Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Repair, Tendon Laceration of Hand


Related Terms

  • Extensor Tendon Repair
  • Flexor Tendon Repair
  • Tendon Repair

Specialists

Comorbid Conditions

Factors Influencing Duration

The complexity of the injury, involvement of the dominant hand, complications from the injury or surgery, compliance with rehabilitation program, and work requirements, influence disability. Disability time also varies depending on the tendon(s) involved and the ability of the individual and the employer to accommodate the work tasks.

Medical Codes

ICD-9-CM:
82.41 - Suture of Tendon Sheath of Hand
82.42 - Delayed Suture of Flexor Tendon of Hand
82.43 - Delayed Suture of Other Tendon of Hand
82.44 - Suture of Flexor Tendon of Hand, Other
82.45 - Suture of Other Tendon of Hand, Other

Overview

Repair of a tendon that has been cut (lacerated) or torn is a surgical procedure often requiring a skilled hand surgeon and specialized equipment. The goal of tendon repair is to restore the integrity and continuity of the damaged tendon and thereby restore as much function as possible. Tendon repairs are often performed in association with other procedures in the hand.

A tendon injury occurs from a deep laceration, such as a cut from a knife, sharp tool, or broken glass. It also can occur from a crush injury, burn, tissue tear (avulsion), or deep abrasion. Workers using cutting tools are most likely to lacerate the tendons of the hand.

Source: Medical Disability Advisor



Reason for Procedure

Finger dexterity is completely dependent on normal tendon function since the tendons link muscles controlling hand motion to the bones of the hand and forearm. When a tendon is injured (cut, torn, frayed, or pulled apart [ruptured]), repair is essential for restoration of finger and hand function.

Many tendons in the hand are quite long, extending from the fingertips through the carpal tunnel at the wrist and attaching to muscles in the forearm. Flexor tendons control bending (flexion) and extensor tendons control straightening (extension) of all parts of the hand and fingers. Flexor tendon injuries commonly result from cuts (lacerations) or punctures to the palm (palmar surface) of the hand. Extensor tendons are found close to the surface of the skin on the top (dorsal surface) of the hand. They spread out to form a dorsal hood over the fingers. Extensor tendons are especially susceptible to crush injuries, as well as lacerations, burns, bites, or blunt trauma (Netscher; Rosh).

Source: Medical Disability Advisor



How Procedure is Performed

Surgical repair is usually an outpatient procedure unless complicated by infection or massive injuries to the extremity. Often the wound can be cleaned, closed, and splinted by the emergency room staff and referred to the hand surgeon for definitive repair. Definitive repair of cleanly cut tendons should take place within the first 48 hours following initial injury. If a wound is potentially contaminated, antibiotic treatment should occur first as prophylaxis against infection, followed by surgical repair of the tendon within 10 days after injury (Netscher). Repair also may be delayed up to 10 days in cases where bones near the tendon have been crushed, nearby joints severely injured, or where skin loss will necessitate a graft or skin flap. Some simple, uncomplicated tendon repairs can be performed in the emergency room or a hand surgeon's office. Complex or multiple tendon repairs should be performed in the operating room.

Lacerated tendons often pull away from the site of the laceration and will contract up toward the forearm and / or down toward the fingers when damaged, similar to a rubber band that has been stretched and then snaps. Repair requires surgical exploration of the normal course of the tendon and may require a long incision to find the proximal and distal ends of the tendon. Once the incision is made, the ends of the tendon are located and the tendon is stretched to its original position or attachment. Often, the sheath that surrounds, protects, and nourishes the tendon will be damaged. If the pulley system that enables smooth gliding of the tendon is damaged, repair will be required. Surgeons performing these delicate procedures employ intricate suturing techniques using very fine materials and magnification.

After the tendon is repaired and the wounds are closed, a soft compressive dressing is applied followed by a protective device such as a splint or "outrigger." An outrigger is a device attached to the fingernail to provide protected flexion of the finger for flexor tendons, or around the finger to provide for supported extension for extensor tendon injuries. These splints require specially trained therapy to build and maintain. Recovery from surgery is a complex process: time for the tendon to heal must be balanced against the need for early mobilization to restore optimum hand and finger function. Sometimes, a temporary cast is applied over the dressing instead of a splint.

Source: Medical Disability Advisor



Prognosis

Outcome depends on the cause, type, site, and extent of the tendon laceration, length of time between injury and repair, and the type of repair. If the damaged tendon can be restored to its normal length with adequate strength, good function should return. Fractures, infection, involvement of more than one tendon, or concomitant injuries to the hand make it more difficult to achieve complete restoration of finger and hand function. Staged reconstruction of a flexor tendon repair following initial surgery is often necessary for complex cases and results in prolonged incapacitation.

Proper postoperative splinting, hand therapy, and excellent compliance with treatment plans are essential to the success of any tendon laceration repair (Netscher and Fiore). If normal tendon function cannot be completely restored or if there are concomitant injuries to the joints, manual dexterity may be compromised. Tendons do not heal as well as other body tissues, so recovery is guarded in extensive or more complicated cases. Smoking may affect tendon strength. Late tendon repair is not very successful and sometimes not even possible.

Source: Medical Disability Advisor



Rehabilitation

Recovery from hand flexor tendon and complex extensor tendon repair for laceration is an intricate process and requires substantial intervention by a hand therapist, when possible. Common clinical practice suggests that rehabilitation is influenced by many factors including the individual's age, general health and healing potential, as well as by the surgical procedure, rate and quality of scar formation, level and type of injury, and expertise of the practitioners. The injured tendons may be part of the mechanism of opening the hand (extension) or closing it (flexion). Careful analyses of the initial trauma as well as the corrective treatment procedures are a determinant in creating and directing an effective rehabilitation plan. Progression is determined by the individual's clinical response and functional improvement (Evans; Pettengill).

The tendons involved and type of operation performed determine the type and duration of immobilization, and when mobilization can be initiated. Simple, closed extensor tendon ruptures of the tip of the finger (distal phalanx) may not require surgery (Wright). For more complex tendon injuries, the ability to return to work depends on the options of accommodating splint wear. The primary goals are to restore maximum tendon gliding, to ensure effective motion, and to restore hand function, while preventing tendon rupture, scarring with adhesions, or tendon contracture. The type of surgery and immobilization influence the amount of early motion the individual can achieve and the type of splinting required (Kasashima). Therapy focuses on maintaining the motion and strength in the unaffected anatomical regions while providing directed treatment to the injured anatomical region (Evans).

The therapist assists the healing tendon through a progressive protocol that involves controlling for edema and pain, using splints for alignment and specific movement, providing protected passive and active range of motion exercises as indicated, providing the needed wound care and scar management techniques, and monitoring the integrity of the hand structures (Evans; Galanakis; Pettengill). Protected motion may be allowed by the surgeon in the first 6 weeks post operatively; however, the surgeon will determine the progress of therapy relative to the risk of tendon rupture (Netscher). In some cases of an extensor tendon central slip repair, limited range of motion may begin within a few days of surgery (Wright).

Strengthening and functional activities are dependent on the type and location of tendon injury and repair. Complex cases may require 10 to 12 weeks of protected splint wear postsurgery. The therapist may teach breathing techniques to reduce the individual's anxiety and anticipation of pain that can cause contraction of muscles and increased muscle tension. Once performance of tendon gliding exercises suggests a return of proper hand mechanics, the individual progresses to a strengthening program when the treating physician determines that the tensile strength of the tendon is adequate (Evans; Pettengill).

Return to work is variable as it is dependent on the functional recovery of the tendon as well as on the demand that work tasks may place on the newly repaired tendon. An ergonomic evaluation may be indicated as the work environment may need modification to accommodate residual weakness, incomplete movement, or to decrease repetitive strain on the hand. If individuals cannot return to their current occupation, a vocational rehabilitation counselor may be helpful in guiding the individual toward reemployment (Pettengill).

Prior to discharge from therapy, the individual should be instructed in an independent home exercise program. It may be necessary for the individual to continue some form of exercise to maintain function of the hand. Throughout rehabilitation, the therapist monitors for potential complications such as severe edema, continued pain, tendon rupture, joint stiffness, or infection (Evans). In some cases with unsatisfactory results, a tenolysis may be done after 3 months of therapy (Wright).

FREQUENCY OF REHABILITATION VISITS
Surgical (extensor tendons)
SpecialistRepair, Tendon Laceration of Hand
Occupational / Hand / Physical TherapistUp to 28 visits within 16 weeks
Surgical (flexor tendons)
SpecialistRepair, Tendon Laceration of Hand
Occupational / Hand / Physical TherapistUp to 32 visits within 16 weeks
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Complications that impair finger and hand movement by hindering the ability of the tendon to glide smoothly include adhesions between repaired tendons and surrounding tissue, stretching (attenuation) or rupture of the repair (most common between 7 and 14 days following surgery), and joint or soft tissue contractures. Other potential complications following surgery include infection, nerve and blood vessel damage, and delayed healing due to underlying medical conditions. In some cases, the severity of tendon damage is underestimated at the time of the original evaluation, especially if a hand surgeon was not involved at this stage. This may result in long-term disability from what initially was thought to be a rather insignificant injury.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

During initial recovery phase, individuals should limit use of the injured hand to activities recommended by the physician and as part of a rehabilitation program under the direction of a hand therapist. The timetable for increasing use of the hand will depend on the healing process and tolerance of the tendon repair to physical stressors. Individuals are often required to spend several hours in occupational or physical therapy sessions per week as well as participate in a daily home exercise program. Use of splints, outriggers, or casts may be necessary to enhance the healing process. Use of prescribed medications to control pain and swelling may require review of drug policies.

If one-handed work is available or limited-hand use with splint on, individuals may be able to return to work sooner. Return to job requirements that involve intricate dexterity, strength, or endurance of the hand are highly dependent on the rehabilitation process and the individual’s motivation for recovery.

Risk: The risk for tendon rupture after repair is dependent on gap formation at the site of the repair. In other words, tendon rupture occurs if the two ends of the tendon pull apart from each other. Gap formation is decreased by using multiple stranded repairs, special splinting, and specific therapy protocols. Even with all of these factors being addressed, wound healing and tendon healing are also dependent on the individuals’ age, general health, and comorbidities.

Capacity: Capacity is limited by tendon healing. Specific limits are placed for use of the injured hand. Splinting is often required. Employer willingness to modify is key to early return to safe work.

Tolerance: Tendon repairs are painful. This can be an advantage as the individual is often careful about activities and therefore less likely to rupture the repair. Unfortunately, some individuals have low pain thresholds and are not compliant with their exercise program, with the result that they then develop tendon adhesion and joint contractures. There is a very fine line that requires close monitoring by the physician, therapist, and patient.

Accommodations: Since splinting is usually required for 8 to 12 weeks, the ability of the employer and employee (patient) to work with accommodations is key. Some modified activities at work can be therapeutic or beneficial for the tendon healing.

Source: Medical Disability Advisor



Maximum Medical Improvement

168 to 252 days to allow for improvement in range of motion and strength.

Source: Medical Disability Advisor



References

Cited

Evans, R. B. "Clinical Management of Extensor Tendon Injuries." Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002.

Galanakis, I., et al. "Functional Evaluation after Primary Flexor Tendon Repair in Zone II." Acta Orthopaedica Belgica 69 3 (2003): 252-256. National Center for Biotechnology Information. National Library of Medicine. 25 Sep. 2008 <PMID: 12879708>.

Kaisha, W. O. , and S. Khainga. "Causes and pattern of unilateral hand injuries." East African Medical Journal 85 (2008): 123-128.

Kasashima, T., H. Kato, and A. Minami. "Factors Influencing Prognosis after Direct Repair of the Flexor Pollicis Longus Tendon: Multivariate Regression Model Analysis." Journal of Hand Surgery 7 2 (2002): 171-176. National Center for Biotechnology Information. National Library of Medicine. 25 Sep. 2008 <PMID: 12596274>.

Netscher, D., and N. Fiore. "Chapter 74, Section XIII - Hand Surgery." Sabiston Textbook of Surgery. Ed. C. M. Townsend. 18th ed. St. Louis: Saunders, 2008.

Oliver, T. I. , and L. S. Glass. "Glass laceration injuries and prevention." Medical Journal of Australia 1 (1979): 190-191.

Pettengill, K. M., and G. van Strien. "Postoperative Management of Flexor Tendon Injuries." Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002.

Rosh, Adam J., and Nancy Kwon. "Extensor Tendon Repair." eMedicine. Eds. Gil Z. Shlamovitz, et al. 23 Oct. 2008. Medscape. 23 Dec. 2008 <http://emedicine.com/proc/topic109111.htm>.

Sonmez, A. , et al. "Injury patterns and psychological traits of patients with self-inflicted wounds produced by punching glass." Journal of Trauma 69 (2010): 691-693.

Wright, Phillip E. "Chapter 61 - The hand." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beaty. 11th ed. Philadelphia: Mosby Elsevier, 2008.

General

Thien, T. B., et al. "Rehabilitation after Surgery for Flexor Tendon Injuries in the Hand." Cochrane Database of Systematic Reviews 4 (2004): NA.

Source: Medical Disability Advisor






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