forty-four) were classified as type C. Radiographic assessment showed that the plating system maintained anatomic reduction at the follow-up periods. At the time of the twelve-month follow-up, the mean grip strength on the injured side was worse than that on the contralateral side (18 compared with 21 kg; p<0.01), the mean pinch strength on the injured side was not significantly different from that on the contralateral side (8.7 compared with 8.9 kg; p=0.27), and the mean flexion of the wrist on the injured side was 86% of that on the contralateral side. All Michigan Hand Outcomes Questionnaire domains approached normal scores at six months, with small continued improvement to one year.

CONCLUSIONS

The volar locking plating system appears to provide effective fixation when used for the treatment of initially inadequately reduced distal radial fractures.

A Prospective Outcomes Study of Four-Corner Wrist Arthrodesis Using a Circular Limited Wrist Fusion Plate for Stage II Scapholunate Advanced Collapse Wrist Deformity

BACKGROUND

Scapholunate advanced collapse wrist deformity is a common pattern of degenerative arthrosis of the wrist. This study prospectively evaluated a series of patients who underwent four-corner fusion using a circular plate internal fixation technique.

METHODS

Patients with symptomatic stage II scapholunate advanced collapse wrist deformity were treated with scaphoid excision and four-corner fusion using the Spider Limited Wrist Fusion Plate (KMI, San Diego, Calif.). Patients were prospectively evaluated at 6 months and 1 year using a standard study protocol with radiographs, functional tests, and an outcomes questionnaire. Outcomes were compared with those of historical series from the literature.

RESULTS

Eleven patients were enrolled and 10 patients completed their 1-year follow-up. Grip strength, lateral pinch strength, and Jebsen-Taylor test scores at 1 year were not significantly different from preoperative values. Mean active range of motion was 87 degrees preoperatively and 74 degrees at 1-year follow-up (p = 0.19). The Michigan Hand Outcomes Questionnaire showed no significant improvement in function, activities of daily living, work, pain, or patient satisfaction. The mean pain scores decreased from 54 preoperatively to 42 1-year postoperatively (p = 0.30), indicating persistent wrist discomfort. Three patients had broken screws: one was asymptomatic, one required 3 months of strict wrist immobilization, and one was reoperated for symptomatic nonunion.

CONCLUSIONS

Four-corner fusion using the first-generation Spider plate technique has the advantage of earlier mobility and more patient comfort from absence of protruding Kirschner wires; however, patients continued to have disabling pain, functional limitations, work impairment, and low satisfaction scores postoperatively. Although limited by a small patient sample, this series presents outcomes data that may be useful in counseling patients who are contemplating four-corner fusion using this internal fixation device. Further investigation is necessary to evaluate the biomechanical properties of the Spider plate. The data suggest that better implants should be designed to avoid implant failure, which occurred in three of the 11 patients in this series.

Carpal tunnel syndrome and ulnar neuropathy at the elbow in floor cleaners

OBJECTIVE

To determine the occurrence of carpal tunnel syndrome (CTS) and ulnar neuropathy at the elbow (UNE) in a cohort of floor cleaners and to check differences between workers with and without CTS.

METHODS

All female floor cleaners of three major hospitals in Tuscany (Italy) were contacted. Clinical and electrophysiological severity of CTS and UNE were evaluated with standardized scales and symptoms were assessed with the self-administered Boston Questionnaire (BQ); demographic and non-occupational factors and durations of current and previous occupations were recorded. Univariate analysis of risk factors was performed in workers with and without CTS. Logistic regression was used to evaluate the capacity of independent variables to predict CTS.

RESULTS

Out of a total of 179 cleaners, 145 (81%)-mean age 39.6 years (20-64 years)-were enrolled in the study; 70 (48%) had CTS (diagnosis based on clinical and electrophysiological findings). BQ symptom and hand function scores were anomalous in 108 (74%) and 84 (58%) subjects, respectively. UNE was detected in 7/103 women. Univariate analysis showed that cleaners with CTS were older, had greater BMI and longer exposure to cleaning with previous employers than those without CTS. In the logistic regression, the only predictor of CTS was cleaning with previous employers (O.R. 12.1, 95% CI 3-49.9).

CONCLUSIONS

These results indicate a high occurrence of CTS in floor cleaners; UNE is less frequent than CTS, presumably due to repetitive movements that stress wrists more than elbows. The only predictive factor of CTS was cleaning as an occupation with previous employers. Therefore, the actual risk factor for CTS could not be cleaning per se, but how this job is performed.

Reconstruction of thumb loss complicated by skin defects in the thumb-index web space by combined transplantation of free tissues

OBJECTIVE

To introduce a new technique of 1-stage reconstruction for thumb loss complicated by thumb-index web space contracture and to report its clinical effectiveness.

METHODS

From November 1994 to September 2004 there were 11 patients with thumb loss and contracture in the thumb-index web space who had a combined transplantation of free tissues to reconstruct the missing thumb and to rebuild the web space. The reconstructive procedure used the second toe and the anterolateral thigh flap in 5 patients, the second toe and the scapular flap in 2, the big toe wraparound flap and the anterolateral thigh flap in 3, and the big toe wrapround flap and the scapular flap in 1. The 2 independent free tissues were connected together by a vascular combination to form an assembly with 1 common vascular pedicle, which then was anastomosed to the selected vessels in the recipient hand. In this vascular series the dorsalis pedis artery and the greater saphenous vein served as the common vascular pedicle of the flap transfers and the radial artery and the cephalic vein provided the recipient vessels. The outcomes of the reconstructions were evaluated using the Michigan Hand Outcomes Questionnaire.

RESULTS

The flaps survived completely in all patients except 1. In this patient a small area in the distal part of the transplanted anterolateral thigh flap became necrotic but healed after dressing changes without the need for further surgical intervention. A mean follow-up period of 3.6 years showed a mean increase of 4.3 cm in the width of the thumb-index web space and a considerable improvement in overall hand function was noted on the Michigan Hand Outcomes Questionnaire with effect sizes of greater than 3 (large effect) in all domains.

CONCLUSIONS

Combined transplantation of the second toe or the big toe wraparound flap and a free skin flap is suitable to reconstruct a missing thumb and repair the associated skin defect in the adjacent thumb-index web space. We found good functional recovery and an acceptable appearance in this series of patients. Type of study/level of evidence: Therapeutic, Level IV.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.

Prevalence and associations of symptoms of upper extremities, repetitive strain injuries (RSI) and 'RSI-like condition'. A cross sectional study of bank workers in Northeast Brazil

Background

The repetitive strain injury syndrome (RSI) is a worldwide occupational health problem affecting all types of economic activities. We investigated the prevalence and some risk factors for RSI and related conditions, namely 'symptoms of upper limbs' and 'RSI-like condition'.

Methods

We conducted a cross-sectional study with 395 bank workers in Recife, Northeast Brazil. Symptoms of upper limbs and 'RSI-like condition' were assessed by a simple questionnaire, which was used to screen probable cases of RSI. The diagnosis of RSI was confirmed by clinical examination. The associations of potential risk factors and the outcomes were assessed by multiple logistic regression analysis.

Results

We found prevalence rates of 56% for symptoms of the upper limbs and 30% for 'RSI-like condition'. The estimated prevalence of clinically confirmed cases of RSI was 22%. Female sex and occupation (as cashier or clerk) increased the risk of all conditions, but the associations were stronger for cases of RSI than for less specific diagnoses of 'RSI-like condition' and symptoms of upper limbs. Age was inversely related to the risk of symptoms of upper limbs but not to 'RSI-like' or RSI.

Conclusion

The variation in the magnitude of risk according to the outcome assessed suggests that previous studies using different definitions may not be immediately comparable. We propose the use of a simple instrument to screen cases of RSI in population based studies, which still needs to be validated in other populations. The high prevalence of RSI and related conditions in this population suggests the need for urgent interventions to tackle the problem, which could be directed to individuals at higher risk and to changes in the work organization and environment of the general population.