MBBS IV Occupational Medicine Workshop

Occupational Medicine Workshop

Case 1
 De Quervain’s

o History
 Pain (especially location of the pain) – very specific location
 De Quervain syndrome is inflammation of two tendons that
control movement of the thumb and their tendon sheath.
 Pain at the outside of the wrist
 Pain is typically increased with gripping or rotating the wrist
 Results in difficulty in thumb movement
 No trauma, relevant work history
o Physical examination
 Inspection: radial side to the skin  palpate  positive sign
 Finkelstein test:
 Wrap finger over thumb
 Adduction  provoke pain

 Inflammation
 Active and passive range of motion
 2 point discrimination (sensory)
 Motor function (radial, ulnar nerve)
o Etiology
 Occupational/repetitive activities
 Postures that maintain: thumb extension and abduction (e.g. opening
envelopes and stapling)
o Treatment
 Non-surgical intervention
 Splint (forearm-based thumb spica splint)
 NSAID
 Ice application
 Local glucocorticoid injection with local anesthetic
MBBS IV Occupational Medicine Workshop

 Surgery
 Indication: persistent symptoms despite non-surgical treatment
 Opening (cutting and releasing) of first extensor (dorsal)
compartment at the radial styloid process
 Sprained wrist
o Presentation
 Acute wrist pain associated with trauma history
 Inflammatory signs: swelling, warmth, tenderness
 Bruising, “popping” feeling, ROM limited, weakness with overuse
 Injury to supporting ligament in radiocarpal joint
o Etiology: overstretching, tearing, seen with tendonitis
o Classification: duration, severity
o Other ddx
 Occult fracture (e.g. fracture of scaphoid bone)
o Treatment
 Conservative therapy: ice, immbolization, gentle passive stretching
o Prognosis: resolve within 2 weeks
 Carpal tunnel syndrome
o Notifiable occupational disease
o Pathology: entrapment of median nerve within the carpal tunnel
o Presentation (sensory often present prior to motor)

o Physical exam
 Tinel’s sign: Tinel's sign is a way to detect irritated nerves. It is
performed by lightly tapping (percussing) over the nerve to elicit a
sensation of tingling or "pins and needles" in the distribution of the
nerve
 Phalen’s sign: Phalen's maneuver is positive when flexing the wrist to 90
degrees for 1 minute elicits symptoms in the median nerve distribution.
Tinel's sign is positive when tapping over the carpal tunnel elicits
symptoms in the distribution of the median nerve.
o Nerve conduction study
 Delayed latencies
 Slowed conduction velocities
 Reduced motor/sensory nerve action potential amplitude
 Sensory fibres affected earlier than motor fibres
 Abnormalities only demonstrated on median nerve but not the other
nerves e.g. radial/ ulnar nerve
MBBS IV Occupational Medicine Workshop

o Etiology
 Repetitive hand and wrist use (office work,
production/manufacturing, food processing and preparation)
 Forceful hand and wrist use
 Work with vibrating tools
 Sustained wrist or palm pressure
 Prolonged wrist extension and flexion
 Use of hands in cold temperatures
o Computer work?
 Sustained wrist and palm pressure
 Prolonged wrist extension/flexion
 Suggestions for job modifications
o Reduce aggravating factors (change job work)
o Use of instruments (to help open envelopes/stapling)
 GP
o Diagnosis
o Identify underlying medical problem related to occupational health risks
o OM history taking
o Management of patient
 OM specialists (only 14 in HK)
o More specific to occupational disease
o Promotion of health and safety at work
o Clinically:
 Diagnose occupation disease and help patient to return to work
 Medical examination for pre-employment fit to practice or regular
health check for fit for work
 Investigate compensation cases OMU at Labour department
 Others: aviation medicine (med cert for flying), underwater medicine
(high pressure working environment)

Acute hepatitis (due to refrigerants)

 Case information
o Cause of acute hepatitis due to refridgerant leakage (no protective gear at work)
o S/S: jaundice, RUQ pain
o Investigations: liver function tests (AST, ALT, GGT, total and direct bilirubin,
albumin), viral hepatitis serology are negative
o Liver biopsy – hydrofluorocarbon hepatitis
o Treatment: hydration, vitamin K
o Complication: liver failure
MBBS IV Occupational Medicine Workshop

Workup
 Assess patient
o Hx
o PE
 Diagnose
o Take occupational Hx

o Work exposure
o Hazards present
 Management
o Notifiable occupation diseases
o Referral to occupational medicine specialists in Labour Department (further
investigations and compensation)
o Treatment of the disease itself
o Sick leaves
o Ensure medical fitness for work
 General problems
 Underlying health conditions more vulnerable to certain work
condition
 E.g. epilepsy and machine use
 Certificate of medical fitness to dive (issued by medical practitioner)
 Not more than 12 months before the date of operation
 Certain medical requirements (e.g. diastolic BP, BMI, Hb)
 Advise and prevent disease
 Ensure and promote occupational safety