Thursday, May 22, 2008

Return to Work Resource

1) Return to Work Knowledge Base:

http://rtwknowledge.org/

Wednesday, January 23, 2008

Nickel Dermatitis

Nickel dermatitis is a common type of allergic contact dermatitis. It is the most common allergen found with allergy patch testing. Nickel allergy is more common in women. It can occur at any age, and once it develops, it persists for many years. The most common source of nickel allergy is after ear piercing and contact with nickel containing ear rings.

The degree of nickel allergy and the development of dermatitis varies. It may occur after a brief contact with a nickel product, or it can occur after many years exposure to a nickel containing material.

The dermatitis develops either in the area where the product comes in contact with the skin, or sometimes people develop blistering dermatitis on their hands and feet known as pompholyx.

Nickel allergy is diagnosed by the clinical history and by allergy patch testing.

The treatment for nickel dermatitis involves the use of potent topical steroids to the area of dermatitis. This may be used under wet compresses to aid in penetration, and to dry up the weepy skin. If the nickel dermatitis is severe or widespread, systemic steroids may be needed.

It is essential to avoid nickel containing metals once nickel allergy has been confirmed on history and with patch testing. To test if metal items contain nickel, a nickel testing kit containing solutions of dimethyglyoxime and aluminium hydroxide are mixed together, and in the presence of nickel, it turns a pink colour. Unfortunately desensitization to nickel with injections or pills is not possible. Nickel allergy is difficult to prevent once it occurs as nickel products are found so commonly in everyday use.

Dr. Ernest Tan
MBBS FACD
Consultant Dermatologist
Burswood Dermatology
87 Burswood Road
Victoria Park WA 6100
Australia

Tel: 618 9470 3064
Fax: 618 9470 4479

Labels: Dermatitis

Tuesday, November 27, 2007

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 9104

Labels: Ankle Injuries

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 9104

Labels: Knee injuries

Monday, November 26, 2007

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

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.

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.

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 4479

Labels: Dermatitis

Tuesday, November 20, 2007

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