Boning Up

• By Valerie Weadock
• Jun 01, 2003

A vast range of human activities--from writing to laying bricks, to opening a can of soda--would be impossible without the healthy functioning of the elbow, wrist, and hand. Yet this area is one of the most intricate and one of the most vulnerable to injury in the human body.

Occupational physicians and therapists are no strangers to these types of injuries; they can't afford to be. Among the most severe injuries, measured in lost workdays in all major industry divisions in Texas alone, carpal tunnel syndrome, tendonitis, and other wrist injuries ranked as the top three, according to the 2000 Bureau of Labor Statistics Annual Survey of Occupational Injuries and Illnesses.

In addition to repetitive motion activities, one of the most common mechanisms of wrist injury is a fall onto an outstretched hand, usually occurring when an individual tries to break his fall or catch himself with his hand. Strains, sprains, and even fractures often result. A scaphoid fracture is one of the most common broken bones in the wrist area. Scaphoid bones are particularly delicate due to a notoriously poor blood supply. When the scaphoid bone is struck, the already poor blood supply to the bone is damaged, which can interrupt the flow of healing nutrients. This has a negative effect on the healing process, and a subsequent fracture or break frequently occurs.

A Unique Learning Tool
The American Society of Hand Therapists (ASHT) recognizes the prevalence of scaphoid fractures and other wrist injuries and the subsequent need for information on their treatment, rehabilitation, and prevention in its CD-ROM, Surgical Demonstration & Therapeutic Management II: The Wrist. The CD and its predecessor (which covers one discussion each on the shoulder, elbow, wrist, and finger) feature lectures and surgical demonstrations taped live at a pre-conference institute held in conjunction with ASHT's 25th annual meeting in September 2002.

While it is aimed at individuals and organizations involved with hand and upper extremity rehabilitation and/or injury prevention, Diane Muller, director of education and development for ASHT, says the CD-ROM-based program also is beneficial to those who need to understand surgical and therapeutic protocols for affected workers. This includes risk managers, case managers, ergonomists, and others, she said.

"As one of the lecturers says in the video, 'anatomy is power.' This CD demonstrates anatomy beautifully, which is paramount to anyone attempting to understand what an individual goes through in trying to recover from an injury or condition," Muller said. "It also provides valuable insight into the delicate nature of the hand and upper extremity and the importance of protection of workers--with both full functional and basic quality-of-life implications."

The CD begins with a lecture on Wrist Basics, which reviews the skeletal components of the wrist, its primary ligaments, and its movements. The lecturer, Rachael Jaffe, OTR/L, CHT, uses several slides during her presentation, but many are hard to read in the CD-ROM format. Still, the information presented is useful as an introduction to the later surgery.

Before diving into the wrist surgery demonstration, Dr. Paul C. Dell leads a discussion on scaphoid nonunion, or fracture, including an explanation of stable versus unstable fractures, indications for surgery, diagnosis, and prognosis.

The program's strength is definitely in the wrist surgery demonstration, but users beware, this portion of the CD is not for the weak of stomach. Using the arm of a cadaver, Dell demonstrates both a dorsal and volar (front and back) approach to screw fixation of a scaphoid fracture. With a little bit of humor and an obvious passion for the subject, he also goes through a capsulodesis of the scapholunate ligament, a treatment for an injury to a ligament that often occurs in the same manner as a scaphoid fracture.

After the surgical demonstration (and every other section), people attending the taping of the program were given a chance to ask questions. While it's hard to make up for a CD-ROM user's not being able to ask for clarification, the questions asked during taping are answered thoroughly, often with further surgical demonstration, truly adding to the program's value.

Ruthie Dell, MHS, OTR, CHT, finishes the program with a lecture on the Therapy Considerations Following Wrist Surgery, including immediate post-operation management and post acute treatment for the spectrum of scaphoid fractures. After working through the program, health care practitioners can earn continuing education hours (0.5 CEUs) by satisfactorily completing the brief post-CD self exam.

The CD's largest faults lie in some audio and video difficulties that occurred during taping, which ideally should have been edited out but do not interfere with any of the sections' content.

Strong Combination
Through the use of lectures, slides, and live surgical demonstrations, this CD-ROM-based program gives the user an in-depth lesson that he/she would be hard pressed to find even in a series of upper-level college courses. "Few practitioners--and even fewer occupational health and safety professionals--have the luxury of regularly observing live surgeries," Muller said. "The insight into a patient's recovery process such as a demonstration provides can make a marked difference on patient outcomes, work environment improvement, and worker understanding."

The best part is that, unlike a college lecture, this program can be stopped and rewound or watched as many times as needed.

This article originally appeared in the June 2003 issue of Occupational Health & Safety.