Occupational Medicine Advance Access originally published online on August 13, 2007
Occupational Medicine 2007 57(6):456-460; doi:10.1093/occmed/kqm029
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Case Report |
Work-related bilateral osteoarthritis of the first carpometacarpal joints
Department of Occupational and Environmental Medicine, Vejle County Hospital, Kabbeltoft 25, Vejle 7100, Denmark
Correspondence to: Jens Christian Jensen, Department of Occupational and Environmental Medicine, Vejle County Hospital, Kabbeltoft 25, Vejle 7100, Denmark. Tel: +45 7940 5360; fax: +45 7940 6858; e-mail: jens.christian.jensen{at}mail.dk
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Abstract |
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Background A 44-year-old industrial worker produced panels for folding doors for 9 years. During this period, he developed osteoarthritis (OA) of both first carpometacarpal joints. Surgery was performed without improvement.
Methods Clinical examination, demonstration and recording of work conditions, with photos and videos. The literature concerning first carpometacarpal OA was reviewed using PubMed.
Results The observation of work conditions demonstrated unusual forceful and repetitive ulnar flexion of both first fingers. No competing causes of OA could be identified.
Conclusion This patient had specific and intense work-related strain of both first carpometacarpal joints. A good temporal relation between work exposure and disease development was demonstrated and it appears likely that the OA was caused by work. However, there is very limited epidemiological evidence relating first carpometacarpal OA to work exposure.
Keywords First carpometacarpal joint; osteoarthritis; repetitive forceful work
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Introduction |
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Osteoarthritis (OA) is perhaps the most common cause of disability in developed countries [1]. Primary degenerative disease of the hand and fingers as a clinical entity is usually considered multifactorial in pathogenesis. Several risk factors have been suggested, most importantly age, sex and body mass index (BMI; weight/m2). More recently, genetic factors have attracted attention.
The prevalence of OA of the hand and fingers increases with age. Below the age of 40, <10% of individuals are affected against >70% of individuals over the age of 70 [2,3]. The same studies showed that first carpometacarpal OA followed the same age-related increase, but carpometacarpal OA lags behind interphalangeal OA by a decade although first carpometacarpal OA, when established, progresses faster.
A study of independent determinants of first carpometacarpal OA based on 639 hand radiographs obtained from the Ulm OA study, showed an OR of 1.8 (95% CI: 1.2–2.7) for female gender [4]. A similar but smaller effect for female gender was described in a study based on 3595 hand radiographs, OR 1.28 (95% CI: 1.08–1.53) [5].
The impact of BMI on hand OA is a matter of dispute. The previously mentioned study showed no significant impact of BMI [4], while the other study showed an impact if BMI was 35 kg/m2 or greater, OR being 1.98 (95% CI: 1.19–3.37) [5].
A genetic influence on OA was suggested in a study of 500 unselected female twins (130 identical and 120 unidentical) between 45 and 70 years of age who were screened radiologically for OA of the hands and knees [6]. The study suggested that genetic influence is between 39 and 65%. Recently a genome scan for joint-specific hand OA susceptibility, based on the Framingham study, has pointed to a linkage region on chromosome 15 for OA of the first carpometacarpal joint [7].
The overall prevalence of OA of the first carpometacarpal joint varies. The most commonly used method of assessment is by hand radiograph using the Kellgren and Lawrence score (K–L score) [8]. However, a recent study found that up to 15% of cases among men and 20% among women could not be classified by the K–L score [9]. The study found a prevalence of K–L grade 
2 to be 4% in males and 7% in females. By comparison, a Finnish study found a prevalence of 4% in men and 9% in women [5]. A literature review on occupational use of precision grip and forceful gripping, and OA of finger joints found a somewhat higher prevalence, namely, 10% for males and 16% for females [10].
The impact of occupational exposure on OA is controversial. However, in Denmark, the National Board of Industrial Injuries has recently recognized OA of the hip and knee as occupational diseases under certain circumstances [11].
Long-term repetitive and stereotyped manual tasks have been related to different patterns of hand OA according to task. Interphalangeal OA was related to fine repetitive movements while first carpometacarpal OA was related to power grips [12]. In a cross-sectional survey, 1394 physicians recruited the two first patients consulting them for OA of the hip, knee or hand. The patients were given a questionnaire concerning their occupation and occupational exposure e.g. lifting, vibrating tools, repetitive movements, uncomfortable positions and pace. In women, repetitive movements and pace were associated with hand OA, OR 3.6 (95% CI: 2.4–5.7), while no definite association was seen in men [13]. A German survey found no association between heavy physical exertion in the workplace and OA of the first carpometacarpal joint [4]. Two cases of OA of the first carpometacarpal joint, which bear some resemblance to the case presented here, have been reported among Swedish carpenters [14].
The case of a 44-year-old male industrial worker, who developed bilateral OA of the first carpometacarpal joints, after 9 years of producing folding doors, is reported here. Demonstration and recording of work conditions were carried out and a literature search was performed.
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Case report |
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The factory in which the patient was employed is a subdivision of a larger company and has
100 employees, mostly men. It manufactures various building components, among them folding doors for use in agricultural and industrial constructions. The folding doors are made of individual panels, either aluminium or steel plates with a layer of polyurethane foam between them. The panels are hinged together, making a very flexible folding door.
The panels were produced one at a time on a large chest high table. Metal plates, either aluminium or steel, each of them between 4 and 8 m long and all 60 cm wide, were placed on the table. On the long sides, the panels were fitted by hand with plastic mouldings. The mouldings were made of semi-hard plastic, 3 cm wide. The edges bend at 90 degrees and are fitted with small hooks, that were supposed to grab the bend edges of the panels. The patient would achieve this by applying pressure with both thumbs on the moulding, until the hooks would snap into their fittings. This required powerful grip, pressing both thumbs in ulnar flexion, while achieving counter pressure with the rest of the fingers (Figure 1). The patient would move his hands a few centimetres between each grip, gradually working his way along the edge, until he reached the end of the moulding.
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The panels would require mouldings both at the top and bottom, making the total length of plastic moulding between 8 and 16 m for each panel. The patient would make 20 panels a day, on busy days up to 30, and 80% of the panels were 8 m long. This meant that the total length of mouldings to be fitted on 1 day could amount to something between 320 and 480 m. During the final year of his employment, the patient would use a small hammer to fit the mouldings, due to the growing disability and pain in his hands.
When the patient had fitted the mouldings, he would fill the space between the plates with polyurethane foam. The spraying head was made of a simple piece of pipe. Between each panel production, this piece of pipe had to be cleaned in a rather unorthodox way, using a simple electric drill and a pair of pliers (Figure 2). This would require a powerful grip with both hands while pressing the power button on the drill with the left thumb.
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The patient was a 44-year-old male Caucasian, who had been employed for 9 years producing the folding doors. Previously, he had worked in non-manual work. He was physically fit, and had been a judo instructor and coach. He was right handed and had no previous history of hand trauma. There was no predisposition for OA in his family.
After 5 years of making panels, he developed pain at the base of his left thumb, especially when applying pressure or gripping. The pain worsened and became constant. Furthermore, he developed trigger fingers in the third and fourth fingers of the same hand. After consulting his general practitioner, radiology of the left hand and first carpometacarpal joint was performed, showing severe narrowing of the joint space and subluxation of the first carpometacarpal joint and severe OA was diagnosed. The patient continued to attend his job, and there were no alterations in the workplace. The following year, he developed similar symptoms on the right side with pain at the base of the thumb and trigger fingers in exactly the same positions as on the left side. Radiographs of the right hand showed changes identical to those previously seen on the left side. Because of his pain, the patient used a hammer when fitting the mouldings during the last year of his employment. He suggested other major changes in the work process, and the cleaning of the spraying head was automated. For this reason his function at work was changed, almost removed, and the company, no longer having use for him, laid him off.
An orthopaedic surgeon found bilateral OA of the first carpometacarpal joints and trigger fingers on the third and fourth fingers on both sides. The trigger fingers were treated with steroid injections and in September 2004 surgery was performed on the left first carpometacarpal joint with a resection–interposition arthroplasty a.m. Weilby. In May 2005, the same surgery was performed on the right side. However, the outcome was poorer than expected and the patient could no longer perform manual work that required any force.
By the time he was referred to the Department of Occupational Medicine, Vejle County Hospital, he had been on sick leave for 5 months. The right hand was still covered in a bandage at the initial examination in June 2005. On the left side, tenderness was found at the first carpometacarpal joint, and left hand grip force was measured to 5 kPa using a Martin vigorimetre. At the next examination in November 2005, the patient complained of nightly pain, and was unable to use a knife to cut meat and bread. There was tenderness at both first carpometacarpal joints, and grip force was reduced to 5 kPa on the left side and could not be measured on the right side. Radial flexion at the right wrist was reduced to 0 degrees.
Since the patient had lost contact with the workplace, and the work process had been changed, we were not able to obtain access to the workplace to perform exposure measurements. We therefore had to rely on the patient demonstrating his work task at the department. Digital photos and video recordings were made of this demonstration, using original materials and tools from the factory. As the patient had undergone surgery and suffered from weakness over the first carpometacarpal joint, no good estimate of task-related force could be obtained.
The department cooperated with the county social welfare office to help the patient get a job as a salesman, dealing in shop inventory.
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Discussion |
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TopAbstractIntroductionCase reportDiscussionConflicts of interestReferences |
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While OA of the first carpometacarpal joint is a common disease, bilateral OA in a 40-year-old male is uncommon. In this case, the exposure was rather unusual too. Unfortunately, it was not possible to obtain any good measurements of the force used by the patient, partly because the work process had been changed and the patient had no contact with the workplace and partly because he had undergone surgery that had radically changed his hand grip force. Obtaining good exposure measurements is often one of the greatest challenges in occupational medicine. It is also a major limitation in most of the studies that have tried to link work exposure to OA of the first carpometacarpal joint. Most studies are cross sectional, and rely on study groups referred because of the illness [13], with a resulting risk of overestimation of the problem. Other studies are based on job categories which makes it difficult to compare studies and questionnaires that might lead to overreporting and overestimation.
Attempts have been made to do more precise exposure measurements. Hadler et al. [12] had tasks described by a consulting industrial engineer and ergonomicist, although micromotion analysis was not performed. In the Danish PRIM study which deals with physical exposure assessments in monotonous repetitive work, 103 exposure groups were formed, and task-related exposures were quantified by 43 single exposure items using real-time video-based observation. This allowed computerized estimates of repetitiveness, body postures, force and velocity [15]. The PRIM study dealt only with tendinitis, epicondylitis and carpal tunnel syndrome and did not include OA. If a similar prospective study should be made on OA, the follow-up time would probably also have to be much longer since OA develops over decades.
A direct method of measuring forces applied by the thumb could be to use a pin gauge. A rather sophisticated method used in a study of thumb pain in physiotherapists, involved radiographs and a B & L pin gauge for testing strength. The hands were placed on a radiograph cassette and thumb pressure was applied on the pin gauge. In this way, the force applied could be measured and the joint movements including radial subluxation in the first carpometacarpal joint could be seen and measured simultaneously on the radiographs [16]. Forces up to 27.2 kg were measured.
It has been suggested that systemic factors such as sex, age and genetics may determine cartilage properties, but that local biomechanical factors, such as joint loading may determine the site and severity of OA [5].
In the presented case, stiffness of the plastic mouldings and the fact that they had hooks that had to be fitted into slots on the panels required significant pressure. The slippery surfaces of the metal panels made the patients fingers slide, most likely forcing him to increase thumb pressure. The patient had repetitively used forceful grip. The grip was not unusual in its character, but perhaps extraordinary by its repetitive, stereotyped nature. The patient had specific and intense work-related strain on both first carpometacarpal joints. A good temporal relation between work exposure and disease development existed. Thus, it is probable that work exposure played a major role in development of OA in this patient.
Because of the limited epidemiological evidence concerning first carpometacarpal OA and work exposure, there is need for further research including occupational measurements and dose–response relationships.
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Conflicts of interest |
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None declared.
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References |
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