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Table of Contents
Year : 2014  |  Volume : 17  |  Issue : 4  |  Page : 299-301
Toe thumb: A musculoskeletal disorder related to transesophageal echocardiography

1 Department of Anaesthesiology, SGPGIMS, Lucknow, Uttar Pradesh, India
2 Department of Anaethesia, Vijaya Hospitals, Chennai, Tamil Nadu, India
3 Department of Anaesthesiology, AIIMS, Raipur, Chhattisgarh, India

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Date of Submission22-Apr-2014
Date of Acceptance15-Jul-2014
Date of Web Publication1-Oct-2014


The musculoskeletal disorders (MSD) are common in healthcare providers and those who are doing sonography are also affected. There are reports of MSD in healthcare providers who do transthoracic echocardiography. Transesophageal echocardiography (TEE) is being regularly used in peri-operative setting. We describe MSD of hand in a cardiovascular and thoracic anesthesiologist who has been performing TEE scanning for 10% of his work-time in operating room and critical care area for the last 8 years. As the role of TEE is increasing and many doctors are doing it on a routine basis, the knowledge of association of MSD with TEE and measures to prevent it is important.

Keywords: Ergonomics; Musculoskeletal disorder; Transesophageal echocardiography

How to cite this article:
Tewari P, Raju P, Neema P K. Toe thumb: A musculoskeletal disorder related to transesophageal echocardiography. Ann Card Anaesth 2014;17:299-301

How to cite this URL:
Tewari P, Raju P, Neema P K. Toe thumb: A musculoskeletal disorder related to transesophageal echocardiography. Ann Card Anaesth [serial online] 2014 [cited 2022 Nov 29];17:299-301. Available from:

   Introduction Top

Healthcare professionals undertaking diagnostic imaging work using ultrasound equipment have a high prevalence of musculoskeletal disorders (MSD). [1] The important point is that the MSD related to transthoracic echocardiography (TTE) are cumulative in nature and repeated and sustained exposure for years can cause fatigue around the joints and sustaining inflammation can be crippling. Substantial information on MSD risk management specific to sonography and TTE is available. This is the first report of its kind describing transesophageal echocardiography (TEE) being the cause of a painful MSD. The authors coined it as "Toe Thumb" taking TOE from acronym of English version of TEE.

   Case report Top

A 53-year-old cardiovascular thoracic anesthesiologist by profession reported pain and swelling in the left thumb. The total duration of the pain spanned approximately 45 days. It started gradually with pain occurring while conducting TEE examination and only on pressing at the base of the left thumb. Gradually the pain increased, became severe in adduction of the thumb and swelling appeared to restrict the movement of the thumb in the beginning, later the movement of left index finger also became painful and restricted. There was no history of any direct injury of the thumb and the index finger in the past or any systemic disease of rheumatic or rheumatoid origin. The doctor used 10% of his work-time in operating room (OR) and critical care unit doing TEE. The holding of the heavy TEE probe and the awkward posture of the left hand, especially, the thumb and the index finger to manipulate the steering wheels and buttons to change scan angle is shown in [Figure 1]. The doctor had not been performing any other work in which this kind of posture was made. On examination the pain was most severe at trapezium metacarpal joint of the left thumb, and a low intensity pain was present at first and second metacarpophalyngeal joints. The X-ray of the hand showed no specific finding. The doctor was prescribed antiinflammatory medications and a thumb rest [Figure 2] to be worn around the left thumb throughout the day and was asked to limit TEE examination to bare minimum. The swelling completely subsided after 4 months of thumb rest application. The pain also subsided but a low intensity pain recurred during long sessions of TEE examination.
Figure 1: The instance of the left hand and the posture of the thumb and the fingers during transesophageal echocardiography probe handling. White arrows show the areas of pain and the size of the arrow shows the intensity of the pain

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Figure 2: Use of thumb rest to restrict the motion of the thumb

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   Discussion Top

Healthcare workers face a number of serious health hazards and out of which ergonomic hazards as MSD due to lifting, holding and repetitive tasks at various joints are common. MSD in association to TTE is well recognized and documented but association of TEE with MSD is not described in the literature. While performing TTE examination, the performer holds the TEE probe in the hand and tilt, glide and rotate it for scanning and for these maneuvers the echocardiographer has to bend his back, expand and extend his arms, and move shoulders in unusual positions to obtain and acquire good quality images. All this adds to stress and strain on shoulders, arms, wrist, hand and fingers. Holding of the TTE transducer becomes important as the sonographer may hold it with extra pressure, rather subconsciously, so that the transducer may not fall and get spoiled. [1] Morton and Delf reported a prevalence of MSD and discomfort to the tune of 63-89.7% and this study summarized the results of ten surveys of ultrasound operators. [1]

The symptoms of MSD can vary from occasional localized discomfort after long session of ultrasonography to severe disabling pain and sometimes neural symptoms of tingling and numbness and can affect many parts of the body. [2] The prevalence of MSD is shown to increase with the years of experience and is common over 50 years of age and more than 20 years of experience. [3] They also found that 15% incidence occurred in those who have practiced it for less than 6 years. [3] Individual differences in anatomy of the joints may be the reason for the difference. [3] Type of ultrasound procedure is also believed to influence the development of MSD. Burnett and Campbell-Kyureghyan [4] assessed the various risk factors associated with different type of scan procedures. According to them forceful transducer application was more when deep vein thrombosis was assessed whereas more wrist deviation was used with thyroid scans. These authors had presented no data on TEE and they summarized that all the types of ultrasound scans can produce MSD, although specific risk factors and their relative importance varied between scan types. [4]

TEE probe has unique features; it is long like a gastroscope and has to be held in both hands. Usually the right handed person holds the heavy and bulky handle by the left hand. The handle has all the controls and the sonographer holds it by keeping the hand below it. The controls are so disposed around the circumference of the handle that the wrist needs to be flexed and rotated to extreme degree and further flexion and extreme adduction of the thumb with added rotation is required. The rotational movement of extended thumb and index finger repeatedly results in gliding movement at metacarpal-carpal joints and may be the likely cause of MSD in our patient. Some operators while performing TEE examination hold the TEE probe handle from top but the manipulation of wheels and buttons for scanning and obtaining desired images needs the similar movement at wrist and thumb. Smith et al. [5] reported that incidence of MSD may increase in those who perform longer scans and more scans per month. In the present report, the patient performed TEE examinations for about 10% of his work-time every day and has been doing so for 4 days a week for more than 8 years now. At present, it is not known if any specific race has greater propensity for such MSD. It is noteworthy that all the literature related to prevalence of MSD addresses to TTE and TEE has not been incriminated to cause MSD. This could be because of under-reporting or may be in the enthusiasm of learning TEE, the pain and discomfort associated with its constant use is disregarded. Now the peri-operative TEE has become a routine in cardiac ORs and more reports may appear in future. Meanwhile, there is a need to reduce the weight of the TEE probe handle and to change the ergonomics of the way TEE probe handles are designed. In very new echocardiography machines, the keys/buttons for scan angle rotation are incorporated on the machine console and that avoids the need to manipulate the buttons on the baton of the probe but that also results in awkward stretching and stress at the shoulder joints in order to acquire desired images.

   References Top

1.Morton B, Delf P. The prevalence and causes of MSI amongst sonographers. Radiography 2008;14:195-200.  Back to cited text no. 1
2.Wihlidal LM, Kumar S. An injury profile of practicing diagnostic medical sonographers in Alberta. Int J Ind Ergon 1997;19:205-16.  Back to cited text no. 2
3.Evans K, Roll S, Baker J. Work-related musculoskeletal disorders (WRMSD) among registered diagnostic medical sonographers and vascular technologists: A representative sample. J Diagn Med Sonogr 2009;25:287-99.  Back to cited text no. 3
4.Burnett DR, Campbell-Kyureghyan NH. Quantification of scan-specific ergonomic risk-factors in medical sonography. Int J Ind Ergon 2010;40:306-14.  Back to cited text no. 4
5.Smith AC, Wolf JG, Xie GY, Smith MD. Musculoskeletal pain in cardiac ultrasonographers: Results of a random survey. J Am Soc Echocardiogr 1997;10:357-62.  Back to cited text no. 5

Correspondence Address:
Prabhat Tewari
Department of Anaesthesiology, SGPGIMS, Rae Bareli Road, Lucknow 226 014, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9784.142069

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  [Figure 1], [Figure 2]