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, Wrist


Related Terms

  • Painful Wrist
  • Sprained Wrist
  • Stiff Wrist

Differential Diagnosis

Specialists

Factors Influencing Duration

Factors affecting the duration of disability include type, location, and severity of injury; method of treatment; individual response to and compliance with treatment; and individual job requirements.

Medical Codes

ICD-9-CM:
842.00 - Sprains and Strains, Wrist, Unspecified Site
842.02 - Sprains and Strains, Wrist, Radiocarpal Joint
842.09 - Sprains and Strains, Wrist, Other; Sprains and Strains, Radioulnar Joint, Distal

Overview

The wrist can have both sprains and strains.

The wrist is a complex joint that links the hand to the forearm. It is a collection of multiple bones and joints. The bones comprising the wrist include the distal ends of the radius and ulna, eight carpal small bones divided in two rows (the bones of the row closer to the arm are scaphoid, lunate, triquetral and pisiform, and those of the row closer to the hand are trapezium, trapezoid, capitate, and hamate), and the proximal aspect of the five metacarpal bones. All of these bones contribute to the complex articulations that allow variable movement of the hand. For example, there are three types of movement possible between the forearm and the hand: (1) flexing and extending, (2) pronating and supinating, and (3) ulnar or radial deviation. In order to maintain this movement without sacrificing stability, the wrist joint has a complex configuration of ligaments. In addition, there are muscle tendon units that insert in the carpal bones. From the wrist's complexity arises a wide array of possible sprains and strains.

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 body's joints, stabilizing and supporting the joints. A sprain can be caused by direct or indirect trauma, such as a fall or a blow that knocks a joint out of position. This results in an overstretching and, in severe cases, a complete tear or rupture of the supporting ligaments.

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—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 there is complete disruption (completely torn), resulting in complete functional loss of the affected muscle or tendon.

Typically, wrist sprains and strains occur when an individual lands on an outstretched hand, such as when one slides into a base, or when a power tool kicks-back. The hand's position and / or rotation at impact determine the type and severity of injury. More severe (third-degree) injuries involve a disruption of the supporting structures and a dislocation of the carpal joint (scapholunate dissociation, lunate or perilunate dislocation), or a fracture. A stretch injury to the ligaments around the joint of the radius, ulna, or carpal bones can lead to improper mechanics of the wrist joint and may result in permanent loss of stability.

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.

In the US, wrist injuries (the majority of which are sprains and strains) account for 2.5% of emergency room visits each year (Beeson). The most commonly sprained ligament in the wrist is the scapholunate ligament, located between the scaphoid and the lunate bones ("Wrist Sprains").

Source: Medical Disability Advisor



Causation and Known Risk Factors

Athletes and individuals who participate in recreational sports are at particular risk for these injuries, as are those who work with their hands and experience lifting or twisting stresses in their occupation.

Source: Medical Disability Advisor



Diagnosis

History: The individual usually will relate a history of injury, such as falling, twisting, or getting hit on the wrist, but may recall the event as insignificant. Some individuals who experience sprains may recall a popping or tearing sensation at the time of injury. The individual often complains of pain, swelling (edema), and weakness.

Physical exam: The physician may find localized swelling of the wrist and pain on range of motion or gentle touch (palpation). Bruising (ecchymosis) may be visible. Neurovascular examination usually is normal in mild and moderate injuries. A grating or grinding feeling at the wrist joint (crepitus) may be present if there is joint instability and / or a fracture.

Tests: X-rays with special views to evaluate clinical findings may help identify fractures of the scaphoid or hook of the hamate. Stress x-rays of the wrist are obtained to evaluate joint instability. Ligaments appear well visualized on MRI examination. X-rays of the joint with contrast medium (arthrograms) are useful in evaluating ligament rupture or joint capsule tear but are only of benefit in the first 5 days after injury, after which blood clotting may fill in defects and provide a false negative reading. Bone scans are useful to rule out occult carpal fractures or intrinsic ligament tears. Diagnostic arthroscopy may be used to evaluate carpal instability in severe cases or in those unresponsive to therapy.

Source: Medical Disability Advisor



Treatment

If the sprain or strain is minor (first-degree), there is no loss of stability and individuals often will not seek medical treatment. Other individuals with mild to moderate (first- or second-degree) injuries and without clinical or x-ray findings of fracture and / or instability, may be treated in the first 72 hours after injury with rest, ice, compressive bandage, and elevation (RICE) to reduce swelling, and later fitted with a splint or cast. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed to reduce swelling and pain.

Because of the potentially serious nature of wrist injuries, referral to a hand surgeon for evaluation and treatment is essential for all significant injuries. Surgical repair of the ligaments may be necessary to preserve wrist stability. For recent (acute) injuries, sewing (suturing) the torn ligament ends back together is the preferred surgical procedure (primary ligament repair). Open surgery, with a single large incision, and arthroscopic surgery, using several smaller incisions and a small camera, may both be used to treat wrist sprains.

For chronic injuries, other procedures that reconstruct and reinforce the torn ligaments are performed. These procedures use tendons or grafts of tough connective tissue (fascia lata) to replace the torn ligament and connect the bones. These wrist reconstruction procedures include Eliason, Bunnell-Boyes, Regan-Bickel, Lowman, Liebolt, and Hill techniques. This type of surgery may require postoperative splinting or casting to maintain the position of the wrist while healing. If the surgery is simple for repair of a minor tear, postoperative casting usually is not necessary. After the wrist has been immobilized for an adequate period to allow healing, gradual return to activity is important to preserve function.

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.*
 
Wrist Sprains
 
* 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

Minor sprains and strains (grade I and possibly grade II) should heal uneventfully. More severe injuries that require splinting or casting usually heal completely. Healing may be delayed, and there may be some loss of function in injuries that are under-diagnosed or that require surgical repair. In grade III sprains and strains, surgical repair (primary repair of ligament or delayed repair of ligament) is usually successful in restoring function but may result in a reduced range of motion postoperatively.

Source: Medical Disability Advisor



Rehabilitation

Common clinical practice indicates that individuals with sprains or strains of the wrist require therapy that begins immediately. Initially, protective static splinting is recommended for moderate to severe sprains or strains, with the duration of use determined by the degree of soft tissue damage. Self-application of heat or cold can be used to control pain and swelling throughout the course of therapy (Hegmann). Physical therapy administered by an experienced hand therapist often is necessary after significant injuries.

The protective splint is removed periodically to allow for controlled active and passive range of motion in the wrist. Full active range of motion is encouraged in the proximal and distal structures. Most cases do not require formal therapy; however patient education and the establishment of a home exercise program may be best accomplished during therapy visits (Hegmann).

The degree of soft tissue damage will determine when strengthening exercises can be initiated. The therapist progresses the treatment as tolerated by the individual. Dexterity tasks, strengthening exercises, and resumption of daily life tasks are introduced to restore the use of the injured wrist during functional activities. If the patient has not made significant progress by 6 weeks, further diagnostic tests should be done to rule out significant carpal ligament injuries or damage to the triangular fibrocartilage complex (Wright).

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistSprains and Strains, Wrist
Occupational / Hand / Physical TherapistUp to 8 visits within 6 weeks
Surgical
SpecialistSprains and Strains, Wrist
Occupational / Hand / Physical TherapistUp to 12 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

Despite appropriate treatment, sprains of the wrist may occasionally result in residual long-term pain, stiffness, or swelling. Missed diagnosis, fractures, and dislocations complicate recovery and contribute to chronic pain and disability. Surgical complications include infection and stiffness. Inflammatory conditions that weaken supporting tissue may complicate treatment. Degenerative joint disease of the wrist (osteoarthritis) may result from the injury.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Return to work is depend 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 the wrist 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 arm. Individuals whose dominant arm is affected may require more accommodations than those whose non-dominant arm is affected.

Restrictions may include limited use of the affected hand. Individuals should especially avoid lifting, carrying, and twisting. Use of a cast or splint may affect dexterity and require a review of safety issues. Typists may not be able to type until casting or splinting is removed and the wrist is healed. Individuals with job requirements that include writing or typing may find alternatives to a standard keyboard, such as speech recognition software or one-handed keyboards, and need appropriate accommodations. Driving may or may not be allowed, depending on the type of immobilization used (i.e., driving may be allowed with some wraps or splints but not with a cast). Any tasks requiring manual dexterity or lifting must be curtailed until healing is complete and full strength and function of the wrist and hand is regained. Some individuals may find ergonomically adjusted or pneumatic tools useful during the healing period. 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 fracture, dislocation, nerve injury, or 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 84 days. Other than surgery, additional treatment after 84 days from the date of injury is not likely to result in dramatic improvement, so MMI is frequently achieved by 84 days 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:

  • Has diagnosis been confirmed?
  • Have conditions such as rheumatoid arthritis, carpal tunnel syndrome, dislocations of the hand and wrist, and other soft-tissue injuries of the hand been ruled out?
  • If pain and stiffness persist despite therapy, has x-ray been done to rule out fracture?
  • Has MRI been done to rule out fibrosis or arthritic degeneration?

Regarding treatment:

  • Has individual undergone comprehensive rehabilitation by a hand therapist?
  • Has individual been evaluated by a hand surgeon?
  • Is surgical intervention warranted?
  • Would individual benefit from ligament reconstruction?
  • Does individual have any underlying conditions such as rheumatoid arthritis, or systemic lupus erythematosus that may affect recovery? Are these being treated?

Regarding prognosis:

  • Did complications delay diagnosis or treatment?
  • Is individual complying with treatment regimen?
  • Is range of motion impaired?
  • How had injury affected occupational functioning?
  • Has individual experienced any complications such as infection, stiffness, inflammatory conditions, or degenerative joint disease? Are these complications being effectively treated?

Source: Medical Disability Advisor



References

Cited

"Wrist Sprains." American Society for Surgery of the Hand. 2006. 4 Jun. 2013 <http://www.assh.org/Public/HandConditions/Pages/WristSprains.aspx>.

Aiello, B. "Wrist and Hand Tendonitis." Hand Rehabilitation: A Practical Guide. Eds. Gaylord L. Clark, et al. 2nd ed. New York: Churchill Livingstone, Inc., 1998.

Beeson, Michael S. "Dislocation, Wrist." eMedicine. Eds. James E. Keany, et al. 18 Apr. 2011. Medscape. 4 Jun. 2013 <http:emedicine.medscape.com/article/823944-overview>.

Hegmann, Kurt E., and Matthew A. Hughes. "Chapter 11 - Hand, Wrist and Forearm Disorders." Occupational Medicine Practice Guidelines. Ed. Kurt E. Hegmann. 2nd ed. ACOEM, 1-156.

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. 4 Jun. 2013 <PMID: 15375809>.

Wright, Phillip E. "Chapter 66 - Wrist Disorders." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beaty. 11th ed. Philadelphia: Mosby Elsevier, 2008.

Source: Medical Disability Advisor






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