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.

Sprains and Strains, Hand or Fingers


Related Terms

  • Break-dancer’s Thumb
  • Gamekeeper’s Thumb
  • Ligament Injury
  • Skier’s Thumb
  • Tendon Injury
  • Trigger Finger

Differential Diagnosis

Specialists

  • Hand Surgeon
  • Hand Therapist
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist

Comorbid Conditions

  • Fractures
  • Injury to joint, muscle tendon, nerve artery
  • Multiple finger involvement
  • Osteoarthritis
  • Rheumatoid arthritis

Factors Influencing Duration

Factors include the location, type, and severity of the injury; whether the dominant hand was affected; severity of the pain associated with the injury; method of treatment; individual's response to treatment and adherence to recommendations; and individual's job requirements.

Medical Codes

ICD-9-CM:
842 - Sprains and Strains of Wrist and Hand
842.1 - Sprains and Strains, Hand
842.10 - Sprains and Strains, Hand, Unspecified Site
842.11 - Sprains and Strains, Hand, Carpometacarpal Joint
842.12 - Sprains and Strains, Hand or Fingers, Metacarpophalangeal Joint
842.13 - Sprains and Strains, Hand or Fingers, Interphalangeal Joint
842.19 - Sprains and Strains, Hand, Other; Midcarpal (Joint)

Overview

The hand, thumb and fingers can have a wide array of possible sprains and strains as a result of the structures: five metacarpal bones, five proximal phalanges, four middle phalanges, five distal phalanges, five metacarpophalangeal (MCP) joints (with both radial and ulnar collateral ligaments and volar plates), four proximal interphalangeal (PIP) joints with both radial and ulnar collateral ligaments and volar plates) and five distal interphalangeal (DIP) joints with both radial and ulnar collateral ligaments and volar plates), nine extrinsic flexor tendons, nine extrinsic extensor tendons, and numerous intrinsic muscles and tendons.

The terms sprain and strain are often used interchangeably. As a result, the data regarding treatment, outcomes, disability durations, return to work options, and costs may be confusing. It is important to understand the specific meaning of each term.

A sprain is a stretching or tearing of ligaments—the tough bands of fibrous tissue that connect one bone to another in the joints, adding support and stability. A sprain can be caused by direct or indirect trauma, such as a fall or a blow that knocks a joint out of position, resulting in an overstretching and, in severe cases, a complete tear or rupture of the supporting ligaments. Typically, this injury occurs when an individual lands on an outstretched arm; slides into a base; or a power tool kicks back.

There are three grades of ligament sprains. A grade I sprain is a mild sprain in which ligaments become stretched with few torn fibers and no loss of joint stability. There may be mild pain with or without swelling. Grade II sprains involve a greater number of injured ligament fibers with possible joint laxity and usually with marked pain and swelling. There may also be bruising (black and blue) around or in the joint. With a grade III sprain, most of the ligament fibers are torn with marked pain, swelling and bruising or there is complete disruption (completely torn), resulting in joint instability.

A strain is a stretching or tearing of muscle and/or tendon, the tendon being a fibrous cord of tissue that connects muscles to bones. Strains may be acute or chronic. Acute strains are caused by a direct blow to the body, overstretching, or excessive muscle contraction. For example, an acute strain might occur when someone starts weight lifting as a new year’s resolution. Chronic strains are the result of prolonged, repetitive movement of muscles and tendons.

Muscle and tendon strains are graded according to the severity of tendon and muscle fiber damage. A grade I strain is a mild strain in which muscles or tendons become stretched with few torn fibers and no loss of muscle strength. There may be mild pain with or without swelling. Grade II strains involve a greater number of injured muscle or tendon fibers with noticeable loss of strength, usually with marked pain and swelling. There may also be bruising (black and blue). With a grade III strain, most of the muscle or tendon fibers are torn with marked pain, swelling and bruising; or the grade III strain involves complete disruption (completely torn), resulting in complete functional loss of the affected muscle or tendon.

As outlined above, the hand contains many small joints, each vulnerable to injury. A system of ligaments and joint capsule tissue maintain the joint stability. When these structures are injured, the joints can become loose and possibly deformed. Sprains that result in partial tearing of the ligaments produce pain and swelling, while rupture leads to loss of stability and dislocation of the joint. Tendon injuries (strains) often happen at the same time because of their close proximity to the joints. When this occurs, individuals experience joint looseness (laxity) and loss of function.

The joints of the fingers (interphalangeal joints) are injured more often than are the joints of the hand. The PIP joints are the most commonly sprained, and sprains of the MCP joints of the fingers are the least common; however, the thumb MCP joint is frequently injured. A particularly difficult sprain to treat is that of the ulnar collateral ligament (UCL) of the thumb, also called "skier's thumb" or "gamekeeper's thumb," which affects the stability of the thumb MCP joint.

The extensor tendons on the top of the hand (dorsum) are the most commonly strained tendons of the hand. These injuries are variable and numerous and are classified by the anatomic zone system of Verdan where seven anatomic zones are described (e. g., zone I is the distal interphalangeal joint of the finger, zone VII is the forearm).

Incidence and Prevalence: Muscle aches and pains are common. Grade I strains and sprains are common. Grade II strains and sprains often require short periods of modified activities. Only the majority of grade III strains and sprains are seen by healthcare providers. Consequently, many strains and sprains are not reported or treated and therefore the precise incidence is not known.

Reported hand injuries account for 5% to 10% of all emergency department visits nationwide and account for 9% of worker's compensation cases (Lese). Skier’s thumb represents 5% to 10% of all skiing injuries; it is the most frequent injury to the upper extremities experienced by skiers (Foye).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Hand injuries are extremely common and affect all age groups and races. They often are caused by occupational or sports injuries. Individuals who ski, fall on an outstretched arm with forceful abduction of the thumb, or who have rheumatoid arthritis have increased risk for ulnar collateral ligament sprain (skier's thumb), as do athletes who participate in football, basketball, and lacrosse.

Source: Medical Disability Advisor



Diagnosis

History: Individuals report a history of hand trauma that they may have believed was insignificant at the time that it occurred. They also may complain of swelling (edema), warmth, and deformity of the hand, depending on the severity of the sprain or strain. In severe cases, pain is constant, but more commonly it is felt only when stress is applied to the injured area; using the hand for lifting, grasping, or typing may be possible but painful. Inquiry should be made about history of previous hand injuries, especially jammed fingers that were never treated.

Physical exam: The joint may appear loose (lax) with stress testing or may appear deformed with loss of function depending on the severity of the injury. Edema at the affected joint is common. Touching (palpating) the hand or fingers along the lateral joint margins often produces pain. Grasping may cause pain and may reveal weakness. If the ulnar collateral ligament is sprained, there may be pain at the ulnar side of the thumb MCP joint. The stability of a joint is assessed by passive and active motion. A painkiller (anesthetic) may be administered locally to allow for a full examination of range of movement (Lese; Foye).

Tests: Stress x-rays may be needed to augment plain x-rays. These involve taking x-rays of the hand while stressing the injured joint (often under local anesthesia) then comparing them to stress x-rays of the opposite, uninjured hand. CT or MRI may be necessary to evaluate avulsion fractures resulting in joint surface damage. This is most common with injuries to the thumb and wrist area. Ultrasound can detect ruptured tendons and ligament injuries. It also may be useful in assessing the dynamic function of tendons in a noninvasive manner (Lese).

Source: Medical Disability Advisor



Treatment

Grade I and grade II strains and sprains are initially treated with rest, ice, compression, and elevation (RICE) for the first 24 hours until swelling subsides. Splints or taping are then used for immobilization (which usually should not continue for more than 2 weeks, at which time range of motion exercises begin). Grade III sprains and strains may require surgical repair especially if the thumb is involved. Repair usually includes primary suturing of the ligament, muscle, or tendon (modified Bunnell technique). In some instances, closed reduction is sufficient and followed by immobilization for 3 weeks. Finger sprains sometimes require closed reduction with pin fixation. In cases where closed reduction cannot produce a good alignment of the joint or if soft tissue is interposed within the joint preventing reduction, open reduction, internal fixation (ORIF) is necessary.

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Mallet Finger
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

Grade I and grade II sprains and strains of fingers and the hand heal well with conservative treatment including rest, splinting, and occupational or physical therapy. Grade III sprains and strains of the hand also usually heal with conservative treatment. Grade III sprains and strains of the fingers generally heal well regardless of type of treatment but some individuals may have residual stiffness, pain, or instability. Individuals with grade III strains of the distal interphalangeal joint of the finger may be left with residual crookedness of the finger (mallet finger, or residual swan-neck deformity). Grade III strains of the proximal interphalangeal joint can result in a boutonniere deformity.

Individuals treated with surgical procedures usually heal but some may experience some residual stiffness. Individuals who have sprained the ulnar collateral ligament (skier's thumb) may be left with difficulty holding objects within the hand due to thumb grip weakness.

Source: Medical Disability Advisor



Rehabilitation

Common clinical practice indicates that individuals with sprains or strains of the hand or fingers require therapy that begins immediately with protective static splinting or buddy taping. The length of time during which the splint or tape should be worn is based on the degree of soft tissue damage. Mild distal interphalangeal strains without laxity may not require splinting/taping while thumb ulnar collateral ligament tears require more prolonged treatment and occasionally surgery (DeLee). The individual is instructed to apply heat or cold as needed to control pain and swelling (Hegmann).

The protective splint or tape is removed periodically to allow for controlled range of motion of the affected structures. Full active range of motion is encouraged in the adjacent joints. If ligamentous laxity is present at the conclusion of protective static splinting, buddy taping is required to prevent re-injury during activity performance. At 3 to 4 weeks after more severe injuries, dexterity tasks, gradual strengthening exercises, and resumption of daily life tasks are introduced to restore the use of the injured structure for functional hand activities.

Protocols for rehabilitation must consider the type of management (operative, nonoperative) and should be guided by the treating surgeon.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical (more complex cases)
SpecialistSprains and Strains, Hand or Fingers
Occupational / Hand / Physical TherapistUp to 10 visits within 4 weeks
Nonsurgical (simpler cases)
SpecialistSprains and Strains, Hand or Fingers
Occupational / Hand / Physical TherapistUp to 6 visits within 4 weeks
Surgical (more complex cases)
SpecialistSprains and Strains, Hand or Fingers
Occupational / Hand / Physical TherapistUp to 16 visits within 8 weeks
Surgical (simpler cases)
SpecialistSprains and Strains, Hand or Fingers
Occupational / Hand / Physical TherapistUp to 10 visits within 8 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 include loss of range of motion, chronic stiffness, discomfort, and impaired grip or pinch strength in the involved joints. Osteoarthritis may develop following injury to the metacarpophalangeal (MCP) joints. Chronic joint instability of the thumb may occur following a ruptured ulnar collateral ligament.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Return to work depends on the grade of sprain or strain and the specific work duties that are required. The individual may benefit from temporary reassignment. Dexterity and use of the affected arm will be limited if an arm sling is worn. The individual with a strain of hand, thumb or fingers muscles / tendons may be temporarily unable to lift and carry heavy objects, operate equipment, or perform other tasks that require lifting, pushing, or pulling against resistance using the injured hand. Individuals whose dominant hand is affected may require more accommodations than those whose non-dominant hand is affected.

Restrictions may include little to no use of the involved hand, with limited lifting and carrying. Dexterity is affected by the injury and by the use of protective splints. Safety issues must be evaluated. Typists, keypad operators, and others whose work requires use of the hands and fingers (fine motor skills) will need to be reassigned to other duties until the injury heals. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Source: Medical Disability Advisor



Maximum Medical Improvement

In the absence of a fracture, a dislocation, a nerve injury, or a spinal cord injury, the cervical sprain/strain is considered a “soft tissue injury.” Like other soft tissue injuries, the majority of the healing occurs in the first 3 months. Other than surgery, additional treatment after 3 months from the date of injury is not likely to result in dramatic improvement, so MMI is frequently achieved by 3 months after injury.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was individual diagnosed with a sprain or strain? To the hand, thumb or fingers?
  • Did individual have symptoms (swelling, warmth, deformity, loss of strength or function, and joint looseness) consistent with the diagnosis of hand sprain or strain?
  • Were other conditions such as arthritis, tendinitis, tendon rupture, infection, and fracture, ruled out?
  • Was diagnosis confirmed with stress x-rays?
  • Were other conditions or associated injuries ruled out with MRI or CT?

Regarding treatment:

  • Was individual treated with rest, ice, compression, and elevation (RICE)? Splinting, taping, or immobilization?
  • Is pain well controlled? If not, have alternative pain management techniques been tried?
  • Is individual participating in a rehabilitation program as recommended?
  • Would a consultation with a specialist (hand surgeon, orthopedic surgeon, physiatrist, occupational therapist, or physical therapist) be beneficial?

Regarding prognosis:

  • Has individual been compliant with physical therapy recommendations?
  • Does individual have any conditions such as peripheral neuropathy, pre-existing rheumatoid or osteoarthritis involving the hand, thumb or fingers that may affect ability to recover?
  • Has individual experienced any complications such as loss of range of motion, chronic stiffness, pain, infection, or nerve injury that may influence length of disability?
  • Is individual’s employer able to accommodate any necessary restrictions?

Source: Medical Disability Advisor



References

Cited

DeLee, Jesse, and David Drez, eds. "Section B: Hand - 1. Athletic Injuries of the Adult Hand." DeLee and Drez's Orthopaedic Sports Medicine. 2nd ed. 2 vols. Saunders, 2003.

Foye, Patrick M., et al. "Skier's Thumb." eMedicine. Eds. Anthony J. Saglimbeni, et al. 9 Aug. 2012. Medscape. 8 Aug. 2013 <http://emedicine.medscape.com/article/98460-overview>.

Hegmann, Kurt T. , et al., eds. "Chapter 11: Forearm, Wrist, and Hand Disorders." Occupational Medicine Practice Guidelines Evaluation and Management of Common Health Problems and Functional Recovery of Workers. 2nd Edition, 2008 Revision ed. OEM Press, 2008. 627-652.

Lese, Andrea, et al. "Hand Injury, Soft Tissue." eMedicine. Eds. Dan Danzl, et al. 21 Jun. 2013. Medscape. 8 Aug. 2013 <http://emedicine.medscape.com/article/826498-overview>.

Michlovitz, S., et al. "Continuous Low-Level Heat Wrap Therapy is Effective for Treating Wrist Pain." Archives of Physical and Medical Rehabilitation 85 9 (2004): 1409-1416. National Center for Biotechnology Information. National Library of Medicine. 8 Aug. 2013 <PMID: 15375809>.

Source: Medical Disability Advisor






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