Falkiner Et Al-2002-ANZ Journal of Surgery

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INTRODUCTION

Carpal tunnel syndrome (CTS), compression of the mediannerve at the wrist, is the peripheral entrapment neuropathyencountered most often. It has an incidence of 99 per 100 000in the general population in the USA and a prevalence of between1% and 10%.1 Approximately 450 000 carpal tunnel releases areperformed annually in the USA at a cost of US$2 billion.

Awareness of CTS as a disorder associated with repeatedtrauma at work is now so widespread that many workers diagnosethemselves, often via the Internet where there are more than 25 000websites.

The costs to the workers compensation system in Australiacannot be quantified, as no state gives CTS its own category. InNew South Wales, for example, CTS is under the heading Dis-

orders of nerve roots, plexuses, and single nerves, where it sharesthe same code as metatarsalgia and brachial plexus injury, and istherefore indistinguishable from them. This code accounted for1.9% of all workplace illnesses and injuries in 19981999.2 InSouth Australia in 1998/9, the average cost of a claim for thiscode was A$8987 and the total cost was A$3 379 112.3

The incidence of work-related musculoskeletal disorders (whichincludes CTS) in the USA has remained static since 1992 it has

not steadily declined like other work-related injuries and ill-nesses since peaking in 1992.4 In 1999, CTS accounted for 1.6% ofinjuries that resulted in time off work.4 In comparison to otherwork-related injuries and illnesses, median days away from workdue to work-related injury have been highest for CTS each yearsince 1994. In 1999, for example, the average worker with CTSrequired 27 days off work compared with 20 days for a fracture and18 days for an amputation, which compares unfavourably to themean time off work for all injuries of 6 days.5 This adds signifi-cantly to claim costs.

The average cost of a CTS claim in the USA in 19961997was US$13 263,6 which was surpassed only by costs of vehicleaccidents, other trauma and fracture/crush/dislocations.

Additional costs would include costs of any civil claims, of lost

ANZ J. Surg. 2002; 72: 204209

ORIGINAL ARTICLE

WHEN EXACTLY CAN CARPAL TUNNEL SYNDROME BE

CONSIDERED WORK-RELATED?

SONJA FALKINER* AND STUART MYERS

*Royal Hospital for Women and Sydney Childrens Hospital andPrince of Wales Hospital, Randwick,

New South Wales, Australia

Background: Carpal tunnel syndrome (CTS), compression of the median nerve at the wrist, is the most frequently encountered periph-

eral entrapment neuropathy. Whilst rates of all other work-related conditions have declined, the number of work-related musculoskeletal

disorders (which include CTS) has not changed for the past 9 years in the USA. Median days off work are also highest for CTS:

27 compared to 20 for fractures and 18 for amputations. This results in enormous Workers Compensation and other costs to the com-

munity. Awareness of CTS as a disorder associated with repeated trauma at work is now so widespread amongst workers that many

have diagnosed themselves before being medically assessed, often by means of the Internet. Surprisingly, however, a definite

causal relationship has not yet been established for most occupations. Although the quality of research in this area is generally poor,

CTS research studies are being used as the basis for acceptance of Workers Compensation claims, substantial expensive ergonomic

workplace change and even workplace closures. The fact that the incidence of work-related musculoskeletal disorders has not

changed despite these latter measures would suggest that a causal relationship is not proven and that some resources are being

misdirected in CTS prevention and treatment.

Method: A literature review of 64 articles on CTS was conducted. This included those articles most frequently cited as demonstrating

the relationship between CTS and work.

Results: Primary risk factors in the development of CTS are: being a woman of menopausal age, obesity or lack of fitness, diabetes

or having a family history of diabetes, osteoarthritis of the carpometacarpal joint of the thumb, smoking, and lifetime alcohol

intake. In most cases, work acts as the last straw in CTS causation.

Conclusion: Except in the case of work that involves very cold temperatures (possibly in conjunction with load and repetition) such

as butchery, work is less likely than demographic and disease-related variables to cause CTS. To label other types of work as having

caused CTS, therefore, would result in inappropriate allocation of resources. It would also relieve individuals of the responsibility of

addressing correctable lifestyle factors and treatable illnesses such as obesity, diabetes, smoking and increased alcohol intake

which may have contributed to their CTS more that their work. This results in both avoidable long-term health effects and ongoing costs

to the community.

Key words: carpal tunnel syndrome, work-relatedness, causation.

Abbreviations: CTS, carpal tunnel syndrome; NCS, nerve conduction study.

S. Falkiner M. App. Sc. (OHS); S. Myers FRACS.

Correspondence: Ms S. Falkiner, OHS Coordinator, Royal Hospital forWomen and Sydney Childrens Hospital, Randwick, NSW 2031, Australia.Email: [email protected]

Accepted for publication 12 November 2001.


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productivity, training/retraining, ergonomic change and even work-place closure.7 Yet this expenditure has had minimal impact on inci-dence and claim costs have increased, suggesting that the roleof work in causation may be overstated and that funds may bebeing misdirected in CTS prevention and treatment.

Rates of work-related musculoskeletal disorders have notchanged since 1992 despite considerable workplace modifica-tions aimed at reducing perceived work risks. This suggests thatfactors other than work may be responsible. One investigatorsuggests the incidence rate is due to the likelihood of a worker suc-ceeding in a claim,8 while another suggests it is due to reduced rigorof diagnosis and the desire by doctors to give patients a label forsymptoms that would otherwise only be diagnosable as handpain.9 Other investigators cite increasing age, hand dominance,obesity, reduced physical fitness, lifetime alcohol intake andsmoking, rather than work, as causes,10,11 whereas another suggeststhe lack of improvement is due to changed work practices and,particularly, the increased use of computers.12

Surprisingly, however, in the research setting, CTS still hasno standardized diagnostic criteria. Furthermore, its pathophysi-ology is not understood completely. Carpal tunnel syndrome is

known to be a result of a combination of intrinsic and extrinsicmechanical factors. These interact with any number of demo-graphic, biomechanical and disease-related variables, some ofwhich may be related to work, to either reduce the size of the carpaltunnel or increase the volume of its contents, thus increasingcarpal tunnel pressure.13

DIAGNOSIS

There are no standard diagnostic criteria for CTS. None of the testsbelow stands alone or represents, by itself, a gold standard fordiagnosis.

History

History may be varied; frequently of waking and shaking withnumbness or tingling in the fingers, usually in the median nervedistribution but often more diffusely in the hand. Symptoms areoften worse in the morning and may be exacerbated by certainactivities, such as driving or reading a book. Pain may be variableand can extend up the forearm and occasionally more proxi-mally. Consideration should be given during the taking of ahistory to the possibility of: (i) peripheral neuropathy (e.g. diabetesor family history of diabetes); (ii) pain in the cervical spine(e.g. double crush (entrapment of the median nerve at morethan one site, which was first reported by Upton and McComasin 197312)); and (iii) past prolonged use of vibrating tools or

machinery, which is associated with handarm vibration syn-drome a sign and symptom complex of median and ulnarnerve symptoms in the hand when exposed to cold or vibration,reduced grip strength, aches and pains in the upper limbs, andRaynauds syndrome.14 Handarm vibration syndrome isreported by the United Kingdom Industrial Injuries AdvisoryCouncil as doubling the expected incidence of CTS in suchworkers.14

Examination

Examination is commonly done using Tinels, Phalens andMedian nerve compression tests, and considered positive if theyreproduce that particular patients symptoms. The reported sen-

sitivity of Tinels and Phalens tests is between 32%15 and 93%16

and their reported specificity ranges from 45%17 to 100%.18

These provocative tests may be negative if a patient has pro-found median nerve dysfunction (e.g. in the late stages of CTS).Examination should also include an assessment of sensation in thehand, inspection for thenar wasting, a grind test of the base of thethumb, wrist range of movement and an assessment of the cervicalspine, brachial plexus and elbow.

Nerve conduction studies

Nerve conduction studies have a reported sensitivity of between60% and 84%, and an excellent specificity of more than 95%. 19

Results are dependent on operator skill, and such studies do notdistinguish peripheral neuropathy or double crush. Methodologyis standardized, and adjustments can be made for age, gender,Body Mass Index, wrist geometry and for temperature of thelimb,8 many of which are confounders.

Others

Finally, diagnosis might include: (i) a positive response to asteroid injection by an experienced operator; and (ii) a positiveresponse to carpal tunnel release. Note that radiographs are notuseful unless there is reduced range of movement of the wrist, indi-cating possible underlying carpal derangement. This may alertto the possibility of persistent pain in the wrist following adequatecarpal tunnel surgery for secondary CTS. If a space-occupyinglesion is suspected a magnetic resonance image may also beordered.

DIAGNOSTIC CRITERIA:THE DIAGNOSTIC DILEMMA

The diagnosis of the clinical syndrome CTS is routine to themajority of surgeons involved in hand surgery. There is consider-able debate about the need for positive nerve conduction studiesin patients with classical symptoms and signs of this condition.We believe that:

1. Patient self-reports are inadequate to diagnose this condition.2. It is inadequate to diagnose CTS without a history and

examination.3. In practice, if there are any unusual features about the pre-

sentation, then nerve conduction studies are indicated.4. If nerve conduction studies are negative but the clinical

presentation is typical, then an injection of cortisone into thecarpal tunnel is a useful diagnostic test. A positive response tocortisone in this setting is a good predictor of a satisfactory

result from surgery performed well.5. In the research setting, however, there is an increased need for

diagnostic rigor and, in this setting, we believe that it is reasonableto include the results of nerve conduction studies.

EPIDEMIOLOGY OF CHRONIC CARPALTUNNEL SYNDROME

The cause of CTS as will now be described is multifactorial,work being but one factor every worker with CTS must beassumed to have a combination of personal (including non-occupational sources of exposure, such as hobbies and sport) andwork factors, the contribution of each needing to be carefullyassessed.

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Gender and age

Carpal tunnel syndrome is more common in women, the reportedratio being 3 : 1.20 That women generally have a smaller carpaltunnel than men, but the same size tendons, resulting in a lowercarpal tunnel volume, has been used to explain this increasedincidence by some investigators.21 However, the relationshipbetween CTS and carpal tunnel area is controversial. One study has

found that CTS patients had a significantly larger carpal tunnel areathan matched controls.22

Peripheral nerve function declines with age. An increasedincidence of CTS with increasing age has been shown in menbut the incidence in women peaks at 4554 years (menopause), andthen declines.23

Obesity and reduced fitness

One study found that obese patients (Body Mass Index > 29)were 2.5 times more likely than non-obese patients to haveCTS,24 and another study has found a statistically significantassociation between obesity and CTS.23 A study of 630 hands in316 workers in a variety of occupations over 5 years found that

their likelihood of developing CTS (diagnosis confirmed onnerve conduction study) was related primarily to their weight,change in Body Mass Index and fitness level.11

Legal drug use

A study of 1464 industrial workers found that those workerswith CTS (diagnosis confirmed on nerve conduction study) hada 26% greater current use of tobacco and 5% of caffeine, a 19%greater lifetime use of tobacco, and a 75% greater past alcohol usethan those without CTS (the association with current alcoholintake was not significant),25 indicating the workers lifetimealcohol history is very important in diagnosis.

Arthritis and flexor tenosynovitis

Osteoarthritis of the carpometacarpal joint and CTS frequentlycoexist26 because of a combination of alteration of the bonyarchitecture of the carpal tunnel and reduced volume due toflexor tenosynovitis.27 Carpal tunnel syndrome is the mostcommon compression neuropathy in patients with rheumatoidarthritis, and may be the first symptom of flexor tenosynovitis.28

Radiocarpal subluxation and carpal derangement play a contribu-tory role.13 A strong relationship has been found between flexortenosynovitis and CTS.29

Diabetes

There is agreement in the literature that diabetes is the disordermost commonly associated with CTS, whereby its reported inci-dence in CTS patients is up to 20%,30 with up to 27% having afamily history.29 Carpal tunnel syndrome in diabetics is usuallybilateral and symmetrical,31 and is considered by most investigatorsto be separate from peripheral neuropathy, although it rendersthe median nerve more susceptible to compression.30,32 There is alsoagreement that diabetes is strongly associated with other con-nective tissue and joint disorders, many of which are themselvesassociated with CTS, such as tenosynovitis (evidenced by triggeringor de Quervains disease) and osteoarthritis. For example, onestudy found that 20% of the diabetic patients studied either hadCTS, flexor tenosynovitis or Dupuytrens contracture.33 They

found a positive correlation between the duration of diabetes andthe incidence of these conditions, but not with the type of diabetes.Another study found these disorders to be most common inpatients with insulin-dependent diabetes mellitus, and found apositive correlation between these conditions, the age of thepatient and duration of their diabetes.32

Renal and thyroid disease

There is a high incidence of CTS in chronic haemodialysispatients (9.2%),34 especially those with an arteriovenous shuntand, atypically, it affects men and women equally.35 The inci-dence of CTS increases with the length of time on dialysis, andpatients with chronic renal failure may suffer uraemic polyneu-ropathy in addition to CTS, the incidence of which is reported as25%.35 Carpal tunnel syndrome occurs in patients with myx-oedema, particularly those who are overweight, and CTS symptomsresolve once the patient is rendered euthyroid.19 Carpal tunnelsyndrome as a result of hypothyroidism is also reversible withtreatment of the underlying disorder.19

Pregnancy and lactation

Carpal tunnel syndrome in pregnancy is usually reversible andoccurs in the third trimester, and has a reported incidence ofbetween 1% and 50%.36 It is more common in primiparouswomen37 and recurs in 50% of subsequent pregnancies.38 Oneinvestigator notes that as women expect to experience discomfortin late pregnancy, many might not seek treatment and, therefore,these figures may be underestimates.39 Carpal tunnel syndromein pregnancy is best explained by oedema around the mediannerve, probably as a result of hormones.38

Likewise, CTS in lactation usually resolves within 6 weeks ofcessation, and is more common in elderly primiparous women.36

A recent study questioned not investigating these patientswith nerve conduction studies. The author found that 20 of the 30pre- and postnatal women with CTS he examined had an acutemedian nerve lesion at the carpal tunnel with a sensory and/ormotor conduction block, and a further five had severe denervationon nerve conduction study.40

Use

A doseresponse relationship has not been established for use-related factors. The hand is not only used at work greater or equalexposure to these factors may potentially occur out of workhours such as during hobbies, home duties and sport.

PostureElevation in normal carpal tunnel pressure occurs with 90 wristflexion and extension to up to an average of 79.5 mmHg and101.2 mmHg, respectively, from a normal at-rest pressure of24 mmHg.7 Having the metacarpophalangeal joints in neutralextension with 40 wrist extension produced the highest carpaltunnel pressure (67 mmHg) of all metacarpophalangeal joint angles inone study.41 Another study found that the highest carpal tunnelpressures (55 mmHg) in their patients occurred in full forearmsupination with 90 metacarpophalangeal joint flexion.42 Neitherof these postures would be commonly used at work, however.

While doing frequent workstation assessments as an Occupa-tional Health and Safety Coordinator, I find that keyboardworkers use an enormous variety of upper limb postures at

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work, even when advised of WorkSafe recommendations43

(i.e. wrist neutral, forearms parallel to floor), as they find theirchosen posture more comfortable.

Grasp

One study found that the incursion of lumbricals into the carpaltunnel when making a fist increased carpal tunnel pressure to upto 503 mmHg.44 Power grip increases carpal tunnel pressure toup to 234 mmHg.7 Chao et al. (cited in Armstrong and Chaffin45)found that a pinch grip resulted in up to 50% more force on themedian nerve than a power grip. Finger tip loading to 6 N, 9 N and12 N was found by one group to significantly increase carpaltunnel pressure, regardless of wrist posture.46

Reduced median nerve glide

The greatest median nerve excursion in the upper limb (35.4 mm)occurs at the wrist.47 After surgery this glide may be reducedby adhesion, resulting in potential for median nerve traction andfibrosis at the wrist. In the presence of another site of compressionor injury elsewhere in the upper limb, arm movement places

additional force on the median nerve at the wrist.

Weight-bearing in wrist extension

Increased carpal tunnel pressure is due initially to extreme wristextension with force external to the carpal tunnel. With time,two factors can potentially increase carpal tunnel pressurefurther by reducing the size of the carpal tunnel. These areosteoarthritis of the wrist, which is associated with long-termcane and crutch use, and flexor tenosynovitis,48 which is associatedwith overuse, such as that which may occur after a cerebrovascu-lar accident.

Sport and work

Sport

Carpal tunnel syndrome has been reported in tennis players,weightlifters, archers and golfers. The incidence in athletes isalso increasing exponentially and that double crush in sportspeople is common.49

Work

Carpal tunnel syndrome has been reported in most occupations,from secretaries, dental technicians and ultrasonographers tofactory and slaughterhouse workers.

The literature on CTS as a work-related disorder is conflictingand, generally, of poor quality. After assessing 52 articles on

CTS and work, one study concluded that only 14 articles warrantedfurther investigation in that they met basic medical criteria for diag-nosis the diagnostic criteria used were defined and accurate,and diagnosis was based on the taking of a history, physicalexamination and nerve conduction study.50 Five of these articleswere excluded as they were descriptive only, and the remainingnine articles were discounted because of flaws in researchdesign. The authors concluded that there was no relationshipbetween CTS and work.

Three studies already mentioned previously have also con-vincingly refuted the link between CTS and most types ofwork.10,11,25 For example, one study found that age and handdominance (not work) were the best predictors of decliningmedian nerve function after 5 years.11

Another study found that for the right hands of long-standingpoultry processors, the risk of developing CTS (diagnosed onnerve conduction study) was equal to that which would beexpected due to ageing, and for matched controls the risk was evenless.51

Almost all of the studies commonly cited suffer from at least oneand, frequently, all of the following flaws:

1. Inaccuracy of diagnosis, such as inclusion of signs andsymptoms not of CTS, such as of osteoarthritis.

2. Incomplete diagnosis, including complete failure to examineany patients, prior to making diagnosis.

3. Methodological flaws, such as failure to: (i) use a controlgroup; (ii) apply the same diagnostic criteria to all subjects ina group; (iii) screen for differential diagnoses; (iv) considernon-occupational sources of exposure, such as hobbies, sportand home duties; and (v) consider normal age-related deteriorationin nerve function.

The highest incidences of CTS reported across all studies are forfrozen food workers and butchers.3 Such workers are unable towear gloves to adequately protect their hands from the effects of thecold for reasons of dexterity and hygiene. Also, some of these

workers, such as meat packers, lift significant loads of up to 55 kgof boxed meat. Despite the flaws in these studies, the higherincidence of CTS in these workers suggests a probable role for coldtemperature in addition to repetition and load in the develop-ment of CTS because of work-related factors.

A literature review of 164 studies on CTS found that the 4%that used the nerve conduction study in addition to history andspecial tests for diagnosis reported incidences of between 19%(for ski manufacturing workers) and 53% (for butchers).52 Chiang,as cited in Hales and Bernard,53 found frozen food workers,whose work also involved repetition and load, had four timesthe risk of developing CTS (diagnoses confirmed on nerve con-duction study) compared with workers doing high repetitionwork at normal temperatures. A study of 788 workers who hadundergone carpal tunnel release found enormous variationsbetween groups.54 Ninety per cent of boners who worked in anenvironmental temperature of 4C handling meat at tempera-tures of 11C and using extremes of bilateral wrist motion andload had CTS compared with 4% of workers in the loadingdock. Another study found a smaller but significant difference(7.7%) of deboners in a slaughterhouse had CTS compared with1.6% of workers in a chemical plant,55 and a third study founda CTS prevalence of 21% in 655 employees in a meat packingplant.56

However, for most other workers, such as data processors andfactory workers, no definite link has been shown between CTS andwork. Perhaps work has acted as the last straw in causation,

but to label CTS as being work-related in these groups wouldprobably be inaccurate and result in inappropriate allocation ofcompensation monies and other resources. Furthermore, theworker may, as a result, not be motivated to address the treatablelifestyle factors and illnesses that may have contributed to theirdisease, such as smoking, diabetes and obesity. This wouldresult in long-term health effects and increased health costs tothe community.

The limitations of papers cited most frequently as demonstratingthat work causes CTS will now be discussed.

In their study of 700 electronic assembly workers, Feldman andcolleagues included signs and symptoms of both handarm vibra-tion syndrome (Raynauds syndrome, when many of their patientsworked with vibration) and osetoarthritis of the carpometacarpal joint



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(reduced web space and difficulty opening jars) in their CTSdefinition, and they failed to control for normal age-related nervedeterioration.57 Their study found changes in median nerve functionover time.

A study by Orsorio et al. included patients with symptoms ofmore proximal median nerve compression (under pronator teres)and of thoracic outlet syndrome in their CTS definition. Only 33 oftheir 56 subjects underwent either a physical examination or a nerveconduction study.58

Blanc and colleagues calculated both the prevalence and oddsratio for CTS development due to work based solely on self-reports by 33 232 workers of symptoms and hand use at work.They ignored non-occupational sources of exposure.59

Margolis and Kraus relied solely on supermarket checkersself-reports of symptoms in order to make a diagnosis of CTS.60

Tanaka et al. relied solely on patients self-reports for diagnosisand average hand use at work, and determined that 2% (fewer thanwould be expected by chance) of their 30 074 workers hadCTS.61

De Krom et al. relied on self-reports of hand use over a 5-yearperiod in 156 patients with CTS (diagnosis confirmed on nerve

conduction study) and 473 controls. They ignored non-occupationalsources of exposure.62

A study by Weislander and colleagues also relied on thememory of workers hand use at work over their entire life of34 patients with CTS (diagnosis confirmed on nerve conductionstudy) and 143 matched controls.63 They found that the patientgroup had significantly more exposure to vibration and repeti-tive wrist motion than controls, but failed to show they hadcontrolled for patients with handarm vibration syndrome (asso-ciated with a doubling of the expected incidence of CTS inworkers who have the condition (discussed earlier)). They alsofailed to consider non-occupational sources of exposure.

In their video and electromyography study, which compared18 industrial sewing workers with 18 controls, Armstrong andChaffin based their diagnosis on either history or a positivePhalens orthenar eminence atrophy (which may indicate osteo-arthritis of the carpometacarpal joint and not CTS) ora historyof carpal tunnel release (operative findings were not reported toindicate accuracy of diagnosis).45

Masear and colleagues conducted a retrospective study, whichcovered a period of 12 years, of 788 workers who had undergonecarpal tunnel release by 17 different surgeons, and includedsome patients who had not had a nerve conduction study (19%);furthermore, their diagnostic criteria were not reported.54

Atterbury et al. used results of self-reports of symptoms by322 subjects, from which to select a subgroup of 25 CTS and35 matched controls, on whom a physical examination and

nerve conduction study were performed, and the results ofwhich were used to draw conclusions about the CTS incidencein carpenters.64

CONCLUSION

Except in the case of work that involves very cold temperatures,possibly in conjunction with load and repetition, work is lesslikely than demographic and disease-related variables to causeCTS.

Recommendations

1. That there be a world-wide agreed system of CTS diagnosis,which recognizes that all CTS is multifactorial in aetiology.

This is particularly important in research as it will allow compar-ison between studies. This should include the taking of a history ofmedian nerve symptoms night (or day), and examination of thepatient (wasting, Tinels, Phalens, sensation, including screenfor peripheral neuropathy, grind and neck examination).

2. That WorkCover in Australia afford a separate statisticalcategory to CTS.

3. That prevention and treatment of CTS address correctablelifestyle factors in addition to disease-related variables.

4. That incidences of CTS be evaluated for various job des-criptions, using large numbers of workers in the same job descrip-tion across many workplaces.

5. That results of intervention (e.g. conservative manage-ment, carpal tunnel release, fitness programmes, changed workpractices) also be evaluated for each job description acrossmany workplaces.

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