Upper Extremity Montana Utilization and Treatment Guidelines Effective July 1, 2011 to December 31, 2016 Presented by: State of Montana Department of Labor and Industry EMPLOYMENT RELATIONS DIVISION Copyright ©2011 - State of Montana 1 July 1, 2011 A. Table of Contents A. Table of Contents B. General Guideline Principles ………………………………………………………….. 4 C. Definitions and Mechanisms of Injury …………………………………………………. 7 D. Initial Diagnostic Procedures …………………………………………………………... 8 D1. History Taking and Physical Examination (Hx & PE) …………………………….. 8 D2. Laboratory Testing …………………………………………………………………. 16 D3. Medical Causation Assessment for Upper Extremity Conditions …………………..18 E. Follow-up Diagnostic Imaging and Testing Procedures ……………………………….. 35 F. Specific Cumulative Trauma Conditions Diagnosis, Testing and Treatment Procedures 42 F1. Aggravated Osteoarthritis ………………………………………………………….. 42 F2. De Quervain's Disease ………………………………………………………………47 F3. Epicondylitis - Lateral Epicondylalgia ……………………………………………... 49 F4. Epicondylitis - Medial (Epicondylalgia) …………………………………………… 55 F5. Extensor Tendon Disorders of the Wrist …………………………………………… 59 F6. Flexor Tendon Disorders of the Wrist ……………………………………………... 61 F7. Hand Arm Vibration Syndrome ……………………………………………………. 63 F8. Triangular Fibrocartilage Complex Tear (TFCC) ………………………………….. 65 F9. Trigger Finger ……………………………………………………………………… 68 F10. Thoracic Outlet Syndrome ………………………………………………………... 70 G. Specific Peripheral Nerve Diagnosis, Testing and Treatment Procedures …………….. 76 G1. Carpal Tunnel Syndrome …………………………………………………………... 76 G2. Cubital Tunnel Syndrome …………………………………………………………. 89 G3. Guyon Canal (Tunnel) Syndrome …………………………………………………. 92 G4. Posterior Interosseous Nerve Entrapment (PIN) ………………………………….. 94 G5. Pronator Syndrome ………………………………………………………………… 96 G6. Radial Nerve Entrapment at the Wrist …………………………………………….. 99 G7. Radial Tunnel Syndrome ………………………………………………………….. 101 H. Specific Musculoskeletal Disorders (MSDs) Diagnosis, Testing and Treatment Procedures …………………………………………………………………………………………….. 104 H1. Amputations and Indications for Replantation ……………………………………. 104 H2. Biceps Tendinosis/Tendinitis and tears/ruptures ………………………………….. 105 H3. Crush Injuries and Compartment Syndrome ……………………………………… 107 H4. Distal Forearm Fractures ………………………………………………………….. 109 H5. Distal Phalanx Fractures and Subungual Hematoma ……………………………… 113 H6. Elbow Contusion ……………………………………………………………………115 H7. Elbow Dislocation …………………………………………………………………. 116 H8. Elbow Fractures including non-displaced radial head fractures ……………………118 H9. Elbow Osteonecrosis [Avascular Necrosis (AVN)] ……………………………….. 120 H10. Elbow Pain, Non-specific ………………………………………………………… 122 H11. Elbow Sprain ………………………………………………………………………123 H12. Ganglion Cyst …………………………………………………………………….. 125 H13. Hand/Wrist/Forearm Pain - Non-specific ………………………………………… 127 H14. Human and Animal Bite Lacerations …………………………………………….. 129 H15. KienbÖck Disease …………………………………………………………………130 Copyright ©2011 - State of Montana 2 July 1, 2011 H16. Laceration Management ………………………………………………………….. 132 H17. Mallet Finger ………………………………………………………………………135 H18. Middle and Proximal Phalangeal and Metacarpal Fractures ………………………137 H19. Olecranon Bursitis …………………………………………………………………140 H20. Scaphoid Fracture ………………………………………………………………… 142 H21. Triceps Tendinosis/Tendinitis and Tears/Ruptures ………………………………. 145 H22. Wrist Sprains ………………………………………………………………………145 I. Therapeutic Procedures - Non-operative ………………………………………………... 148 I1. Acupuncture ………………………………………………………………………….148 I2. Biofeedback …………………………………………………………………………. 150 I3. Injections - Therapeutic ………………………………………………………………150 I4. Jobsite Alterations ……………………………………………………………………154 I5. Medications and Medical Management ……………………………………………... 158 I6. Occupational Rehabilitation Programs ……………………………………………… 163 I7. Patient Education ……………………………………………………………………. 165 I8. Personality/Psychological/Psychosocial Intervention ………………………………..165 I9. Return to Work ……………………………………………………………………….166 I10. Sleep Disturbances ………………………………………………………………… 167 I11. Therapy - Active …………………………………………………………………… 168 I12. Therapy - Passive …………………………………………………………………...170 I13. Restriction of Activities ……………………………………………………………. 176 I14. Vocational Rehabilitation ………………………………………………………….. 176 Appendix: Dupuytren’s Disease ……………………………………………………………177 Copyright ©2011 - State of Montana 3 July 1, 2011 B. General Guidelines Principles The principles summarized in this section are key to the intended implementation of these guidelines and critical to the reader’s application of the guidelines in this document. 1. APPLICATION OF GUIDELINES The Department provides procedures to implement medical treatment guidelines and to foster communication to resolve disputes among the providers, payers, and patients through the Administrative Rules of Montana. In lieu of more costly litigation, parties may wish to request an independent medical review from the Department's Medical Director prior to submitting a Petition for a Workers’ Compensation Mediation Conference. 2. EDUCATION of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of upper extremity pain and disability. An education-based paradigm should start with communication providing reassuring information to the patient. A more in-depth education within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation is optimal. A treatment plan should address issues of individual and/or group patient education as a means of facilitating self-management of symptoms and prevention. 3. TREATMENT PARAMETER DURATION Time frames for specific interventions commence once treatments have been initiated, not on the date of injury. Obviously, duration will be impacted by patient compliance, as well as availability of services. Clinical judgment may substantiate the need to accelerate or decelerate the time frames discussed in this document. 4. ACTIVE INTERVENTIONS emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment, are generally emphasized over passive modalities, especially as treatment progresses. Generally, passive interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant attainment of objective functional gains. 5. ACTIVE THERAPEUTIC EXERCISE PROGRAM goals should incorporate patient strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings. 6. FUNCTIONAL IMPROVEMENT GOALS should be consistently addressed. Positive patient response results are defined primarily as functional gains that can be objectively measured. Objective functional gains include, but are not limited to, positional tolerances, range- of-motion (ROM), strength and endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity measures that can be quantified. Subjective reports of pain and function should be considered and given relative weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on objective findings. 7. RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should be either modified or discontinued. Reconsideration of diagnosis should also occur in the event of poor response to a Copyright ©2011 - State of Montana 4 July 1, 2011 seemingly rational intervention. 8. SURGICAL INTERVENTIONS should be contemplated within the context of expected functional outcome and not purely for the purpose of pain relief. The concept of “cure” with respect to surgical treatment by itself is generally a misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical course, and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic condition(s). 9. SIX-MONTH TIME FRAME The prognosis drops precipitously for returning an injured worker to work once he/she has been temporarily totally disabled for more than six months. The emphasis within these guidelines is to move patients along a continuum of care and return to work within a six-month time frame, whenever possible. It is important to note that time frames may not be pertinent to injuries that do not involve work-time loss or are not occupationally related. 10. RETURN-TO-WORK is therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term pain. The practitioner must provide specific physical limitations and the patient should be released to return to work with specific physical activity limitations clearly spelled out per the specific job requirement. Release to “sedentary” or “light duty” is not a specific physical limitation. The following physical limitations should be considered and modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, overhead work, bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors. Even if there is residual chronic pain, return-to-work is not necessarily contraindicated. The practitioner should understand all of the physical demands of the patient’s job position before returning the patient to full