An Approach to Work-Related Disorders of the Upper Extremity

Management of work-related musculoskeletal disorders has been frustrating for the orthopaedist. The so-called cumulative-trauma disorders have few objective findings, and patients often do not respond to well-established orthopaedic treatments, both nonsurgical and surgical. In some areas of the country the rate of reimbursement is low; that factor, combined with the excessive paperwork and the legal burden, discourages many orthopaedists from treating patients with these conditions. However, the incidence and cost of work-related disorders continue to increase, and the orthopaedic community is being called on to help understand their etiology and to attempt to control the “epidemic” that has significantly affected the survival of certain industries. The authors review the current orthopaedic and occupational medicine literature and suggest a management approach that has been found effective in reducing both costs and disability due to these disorders. The annual incidence of work-related cumulative-trauma and soft-tissue disorders has increased markedly over the past decade.1,2 The “epidemic” of so-called repetitive-strain injuries and cumulative-trauma disorders was first noted in Australia 15 years ago3–6 and then emerged in many of the industrialized countries.3 According to the US Bureau of Labor Statistics, cumulative-trauma disorders have accounted for more than 60% of all occupational illnesses reported in the United States since 1991.7 The resultant costs of these conditions are between $60 billion and $100 billion a year and are thought to affect the very survival of certain industries.8–12 According to an insurance company analysis, the average cost related to an upper-extremity cumulative-trauma disorder in 1989 was $8,070—almost twice the average workers’ compensation claim of $4,075.13 This analysis also found that 25% of the cases accounted for 89% of the costs. Medical expenses were paid for only 49.9% of cases, which indicates that half of the patients had lost no time from work. In contrast, when all work-related injuries were evaluated together, 73.9% of patients had no lost time. This illustrates the significantly longer disability associated with cumulative-trauma disorders.