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Prof
Chris
Oliver
Medical issues
surrounding vibration
exposure & chronic pain
King James IV Professor Royal College Surgeons of Edinburgh
Retired Consultant Trauma Orthopaedic & Hand Surgeon,
Royal Infirmar y Edinburgh
▪Medicolegal Practice
Associate Research Fellow, Transport Research Institute,
Edinburgh Napier University
c.oliver@napier.ac.uk Twitter @CyclingSurgeon
Prof Christopher W. Oliver
https://cyclingsurgeon.bike/
Trauma Orthopaedics
Hand & Wrist
Surgery
Lecture contents:
Upper limb problems seen by a hand surgeon
HAVS
Chronic Pain
Medical issues surrounding vibration
exposure & chronic pain
Carpal Tunnel Syndrome is
caused by compression of
the median nerve, which
controls sensation and
movemen t in the hand
It is not always caused by
work-related factors
Ulnar neuropathy
Neck & Plexus
Raynaud ’s - Medical
Carpal Tunnel Syndrome & Neuropathies
Electromyography
HAVS i s preventable, b u t on c e th e dam a g e is done it is permanent.
HAVS i s serious and disabling, and nearly 2 million people a re at risk.
Damage from HAV S can in c l u de the inability to do fine work and cold
can trigger painful finger b l a n ching a ttacks.
The costs to employe e s and to employers of inaction c o uld be high.
There are simple and cost-ef fective ways to eliminate r i sk of HAVS .
The Control of Vibration at Work Regula t ions focus on the elimination
or control of vibration exposure.
The long-term aim is to prev e n t new cases of HAVS o ccurring and
enable workers to r e m a i n at work without disability.
The most efficient and ef fective way of c ontrolling ex p o sure to h a nd -
arm vibration is to look fo r new or alternative work methods which
eliminate or reduce e x p o s u r e to vibration.
Health surveillance is vital to det e c t an d respond to early signs of
damage
http://www.hse.gov. u k/vibration/hav/keyme s s a g e s . h t m
HSE key messages for HAVS
Exposure action value of 2.5 m/s2A(8) at which level
employers should introduce tec hnical and organisational
measures to reduce exposure.
Exposure limit value of 5.0 m/s2A(8) which should not be
exceeded.
HAVS regulations
Exposure Points System Ready -Reckoner
HAVS monitoring
Reflex sympathetic dystrophy
Sudeck’s atrophy
Causalgia
Minor causalgia
Mimo-causalgia
Algodystrophy
Algoneurodystrophy
Post-traumatic pain syndrome
Painful post-traumatic dystrophy
Painful post-traumatic osteoporosis
Transient migratory osteoporosis
Complex regional pain syndrome
Synonyms
hand or foot
knee
elbow rarely involved
shoulder common
▪frozen shoulder probably CRPS
hip in pregnancy
Sites of predilection
I
II with obvious nerve lesion
CRPS types
Preceding noxious event
Spontaneous pain or
hyperalgesia/hyperesthesia not limited to a
single nerve territory and disproportionate to
the inciting event
Oedema, skin blood flow (temperature) or
sudomotor abnormalities, motor symptoms or
trophic changes are present on the affected
limb, in particular at distal sites
Other diagnoses are excluded
Diagnosis –IASP (1994)
Pain and hyperalgesia are the most
important symptoms.
75% of patients had pain at rest
Nearly all (100%) patients described
hyperalgesia.
Mechanical hyperalgesia explains the
motion-dependent amplification of pain in
all CRPS patients.
Allodynia (brush-evoked pain)
Record Pain 0-10 Scale
Sensory disturbances
77% of CRPS patients have weakness.
Range of motion is reduced by oedema
in acute stages, in chronic stages
contraction and fibrosis
50 % tremor can be seen
30% myoclonus or focal dystonia
After a nerve lesion 45% of the patients
have exaggerated deep tendon reflexes
kinesiophobia
Motor disturbances
acute stages 81% patients have oedema
first months of CRPS skin is red and hot
chronic stages skin turns to bluish/cold
20% of CRPS cases are primarily cold
temperature difference between sides is
more than 1.0 °C
50% of the patients increased sweating
Test Tubes
Autonomic disturbances
50% of CRPS patients.
Increased hair-nail growth initially
Later reduced hair-nail growth
Severe cases atrophy of the muscles
with fibrosis and contracture can
occur
Trophic changes
clinical examination
Radiography - spotty osteoporotic 4–8 weeks. 40%
cases.
Three phase bone scintigraphy - increased bone
metabolism.
MRI - exclude other diseases. CRPS oedema in deep
tissues
After gadolinium injection subtle enhancement is
seen which points to an increased permeability of
blood vessels but not really specific.
CRPS - Diagnostic Tools
Chronic release of neuropeptides?
▪central neuropeptide release facilitates
nociceptive sensitization
▪Nerve lesions
could explain increased skin temperature,
oedema and trophic changes
Sympathetic nervous system failure?
Sympathetico-afferent coupling?
Neurogenic inflammation, pain and
hyperalgesia
Chronic pain might effect cortical
processing of touch in CRPS
Long term activation of primary afferents
triggers cortical changes
HLA-association?
Genetic mechanism?
Psychosomatic background
Why do some patients develop CRPS or
HAVS and others not?
aims CRPS therapy
relief of pain
maintenance or restitution of function
therapy has to start ASAP
Treatment CRPS
Role limited
Not indicated to release contractures
Amputation of a limb affected by severe
CRPS should be approached with great
caution. Unpredictable
Surgery may exacerbate CRPS or
precipitate a new attack
Surgery and CRPS
Steroids
Sympathetic blocks
Radical scavengers
Calctionin –biphosphanates
Antidepressants,
Antiepileptic's
Gabapentin –pregabalin
Specialist Pain Clinic
Drug Treatment CRPS
Physiotherapy
▪Functional restoration
▪Desensitisation
▪TENS
Psychology
▪Depression and anxiety
▪PTSD
Occupational Therapy
Non-drug therapy CRPS
Self-mutilation
Factitious disorders of the upper limb
Body identity disorder
Factitious disorders of the upper limb
Non healing wounds
Factitious disorders of the upper limb
Costs high.
doctor/patient interface undermined by deception,
risk of litigation.
high index of suspicion/adequate notes
Knowledge of characteristic deformities useful.
Potential gain has many different forms.
CRPS Type 1 suspicion a full review of the hospital
records may indicate similar attendances to other
specialities or previous psychiatric problems.
‘‘La belle indifference’’
Patients with factitious disorders are “ill”
Psychology or Psychiatry
Factitious disorders of the upper limb
King James IV Professor Royal College Surgeons of Edinburgh
Retired Consultant Trauma Orthopaedic & Hand Surgeon,
Royal Infirmar y Edinburgh
▪Medicolegal Practice
Associate Research Fellow, Transport Research Institute,
Edinburgh Napier University
c.oliver@napier.ac.uk Twitter @CyclingSurgeon
Prof Christopher W. Oliver
https://cyclingsurgeon.bike/
