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Welcome to OccuMED Articles. The purpose of OccuMED Articles is to provide a library of medical information for OccuMED clients. This information is provided by OccuMED Occupational Physicians and OccuMED's network of medical specialists and allied health professionals.
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Cartilage Injuries of the Ankle
Cartilage Injuries of the Ankle
The normal ankle joint, like most joints in the body, is lined by hyaline articular cartilage. This is a firm smooth surface which allows the two surfaces of the joint to glide smoothly together during movement. Any damage to this articular surface can result in chondral injuries.
Mechanism of Injury
The ankle is commonly involved in work-related injuries. The articular or chondral surface is particularly prone to inversion injuries. This is the typical ankle "sprain" where the foot and ankle turn "inwards". Other types of ankle injuries can also damage the joint surface. This often occurs in work-related settings such as walking on uneven surfaces.
Chondral injuries can vary in size, location and also the depth of the cartilage surface involved. There may only be a partial thickness injury where the most superficial layers of cartilage cells may are involved, or the full thickness of cartilage down to the underlying bone may be affected. Symptoms vary but if the chondral injury is large enough it can lead to acute pain, swelling and stiffness. In addition if a fragment of the torn cartilage becomes loose and separates, it can be caught between the ankle joint surfaces. This can result in the ankle getting stuck or "locked" with certain activities resulting in severe pain and inability to walk. This often results in great difficulty returning to normal work duties.
Natural Progress
As the cartilage lining the ankle joint has only a very limited blood supply and little potential for regeneration in an adult, injuries to the joint surface do not generally heal well. If not appropriately treated the problem is of ongoing pain and swelling which will impede rehabilitation and fitness for work.
Investigations
Following an acute work related ankle injury, the investigations ordered depend on the clinical findings on examination of the ankle. It is reasonable to have an Xray performed to exclude any fractures but this does not actually demonstrate subtle injuries to the cartilage surface given that it is generally not mineralized and thus does not show up on an Xray. As such this may require a special MRI scan to define a cartilage injury.
Treatment
It is generally reasonable to attempt physical rehabilitation in the first instance to accelerate fitness for work. A combination of anti-inflammatory medication and bracing or strapping of the ankle can help. Physiotherapy is also useful to regain strength and movement through the ankle with specific exercises. Other modalities such as ultrasound treatment can also be beneficial. In addition cartilage injuries are often associated with inflammation of the lining of the ankle joint or "synovitis". If this is severe a cortisone injection directly into the ankle joint may help.
While most cartilage injuries of the ankle respond to this treatment, a small proportion of patients have ongoing symptoms. This is usually due to a large full thickness injury or a fragment of loose cartilage which becomes entrapped within the joint surfaces. In such cases surgical intervention may be required. The technology now exists to perform this through arthroscopic or "keyhole" surgery. This is generally performed under a general anaesthetic with the patient asleep.
The injury to the cartilage is assessed and any loose or unstable cartilage fragments are removed to create a smooth surface. If the injury involves the full thickness of the cartilage surface and bare bone is visible, this does not have the potential to heal with normal cartilage. As such the bone is drilled to stimulate healing with a scar tissue response or fibrocartilage. While this does not fully replicate the mechanical properties of the normal hyaline cartilage lining the ankle joint, in at least 80% of patients there is a significant improvement of symptoms.
While the normal hyaline cartilage lining the ankle does not naturally regenerate in an adult, there is the potential in a select group of patients to attempt a cartilage graft. This is still an experimental procedure in which the long term success rates are as yet unknown. At this stage few patients have symptoms bad enough or meet the strict criteria to have this surgery.
Physical Rehabilitation
Arthroscopic surgery is generally performed as an inpatient case. Depending on the specific problems with the ankle most patients will have a cast or brace on the ankle following surgery and will be restricting their weight bearing with crutches. Sufficient pain relief is organized and rehabilitation commences generally in a further two weeks once the wounds have adequately healed. This primarily involves range of movement exercises and strengthening of the muscles, and a rapid return to full weight bearing. A physiotherapist can be helpful in assisting with this.
Depending on the degree of the cartilage injury and amount of surgery required, most patients are comfortably weight bearing and walking without crutches approximately two weeks following surgery. A brace may be required and at this stage fitness for work would be reasonable to consider for office based duties and some manual jobs. Physical rehabilitation increases at this stage and can include hydrotherapy and further muscle strengthening exercise. In general fitness for work for heavy manual labour can be considered between four to six weeks following surgery, when a brace is usually no longer required.
Work Restrictions
Following arthroscopic surgery, the patient should avoid prolonged standing and weight bearing for the first two weeks. Thereafter work-related activity levels can be increased and by six weeks following surgery, few work restrictions generally apply.
Prognosis
In general most patients recover well from work-related articular cartilage injuries of the ankle if they are appropriately treated. There is a theoretical concern of potential arthritic changes occurring after loss of part of the cartilage surface especially as the fibrocartilage scar that forms does not have the same mechanical properties as normal hyaline cartilage. However in general only the abnormal and torn part of the cartilage is removed leaving as much of the normal cartilage intact as possible, and the majority of patients will have a good outcome in the long term. The outcome following removal of loose cartilage is also far better than leaving a fragment locked between the joint surfaces.
Disclaimer: Please note that the information in this article is intended as only a general guide to cartilage injuries of the ankle. Every patient's clinical situation will differ and treatment is modified depending on the specific problems and needs of each patient.
Dr. Rezah Salleh
Orthopaedic Surgeon
MBBS(UWA) FRACS
Suite 217 Saint John Of God Subiaco Clinic
25 McCourt Street
Subiaco WA 6008
Phone: (08) 9382 9102
Fax: (08)9382 9104Labels: Ankle Injuries
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Meniscal Injuries of the Knee
Meniscal Injuries of the Knee
The normal knee contains two semicircular discs lining the joint line known as menisci. These are composed of an elastic fibrocartilage and provide the important job of "shock absorbers" thus reducing stresses through the joint and limiting abnormal wear. They also perform a secondary role in contributing to knee joint stability.
Mechanism of Injury
The knee is commonly involved in work-related injuries. The meniscus is particularly prone to a combination of flexion and rotation of the knee. This often occurs in work-related settings such as heavy load bearing.
Injuries to the meniscus generally result in tears which lead to acute pain, swelling and stiffness. In addition if a fragment of the torn meniscus is caught between the knee joint surfaces this can result in the knee getting stuck or "locked" with certain activities resulting in severe pain and inability to walk. This results in great difficulty returning to normal work duties.
Natural Progress
As there the meniscus has only a limited blood supply in an adult, there is little potential for spontaneous healing in all but small and incomplete tears. If not appropriately treated the problem is of ongoing pain and swelling which will impede rehabilitation and fitness for work.
Investigations
Following an acute work related knee injury, the investigations ordered depend on the clinical findings on examination of the knee. It is reasonable to have an Xray performed to exclude any fractures but this does not actually demonstrate a meniscus tear. As such this may require a special CT or MRI scan to show it.
Treatment
While it would be reasonable to attempt physical rehabilitation in the first instance to accelerate fitness for work, if the knee does not respond quickly to this then surgical intervention may be required. The technology now exists to perform this through arthroscopic or "keyhole" surgery. This is generally performed under a general anaesthetic with the patient asleep.
The injury to the meniscus is assessed and in a small proportion of patients a tear may be repairable. However due to the fact that the meniscus has a poor blood supply and that most tears often result in several fragments, in most cases the torn fragments need to be removed. As much of the remaining normal meniscus is left intact and is trimmed to a smooth surface.
Physical Rehabilitation
Arthroscopic surgery is generally performed as a day case. Depending on the specific problems with the knee most patients can start full weight bearing on crutches immediately following the surgery. Sufficient pain relief is organized and rehabilitation commences immediately. This primarily involves range of movement exercises and strengthening of the quadriceps muscles. A physiotherapist can be helpful in assisting with this.
In general patients are comfortably weight bearing and walking without crutches by approximately two weeks following surgery. At this stage fitness of work would be reasonable to consider for office based duties and some manual jobs. Physical rehabilitation increases at this stage and can include hydrotherapy and muscle strengthening exercise. In general fitness for work for heavy manual labour can be considered between two to four weeks following surgery.
Work Restrictions
Following arthroscopic surgery, the patient should avoid prolonged standing and walking and any twisting movements or deep flexion (such as kneeling) for the first two weeks. Thereafter work-related activity levels can be increased and by six weeks following surgery, few work restrictions generally apply.
Prognosis
In general most patients recover well from work-related meniscus injuries of the knee if they are appropriately treated. There is a theoretical concern of potential arthritic changes occurring after removal of part of the meniscus due to loss of some of the "shock absorbing" capacity. However in general only the abnormal and torn part of the meniscus is removed leaving as much of the normal meniscus intact as possible. The outcome following removal of a torn meniscus is also far better than leaving a fragment locked between the joint surfaces.
Disclaimer: Please note that the information in this article is intended as only a general guide to injuries of the meniscus. Every patient's clinical situation will differ and treatment is modified depending on the specific problems and needs of each patient.
Dr. Rezah Salleh
Orthopaedic Surgeon
MBBS(UWA) FRACS
Suite 217 Saint John Of God Subiaco Clinic
25 McCourt Street
Subiaco WA 6008
Phone: (08) 9382 9102
Fax: (08)9382 9104Labels: Knee injuries
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Contact Dermatitis
The term dermatitis means inflammation of the skin. There are two types of dermatitis, endogenous which means an inbuilt tendency to develop skin dermatitis, and exogenous, where dermatitis is produced through contact with substances on the skin, and is known as contact dermatitis. The most common site for occupational cases of contact dermatitis is the hands, but any exposed area of the body including arms, face, legs, feet, and neck can be involved.
Types of contact dermatitis
Irritant Contact Dermatitis- Acute irritant contact dermatitis is caused by strongly acidic or alkaline substances touching the skin producing a burning sensation for example where skin comes in contact with strong chemicals or wet cement.
- Chronic or cumulative type of irritant contact dermatitis often takes time to develop, and is the result of breakdown of the skin barrier, and is caused by substances which irritate and dry the skin.
Allergic Contact Dermatitis- This is caused by a substance in contact with the skin to which it develops an allergy to. It may be delayed for several hours or days before a reaction develops. However when you become allergic to a particular substance, even a very low concentration of the substance can produce a dermatitis. This occurs much less commonly than irritant contact dermatitis.
Contact Urticaria- This is where the skin develops an immediate allergic response to contact with a particular substance. This produces a localised hive reaction on contact with the substance. It is caused by a different mechanism to the other types of contact dermatitis. The most common is latex allergy.
Almost 3/4 of all occupational (work related) contact dermatitis is caused by irritant contact dermatitis, and 1/4 by allergic contact dermatitis. Cases of contact urticaria are rare except in the health industry.
Irritant contact dermatitis
Causes
The most common cause of irritant contact dermatitis is from constant contact with water. Other skin irritants include soaps, detergents, cleansers, shampoos, disinfectants, solvents, mineral oils, paper towels, dust, hard particles, heat , sweating and low humidity. People who have an atopic history, that is have a previous history of asthma, hayfever or eczema are several times more likely to develop irritant contact dermatitis. It is important to advise patients with this history to avoid or restrict from working in jobs where contact with irritants can occur. Also precautions should be taken in the work place to protect the skin from the beginning.
The damage to the skin by the irritants often take some time to occur, and it can take many months for the skin to recover completely. Once someone develops irritant contact dermatitis and the skin barrier is broken, certain chemicals which can produce an allergic reaction are more likely to penetrate the skin. So it is important to protect the skin before the skin barrier is broken by irritants.
Management and ongoing prevention of irritant contact dermatitis
It is important to alert and identify people with a background of eczema that they have an increased risk of irritant contact dermatitis. They can then take precautions to prevent irritants coming in contact with their skin right from the beginning of their job or career.
It is important where possible for all workers to minimize contact with irritants. This can occur through glove use, and different types of gloves are recommended for different duties. In addition, gloves should be removed or changed regularly to minimize sweating which is irritating to the skin. Protective clothing should be worn when exposure to irritants are likely in a particular job. If chemicals are spilled on to the skin or clothing, this must be thoroughly washed off, and a new set of clothing worn.
Skin care in the workplace should involve avoidance of some soaps and cleansers which are particularly harsh on the skin and substituting these with soap free washes or soap substitutes matched to the same pH as the skin. It is important to dry thoroughly after washing especially between fingers and under rings. Drying the hands with towels or air dryers is less irritating than using paper towels. After washing the hands it is important to moisturize the hands with a non perfumed moisturizer. Always rub the moisturizer into the hands well including the web spaces, and extend this to the fingers and wrists. Develop a routine for the worker, and this will aid in the recovery from the episode of irritant contact dermatitis. It is important to use an appropriately strong topical steroid to the irritant dermatitis till the problem clears completely. Once the dermatitis clears preventative measures must be taken to reduce the likelihood of the same problem recurring.
Allergic Contact Dermatitis
The development of allergic contact dermatitis varies considerably between individuals. Often it takes months or even years of contact with a particular substance, and then suddenly for reasons not well understood, a person becomes allergic to it. However once a person becomes allergic to something, a rash will develop whenever they touch or come into contact with that particular substance. The rash of allergic contact dermatitis is similar to irritant contact dermatitis, but it may occur more suddenly, and more severe sometimes even with blistering. A widespread dermatitis may develop in other areas of the body not in contact with the allergen, and this is a hypersensitivity reaction to the allergen.
The diagnosis of allergic contact dermatitis is made by patch testing, and there are many allergens that can be tested. A standard series which involves the most common allergens encountered is often used. It is important to inform the doctor who is doing the patch testing the various products and material safety sheets of the products used in the workplace.
Management and ongoing prevention of allergic contact
This is similar to that of irritant contact dermatitis. The person who is diagnosed with allergic contact dermatitis should be informed about the sources of the allergen that caused the reaction, and avoid all contact with those sources. If a person cannot work without developing the rash, then either job modification or a change of duties is recommended.
Dr. Ernest Tan
MBBS FACD
Consultant Dermatologist
Burswood Dermatology
87 Burswood Road
Victoria Park WA 6100
Australia
Tel: 618 9470 3064
Fax: 618 9470 4479Labels: Dermatitis
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Blood pressure (hypertension) & Fitness for work
Hypertension
Hypertension is the medical term for high blood pressure. Hypertension increases the risk of blood vessel disease resulting in long term complications such as stroke, heart attack, eye disease and kidney disease. Generally, the higher the blood pressure, the higher the long term risk. Conversely, the lower the blood pressure, the lower the long term risk. There is no single blood pressure cut off level that divides people into 'safe' and 'unsafe'.
Hypertension & fitness for work
Hypertension affects fitness for work because of the risk of sudden incapacity from a stroke or heart attack. It is important to keep in mind that high blood pressure is only one of the risk factors for a stroke or heart attack. Other important risk factors are:
- Previous stroke/heart attack
- Age
- Gender
- Family history of heart disease
- High cholesterol
- Smoking
- Diabetes
- Obesity
- Lack of physical activity
The other way hypertension affects fitness for work is when the use of anti-hypertensive medication causes side-effects such as dizziness, nausea or fatigue. The risk for side-effects is greatest in the first few days of starting or changing medication. Patients are cautioned about this by their treating doctors. Generally, modern anti-hypertensive medications cause no side-effects in most people with regular use.
Assessing fitness for work - minimising the risk
The risk of sudden incapacity from a blood pressure of 160/80 in a young female is different from a blood pressure of 160/80 in an elderly male smoker with high cholesterol and diabetes. Therefore, fitness for work cannot be determined by a single blood pressure reading alone. The overall risk needs to be considered and this occurs when the other risk factors listed above are reviewed together. The risk is minimised by ongoing medical review and risk factor management.
As a rule, only a blood pressure reading of 200/110 or above is an automatic bar to immediate employment. This is because it is associated with a high risk of short term complications.
White coat hypertension
White coat hypertension occurs when a person with usually normal blood pressure has a high pressure reading measured whenever he sees a doctor (usually because of stress!). White coat hypertension occurs commonly at preplacement medicals. To differentiate between true hypertension and white coat hypertension, a person usually has to undergo periodic monitoring and sometimes 24 hour ambulatory blood pressure monitoring. Practically, this means referral to the person's own doctor for ongoing follow-up.
Dr. Roger Lai
MBBS (Hons)
Occupational Medicine Registrar
OccuMED Consulting
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Back Injuries: Getting Injured Workers Back to Work
Background
Back problems are the seventh most common reason for seeking care in general practice in Australia. Despite medical advances, chronic disability from back pain has become a major contributor to the burden of disease in modern society.
Objective
This article provides an overview of evidence-based management for workers presenting with acute low back pain, with the aim of minimising the risk of chronic disability.
Discussion
Approximately 95% of cases of acute low back pain are non-specific. Serious spinal conditions are rare and can be identified by triaging for "Red Flags." A modern biopsychosocial approach does not require a specific patho-anatomic diagnosis for effective management. It is essential to reassure patients to stay active and to resume normal activities quickly - including a return to work. Screening for environmental and psychosocial "Yellow Flags" can identify patients at risk of poorer outcomes - so that additional early intervention can commence.
Read More
AFR.pdf
Dr. John Low
MBBS (UWA) Grad Dip OHS FAFOM
Occupational Physician
OccuMED ConsultingLabels: Back Pain
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Microscopic Haematuria at Pre-Employment Medical
Painless microscopic blood in urine on routine dipstick testing and fitness for work
Microscopic Haematuria (microhaematuria) is one of the commonest abnormalities found during routine checkups. It is always to be considered an abnormality although frequently it is a transient finding and, even if shown to be persistent, the cause of the bleeding may not be obvious even after detailed investigation.
Blood in the urine can originate either from the kidney tissue or anywhere along the urinary tract.
In Australia, approximately five percent of randomly chosen adults over 25 years of age have microscopic haematuria on the first urine dipstick test. This is confirmed by a second test (dipstick or microscopy) in 2.5 percent.
Transient microhaematuria may be caused by exercise, sexual intercourse, menstrual contamination or mild trauma. It can persist for some weeks after urinary tract infection.
Asymptomatic microhaematuria identified on routine dipstick testing during pre-employment medical assessments at OccuMED are referred to the family general practitioner for follow up, specifically repeat dipstick test and microscopy.
In general terms, without specific concern on history and examination findings, this finding poses very little risk in terms of the candidate's Fitness for Work (ability to undertake his/her job safely and effectively). This does not mean that further investigations are not required as there are potentially reversible serious and specific conditions that cause blood in the urine which pose limited risk to health if diagnosed and managed early.
It is therefore important for the patient to follow up with their general practitioner to repeat the urine test and map out a management strategy if required.
Dr. John Low
MBBS (UWA) Grad Dip OHS FAFOM
Occupational Physician
OccuMED Consulting
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Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) is the result of increased pressure in the carpal tunnel (CT) leading to pressure of the median nerve. About 3% of adults in the general population have symptomatic CTS confirmed by nerve conduction studies.
Clinical Features
CTS characteristically presents with pins/needles (paraesthesia), numbness and pain affecting the palmar side of the thumb, index finger, middle finger and radial half of the ring finger, as well as the radial side of the palm. These symptoms must last more than 1 week, or if intermittent, occur on multiple occasions before the diagnosis of CTS is considered. Another prominent feature is the occurrence of the symptoms at night relieved by flicking the hand.
Findings on physical examination indicative of CTS include a positive Tinel’s sign and Phalen’s test.
Other useful clinical tools in assisting diagnosis include the use of hand diagrams, and two-point discrimination test.
Investigations
Investigations used to establish the diagnosis of CTS include nerve conduction studies. The false positive rate of the investigation is ~ 76% (positive nerve conduction study in those without symptoms of CTS).
Response from steroid injection proximal to the carpal tunnel is also a useful tool.
Causes
As a general guide, occupational causes include work which involve:
- Repetitive use of the same or similar movements of the hand/wrist.
- Regular tasks requiring generation of high force by the hand.
- Regular or sustained tasks requiring awkward hand positions.
- Regular use of vibrating hand tools.
- Frequent or prolonged pressure over the wrist.
Interestingly, a recent survey done by the Mayo Clinic found that the frequency of CTS syndrome in computer users was similar to that in the general population.
Non-occupational conditions associated with CTS include:
- Metabolic conditions such as hypothyroidism, diabetes, gout, acromegaly, pregnancy, alcoholism, obesity.
- Systemic inflammatory conditions such as rheumatoid arthritis, lupus, amyloid.
Other important conditions presenting similar symptoms include tendonitis/tenosynovitis, referred symptoms from the cervical spine and other causes of peripheral neuropathy.
Management
General management of this condition would have to include a worksite assessment and workplace modifications to ensure optimal work methods and workplace setup, together with avoidance of any aggravating activity.
Medical management options fall into the non-surgical and surgical groups.
Non-surgical treatment consists of steroid injection proximal to the carpal tunnel. The benefit of night splinting is unknown.
Surgical CT release can be done as an open procedure or endoscopically. Recovery to full function is said to occur after about 6-12 weeks for the open procedure and is somewhat shorter for the endoscopic technique.
Post-operative complications can occur in up to about 15%. Complications include residual palm discomfort for many months (Pillar pain), persistent CTS, local nerve trauma, wound problems, local bleeding, scar hypertrophy and tenderness and reflex sympathetic dystrophy.
Dr. John Low
MBBS (UWA) Grad Dip OHS FAFOM
Occupational Physician
OccuMED Consulting
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Diabetes & Fitness for work
Diabetes
Diabetes is a condition in which the body loses the ability to self-regulate blood sugar levels. High blood sugar levels are associated with long term complications such as blindness, nerve damage, heart disease, kidney disease and vascular disease. Short term complications include blurred vision, frequent toiletting and fatigue. The aim of diabetic medical treatment is to keep the blood sugar levels within the normal range to minimise the risk of complications.
Diabetic treatment - 3 main treatment regimes
- Diet controlled - no risk of hypoglycaemia
- Oral medication - minimal to modest risk of hypoglycaemia
- Insulin - potentially highest risk of hypoglycaemia
Impact of diabetes on work
Diabetes can affect fitness for work in two ways. Firstly, treatment with medication (insulin, hypoglycaemics) may lead to episodes of low blood sugar (hypoglycaemia). When the blood sugar is low, a diabetic person can start to feel hungry, sweaty, agitated and aggressive. As the blood sugar falls further, the person will eventually become confused and lose consciousness. This has obvious safety implications.
Secondly, the long term complications from diabetes itself (blindness, nerve damage, kidney damage, heart disease) can directly affect work ability. For example, diabetes increases the risk of having a heart attack.
Impact of work on diabetes
The nature of the work can affect the management of diabetes. The following are some factors that can increase the difficulty of maintaining good diabetic control:
- Shiftwork
- Very physically demanding work
- Hot work
- Isolation from medical services
- Irregular meals
- Excessive alcohol
Minimising the risk
Diabetes is a common condition. Diabetes is not an automatic bar to employment and many diabetics are employed gainfully in a variety of industries including traditionally 'high risk' industries such as transport, rail and mining.
The risk of problems at work can be minimised by a careful risk assessment at the preplacement stage and regular medical review thereafter. Factors that the doctor takes into consideration are:
- Type of diabetes (insulin dependent, non-insulin dependent)
- Nature of diabetic control, compliance with treatment and self-monitoring of sugar levels
- Risk of episodes of low blood sugar (hypoglycaemia)
- Presence of diabetic complications
- Information from the treating doctor and treating specialist
- Nature of the work (eg. safety critical roles, shiftwork, remote work)
- Arrangements for ongoing medical management
Further reading
Guidance on assessing fitness to work for diabetics in safety critical roles are available in
Assessing fitness to drive - Commercial drivers
Rail guidelines
Dr. Roger Lai
MBBS (Hons)
Occupational Medicine Registrar
OccuMED Consulting
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