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A regional audit of hand and wrist injuries
A REGIONAL
AUDIT
OF HAND
AND
WRIST
INJURIES
A study of 4873 injuries C. HILL, M. RIAZ, A. MOZZAM and NI. D. BRENNEN
From the Northern Ireland Plastic and Maxillo-facial Unit, the UlsterHospital, Dundonald, Belfast, UK This study reports the characteristics, causes and disposal of isolated injuries to the hand and wrist presenting to six accident and emergency departments over a period of 4 months. The rate of isolated injury to the hand or wrist was 6.6%. The male: female ratio was 2.2: 1, with the mean age for injury being 26.4 years in men and 29.2 years in women. The modal age group for injury was 21-25 years in men and 11-15 years in women. The right and left hand were injured almost equally. The dominant hand was more commonly injured although this was influenced by the cause of injury: 16.3% were caused by a fall; 15% by sport; and 7% were work/machinery related. 13.3% were referred to specialities for further treatment.
Journal of Hand Surgery (British and European Volume, 1998) 23B." 2:196 200 Hand and wrist injuries contribute a considerable workload for any individual accident and emergency department as clearly indicated in previous studies (Clark et al, 1985; Edwards, 1975; Myles and Roberts, 1985; Page, 1975; Smith et al, 1985; Wilson, 1986). These previous studies have been restricted to one or two accident and emergency departments and/or a specific type of injury. A more recent study provided information collected using three data collection systems from five Danish accident and emergency departments (Angermann and Lohmann, 1993). Whilst this large study group provided useful information, the paper did not indicate if the same method of cause and diagnosis classification had been used in each of the three systems and whether these were compatible. In clinical audit the use of standardized methods of recording information is essential if data are to be compared. The results of previous studies in the area of hand and wrist injury may be comparable in some areas but differences may occur because of variations in the methods of data recording and classification. This problem can be overcome using a validated method of coding such as the Derby H a n d Codes for coding both the cause and diagnosis of the injury (Burke et al, 1991). In this study we describe in a standardized form the characteristics, causes and disposal of all isolated injuries to the hand and wrist in a period of 4 months in six accident and emergency departments in Northern Ireland using information extracted from the patients' clinical records.
of a Trauma Registry had been slow despite recommendations for its establishment in a White Paper some 25 years before. This problem is compounded by an increasing accident and emergency workload and static or decreasing resources within the current NHS. Hand and wrist injury was defined as any injury occurring distal to the proximal wrist crease including soft tissue injuries to the forearm and fractures of the carpal bones and distal radius and/or ulna. Although the information on individual clinical notes varied it appeared from a pilot study that the following information could be obtained in the majority of cases: patient identification; gender; age; dominant hand; occupation; side and anatomical site of injury; cause of injury; provisional diagnosis; and disposal from department. This information was entered on a data form allowing coding of the cause and diagnosis according to the Derby hand codes before transfer to a computer database. Z2 analysis was carried out for right and left dominance individually in relation to incidence of side of injury. The accepted level for statistical significance was P<0.05. RESULTS During the period of the study there were 73 557 new patient attendances at the participating accident and emergency departments. A total of 4873 copies of the clinical notes were received on patients with a hand or wrist injury as the only injury. Isolated hand and wrist injuries represent 6.6% of all new attendances at accident and emergency. Of the 4873 patients, 3354 were male (69%) and 1519 were female (31%). The mean age was 27.2 years (range 1-93). The mean age for men was 26.4 years and women 29.2 years. The distribution of injury according to age group and gender is seen in Figure 1. This demonstrates two peaks in the distribution, first in the 11-15 years age group which would appear to be influenced primarily by a large increase in hand injuries in male patients. The second peak is in the 21-25 years age group and this would appear to be influenced by an increase in the number of hand injuries in male patients.
MATERIAL A N D M E T H O D S
Information was extracted over a period of 4 months (from February to May 1995) from the clinical records of patients from 6 of the 17 accident and emergency departments in Northern Ireland. Seven declined to participate and four did not complete returns for the full 4 months. Difficulties in data collection in accident and emergency settings are not a new problem. In the United States of America, Boyd (1985) highlighted that the establishment 196
197
REGIONAL AUDIT OF INJURIES Boo
Table 1--Occupation and incidence of injury (%)
700
Occupation
600
6oo
~-rotal z
~
+Male - ~- Fema~
460
300
200
100
Total no. o/ injuries
Percentageof' total
Manual worker
856
17.6
Farming
60
1.2
Butcher
46
0.9
Catering
74
1.5
Pre-school
207
4.2
Student
1474
30.2
Office worker
251
5.1
Retired
221
5
Not specified
848
17.3
Others
586
12
0 1-5
Fig 1
6-19 1%15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-68 66-70 71-75 76-80 81-65 86-99 91-95 AGE GROUP
Frequency of injury and age group.
There was a wide range of occupations in the study group (Table 1). The right side was injured in 2524 (51.8%) cases, the left in 2214 (45.4%) cases and both in 79 (1.6%), with 56 (1.2%) cases not recorded. Hand dominance was unfortunately not recorded in 2468 (50.7%) cases. Of the remaining group, 87% were right handed and 12.6% lefthanded. In the group in which dominance and side of injury were recorded (n=2405) there was a slight increase in the incidence of injury to the dominant hand in both those with right and left hand dominance (Table 2). This was statistically significant for both right hand dominance (P<0.001) and left hand dominance (P<0.01). A breakdown of the anatomical area injured is shown in Figure 2, with thumb, index and little fingers being
PALMAR SURFACE 4% DORSAL
SURFACE
3%
injured most commonly in descending order. Diagnosis was coded according to the Derby hand codes. The diagnostic Derby hand codes comprise eleven major groups with subdivisions within each group carrying a specific code. The major groups are: amputations, burns, bite injury, fractures/dislocations, infections, nerve injury, skin and nail loss, tendons, wounds, vascular injury, complex injuries. Thirty six percent of the diagnoses were coded as wrist/hand/finger contusion and 30% superficial lacerations of forearm/wrist/hand. The largest fracture group was of phalangeal fractures (7%) followed by single/multiple metacarpal (6%) and wrist (5%) fractures (Table 3). The cause of the injury was also coded according to the Derby hand codes. The largest injury groups resulted from falls on to the hand, sports, other cutting/piercing or the hand being caught in a door/window (Table 4). When cause of injury was related to hand dominance and side of injury it was evident that in some groups the cause of injury had a significant influence on the side of injury in relation to hand dominance. In the knife injury group the ratio of dominant to non-dominant injury is more than 1: 3. Increased likelihood of injury to the dominant hand is seen in injury from opening a tin and injury from putting the hand through a window or door (Table 5). Patterns of disposal after initial attendance revealed that 86% were discharged home and 13% referred to another specialty. Of the group discharged home 48% had no follow-up arranged, 27% were referred to their Table 2---Dominance and side of injury
Side of injury WRIST
Number of injuries (%)
12%
Fig 2
Anatomical area of injury. The area of the h a n d injured was not specified in 11% of cases. In a further 10% of cases multiple fingers were injured.
1132 (55)
Right hand dominant
Right Left
922 (45)
Left h a n d dominant
Left Right
174 (58) 124 (42)
198
THE JOURNALOF HAND SURGERYVOL.23B No. 2 APRIL 1998
Table 3--Diagnosis (%). This list represents our majo r diagnosis groups to allow comparison with previous studies. The Derby hand codes offer a large variety of diagnostic codes and a diversity which would not allow clear presentation of the data and which would make comparisons with previous reports difficult
Diagnosis'
No. (%)
Contusion wrist/hand/finger Laceration arm/wrist/hand Fractured phalanx Fractured metacarpal single/multiple Fractured wrist Crushed arm/hand/finger Abrasion hand/finger Dislocated finger Animal bite Mallet finger Human bite
1745 (36) 1483 (30) 337 (7) 295 (6) 241 (5) 96 (2) 81 (2) 61 (1) 55 (1) 32 (< 1) 20 (< 1)
general practitioner and 25% were reviewed at the accident and emergency d e p a r t m e n t . O f the group referred to specialties 80% were to orthopaedics, 8.2% to plastic surgery and 5.6% to general surgery. In the remaining 6.2% the patient was referred to a n o t h e r specialty or the referred specialty was uncertain. A b r e a k d o w n o f the diagnoses o f the patients referred to these specialties is shown in Table 6. Fractures represented 82% o f the referrals to o r t h o p a e d i c surgery, whereas lacerations of the h a n d / w r i s t / a r m including nerve and flexor tendon injuries represented 87.3% o f referrals to plastic surgery. DISCUSSION H a n d injuries are c o m m o n and have implications for patients, employers, the economy, the health service and both personal and corporate insurance (O'Sullivan and Colville, 1993; Smith et al, 1985).
Table 4--Cause of injury, frequency, and percentage. The table excludes all causes of frequency less than 1%. These were agricultural injury, lawnmower, gunshot, electrical burn, suicidal/self-inflicted, opening a tin, road traffic accident, hand through window/door, human bit, high pressure injection, power saw, other power tools, household appliance, frost bite and insect bite. Also excluded is the 'others' group, ie diagnosis not within coded categories [836 patients (14%)l and the group in which a cause was not stated [515 patients (8.9%)]
Cause of injury
Frequency
(%)
Fall on hand Sports related Caught in door/window Other cutting/piercing Knife injury Injury at work/machinery Broken glass Hand caught between objects Assault Burn-other (i.e. excluding electrical) Animal bite
736 732 326 322 262 261 249 237 127 79 68
(15) (15) (6.7) (6.6) (5.4) (5.4) (5.1) (4.9) (2.6) (1.6) (1.4)
T h e contribution of h a n d and wrist injuries to the w o r k l o a d o f accident and emergency d e p a r t m e n t s is variously reported as between 5.7% and 21% (Campbell, 1985; O'Sullivan and Colville, 1983; Smith et al, 1985; Usal and Beattie, 1993). In the present study the rate was 6.6% for isolated injuries to the h a n d and wrist and includes all age groups and injury types. It can be seen f r o m the previously reported studies that the incidence of injury to the h a n d is lower in young children (Wilson, 1986; Usal and Beattie, 1993). In the studies reporting a high incidence of hand injury children are often excluded (Clark et al, 1985) thus increasing the overall incidence of h a n d injury. The male to female ratio in the study group was 2.2: 1. This is in keeping with the findings of previous studies within the British Isles (Edwards, 1975; Clark et al, 1985; Wilson, 1986) however the ratio was
Table ~-Influence of cause of injury on hand injured (dominance)
Causes of injury (no.)
Injury to dominant
Injury to non-dominant
Ratio dominant: non-dominant
Knife injury (262) Broken glass (249) Opening a tin (42) Fall on hand (736) Hand caught between objects (237) Hand through window/door (30) Injury at work/machinery (261)
34 75 17 211 69
100 36 4 156 61
1:3.4 2.1:1 4.3:1 1.4:1 1.1:1
11
3
3.6:1
87
84
1:1
REGIONAL AUDIT OF INJURIES
199
Table 6--Diagnosis of injury in relation to frequency (%) of specialty referral. For the sake of clarity certain diagnoses which had a individual code representing them within the Derby hand keywords have been represented by their major grouping within this table, eg Dislocations Diagnosis'
Plastic surgery (n=59)
Orthopaedic surgery (n=579)
General surgery (n=49)
Laceration arm/wrist/hand
25 (45.5)
5 (0.9)
6 (15.8)
Digital nerve
8 (14.5)
0
0
Flexor tendon palm/digit
5 (9.1)
0
0
Extensor tendon hand/digit
3 (5.5)
1 (0.2)
8 (21.1)
Ulnar nerve
3 (5.5)
0
0
Amputation finger tip
1 (1.8)
0
0
Amputation digit/digits
2 (3.6)
1 (0.2)
0
Infections
1 (1.8)
2 (0.4)
0
Burns
1 (1.8)
0
0
Dislocations
1 (1.8)
21 (3.9)
1 (2.6)
Contusions
1 (1.8)
58 (10.9)
3 (7.9)
Skin/nail loss
1 (1.8)
0
1 (2.6)
Complex injury
1 (1.8)
0
0
Fractured phalanx/phalanges
2 (3.6)
116 (21.8)
2 (5.3)
Fractured metacarpal/s
0
153 (28.7)
1 (2.6)
Fractured wrist
0
164 (30.8)
15 (39.5)
Vascular injury-radial
0
0
1 (2.6)
Mallet finger
0
8 (1.5)
0
much lower in the recent large study from Denmark (1.6: 1) (Angermann and Lohmann, 1993). This may reflect cultural and/or employment differences. The effect of age group and gender on incidence of injury can be seen in Figure 1. This demonstrates a large increase between the 6 10 years group and the 11-15 years group, where the sudden increase may be related to the large number of sports related hand and wrist injuries at this age (Bhende et al, 1993). This may also be reflected by greater increase in the number of male patients injured. A second peak can be seen in the 21-25 years age group, which is likely to be related to work injuries; this is supported by previous studies looking specifically at work related hand injuries (Page, 1975). The mean age of injury for women is 29.2 years and 26.4 years for men, though it can be seen" that increased longevity in the female population has an effect on hand injuries as in all age groups over 70 years women outnumber men. The mode represents a more accurate distribution of hand injuries in relation to age and sex. The modal age for injury is 14 years for male patients (n=113) and 13 years for female patients (n=59). When the ages are grouped in 5 years intervals as in Figure 1 the modal group is 21-25 years for male patients and 11 15 years for female patients. These findings are reflected in Figure 1. A breakdown of the occupations of those injured indicated that 30.2% were students (those in any educational program including primary, secondary and fur-
ther) and 38.4% were in employment. This pattern is not a reflection of the population in Northern Ireland as 21.8% of the population are in education and 20.9% in employment (Department of Health and Social Services, Registrar General Northern Ireland, 1992). It indicates an increased incidence of hand injury amongst the employed and student groups relative to the remaining population. When further analysis of hand injuries in relation to work was undertaken it became clear that whilst the occupation and cause of injury were recorded in most cases, it was often unclear whether the injury had occurred at work or home. This may explain why in the current study only 5.4% of hand and wrist injuries were recorded as being work/machinery related compared with previous reported incidences of between 21% and 32% of all hand injuries (Angermann and Lohmann, 1993; Edwards, 1975; Wilson, 1986). The right and left hands were injured with similar frequency, 51.8% and 45.4% respectively, in keeping with the findings of previous reports (Edwards, 1975; Page, 1975; Smith et al, 1985; Wilson, 1985). Few studies have looked at the incidence of injury to dominant versus non-dominant hands (Clark et al, 1985; Edwards, 1975; Smith et al, 1985). In only one case was a difference found in the incidence of injury between dominant and non-dominant hands. In the present study we found that the dominant hand was more likely to suffer injury; this was statistically significant for both right (P<0.001) and
200
left (P<0.01) hand dominance (Table 2) which supports Clark et al (1985). Analysis of the anatomical site of injury has shown in previous studies that the index finger, then the thumb are most commonly injured (Page, 1975; Smith et al, 1985; Wilson, 1986). We would support this finding (Fig 2) and the suggestion that this is related to the importance of thumbs in fine motor function. After the index and thumb we found the little finger to be most commonly injured as reported by Smith et al (1985). This is likely to relate to its exposed position along a 'border' of the hand. In previous studies there has been little or no standardization in the diagnosis groupings of injuries (Clark et al, 1985; Edwards, 1975; Page, 1975; Wilson, 1986). We have attempted to introduce a comprehensive and standardized method of recording diagnoses of hand and wrist injuries using the Derby hand codes. This produces a good database for further audit and research; however at the present time it is necessary to combine some groups or individual code groups to allow comparison with the results of other studies (Table 3). When the results from previous reports are combined into similar broad diagnostic groups lacerations/sharp injuries are reported as between 36% and 50% of total injuries, contusions/blunt injuries as between 23% and 53% of total injuries and fractures between 8% and 19% of total injuries (Clark et al, 1985; Edwards, 1975; Page, 1975; Wilson, 1986). The results of the current study are in agreement with these findings (Table 3). The cause of injury is not widely reported and again there is no apparent standardization (Campbell, 1985; Edwards, 1975; Smith et al, 1985). Falls both at home and at work have been acknowledged as a major cause of injury but the incidence has not previously been reported. When the cause of injury is related to hand dominance it appears that the non-dominant hand is particularly vulnerable to knife injury, whereas the dominant hand is vulnerable to injury from opening a tin or putting the hand through a window or door. These findings may not be surprising but this relationship has not been previously reported and previous reports have said that there is no significant difference in the incidence of injury between dominant and non-dominant hands (Edwards, 1975; Smith et al, 1985). Patterns of disposal of patients with hand injuries have been reported and are likely to have been influenced by inclusion criteria in each study and local practice in terms of treatment and referral (Angermann and Lohmann, 1993; Clark et al, 1985; Edwards, 1975; Smith et al 1985; Wilson, 1986). In the current study 13.6% of patients were referred immediately to another specialty (orthopaedic surgery, plastic surgery and general surgery). Of those discharged 62% had a review arranged with their general practitioner or at the accident and emergency department. The rate of review appears high but reflects the fact that patients with minor hand injuries can have persistent symptoms
THE J O U R N A L OF H A N D SURGERY VOL. 23B No. 2 A P R I L 1998
(Edwards, 1975) and warrant further attention. It also reflects the policy of most accident and emergency units to review patients with equivocal signs or symptoms within 2448 hours. The group referred to specialties shows only 8.2% (n=55) of referrals were made to plastic surgery. This is not in keeping with the findings of Wilson (1986) whose study from an accident and emergency department included in the present study showed that of the group that required referral for further treatment, 30% were referred to plastic surgery. Wilson's study excluded wrist and carpal injuries; however taking this into account and by looking at our number of emergency operations for the period of the study it was clear that the 8.2% of referrals in the present study was not representative of our emergency workload for hands in a plastic surgery department. Looking at the cases notes of our emergency cases for the period of the study provided three reasons for this apparent shortfall: emergency referrals from hospitals not participating in the study; emergency referrals made following review of a patient at accident and emergency; and a small number of cases that had escaped inclusion in the study. Similar factors causing underestimation of workload have been described (Angermann and Lohmann, 1993).
Acknowledgements The authors gratefully acknowledge the work of the department of clinical audit at The Ulster Hospital in the collection and initial collation of the data. We would also like to thank the staff of the accident and emergency units who participated in the study.
References Angermann P, Lohmann M (1993). injuries to the hand and wrist. A study of 50 272 injuries. Journal of H a n d Surgery, 18B: 642-644. Bhende MS, Dandrea LA, Davis H W (1993). Hand injuries in children presenting to a pediatric emergency department. Annals of Emergency Medicine, 22:1519 1523. Boyd D R (1985). Editorial: Trauma registries revisited. Journal of Trauma, 25: 186-187. Burke FD, Dias JJ, Lunn PG, Bradley M (1991). Providing care for hand disorders: trauma and elective. Journal of Hand Surgery, 16B: 13 18. Campbell AS (1985). H a n d injuries at leisure. Journal of H a n d Surgery, 10B: 300-302. Clark D R Scott RN, Anderson IWR (1985). H a n d problems in an accident and emergency department. Journal of H a n d Surgery, 10B: 297-299. Department of Health and Social Services, Registrar General Northern h'eland. The Northern Ireland Census 1991. Summary Report. Belfast, HMSO, 1992. Edwards D H (1975). The spectrum of hand injuries. The Hand, 7: 46-50. Myles SM, Roberts A H N (1985). Hand injuries in the textile industry. Journal of H a n d Surgery, 10B: 293-296. O'Sullivan ME, Colville J (1993). The economic impact of hand injuries. Journal of H a n d Surgery, 18B: 395-398. Page RE (1975). H a n d injuries at work. The Hand, 7: 51-55. Smith E, Auchincloss JM, All MS (1985). Causes and consequences of hand injury. Journal of H a n d Surgery, 10B: 288592. Usal H, Beattie TF (1992). An audit of hand injuries in a paediatric accident and emergency department. Health Bulletin (Edinburgh), 50: 285-287. Wilson P (1986). A spectrum of hand injuries. British Journal of Accident and Emergency Medicine, 1: 25-27. Received: 19 June 1997 Accepted after revision: 13 October 1997 Mr C. Hill, Northern Ireland Plastic and Maxillo-facial Unit, the Ulster Hospital, Dundonald, Belfast BTI6 0RH, UK. © 1998The British Society for Surgery of the Hand
AUDIT
OF HAND
AND
WRIST
INJURIES
A study of 4873 injuries C. HILL, M. RIAZ, A. MOZZAM and NI. D. BRENNEN
From the Northern Ireland Plastic and Maxillo-facial Unit, the UlsterHospital, Dundonald, Belfast, UK This study reports the characteristics, causes and disposal of isolated injuries to the hand and wrist presenting to six accident and emergency departments over a period of 4 months. The rate of isolated injury to the hand or wrist was 6.6%. The male: female ratio was 2.2: 1, with the mean age for injury being 26.4 years in men and 29.2 years in women. The modal age group for injury was 21-25 years in men and 11-15 years in women. The right and left hand were injured almost equally. The dominant hand was more commonly injured although this was influenced by the cause of injury: 16.3% were caused by a fall; 15% by sport; and 7% were work/machinery related. 13.3% were referred to specialities for further treatment.
Journal of Hand Surgery (British and European Volume, 1998) 23B." 2:196 200 Hand and wrist injuries contribute a considerable workload for any individual accident and emergency department as clearly indicated in previous studies (Clark et al, 1985; Edwards, 1975; Myles and Roberts, 1985; Page, 1975; Smith et al, 1985; Wilson, 1986). These previous studies have been restricted to one or two accident and emergency departments and/or a specific type of injury. A more recent study provided information collected using three data collection systems from five Danish accident and emergency departments (Angermann and Lohmann, 1993). Whilst this large study group provided useful information, the paper did not indicate if the same method of cause and diagnosis classification had been used in each of the three systems and whether these were compatible. In clinical audit the use of standardized methods of recording information is essential if data are to be compared. The results of previous studies in the area of hand and wrist injury may be comparable in some areas but differences may occur because of variations in the methods of data recording and classification. This problem can be overcome using a validated method of coding such as the Derby H a n d Codes for coding both the cause and diagnosis of the injury (Burke et al, 1991). In this study we describe in a standardized form the characteristics, causes and disposal of all isolated injuries to the hand and wrist in a period of 4 months in six accident and emergency departments in Northern Ireland using information extracted from the patients' clinical records.
of a Trauma Registry had been slow despite recommendations for its establishment in a White Paper some 25 years before. This problem is compounded by an increasing accident and emergency workload and static or decreasing resources within the current NHS. Hand and wrist injury was defined as any injury occurring distal to the proximal wrist crease including soft tissue injuries to the forearm and fractures of the carpal bones and distal radius and/or ulna. Although the information on individual clinical notes varied it appeared from a pilot study that the following information could be obtained in the majority of cases: patient identification; gender; age; dominant hand; occupation; side and anatomical site of injury; cause of injury; provisional diagnosis; and disposal from department. This information was entered on a data form allowing coding of the cause and diagnosis according to the Derby hand codes before transfer to a computer database. Z2 analysis was carried out for right and left dominance individually in relation to incidence of side of injury. The accepted level for statistical significance was P<0.05. RESULTS During the period of the study there were 73 557 new patient attendances at the participating accident and emergency departments. A total of 4873 copies of the clinical notes were received on patients with a hand or wrist injury as the only injury. Isolated hand and wrist injuries represent 6.6% of all new attendances at accident and emergency. Of the 4873 patients, 3354 were male (69%) and 1519 were female (31%). The mean age was 27.2 years (range 1-93). The mean age for men was 26.4 years and women 29.2 years. The distribution of injury according to age group and gender is seen in Figure 1. This demonstrates two peaks in the distribution, first in the 11-15 years age group which would appear to be influenced primarily by a large increase in hand injuries in male patients. The second peak is in the 21-25 years age group and this would appear to be influenced by an increase in the number of hand injuries in male patients.
MATERIAL A N D M E T H O D S
Information was extracted over a period of 4 months (from February to May 1995) from the clinical records of patients from 6 of the 17 accident and emergency departments in Northern Ireland. Seven declined to participate and four did not complete returns for the full 4 months. Difficulties in data collection in accident and emergency settings are not a new problem. In the United States of America, Boyd (1985) highlighted that the establishment 196
197
REGIONAL AUDIT OF INJURIES Boo
Table 1--Occupation and incidence of injury (%)
700
Occupation
600
6oo
~-rotal z
~
+Male - ~- Fema~
460
300
200
100
Total no. o/ injuries
Percentageof' total
Manual worker
856
17.6
Farming
60
1.2
Butcher
46
0.9
Catering
74
1.5
Pre-school
207
4.2
Student
1474
30.2
Office worker
251
5.1
Retired
221
5
Not specified
848
17.3
Others
586
12
0 1-5
Fig 1
6-19 1%15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-68 66-70 71-75 76-80 81-65 86-99 91-95 AGE GROUP
Frequency of injury and age group.
There was a wide range of occupations in the study group (Table 1). The right side was injured in 2524 (51.8%) cases, the left in 2214 (45.4%) cases and both in 79 (1.6%), with 56 (1.2%) cases not recorded. Hand dominance was unfortunately not recorded in 2468 (50.7%) cases. Of the remaining group, 87% were right handed and 12.6% lefthanded. In the group in which dominance and side of injury were recorded (n=2405) there was a slight increase in the incidence of injury to the dominant hand in both those with right and left hand dominance (Table 2). This was statistically significant for both right hand dominance (P<0.001) and left hand dominance (P<0.01). A breakdown of the anatomical area injured is shown in Figure 2, with thumb, index and little fingers being
PALMAR SURFACE 4% DORSAL
SURFACE
3%
injured most commonly in descending order. Diagnosis was coded according to the Derby hand codes. The diagnostic Derby hand codes comprise eleven major groups with subdivisions within each group carrying a specific code. The major groups are: amputations, burns, bite injury, fractures/dislocations, infections, nerve injury, skin and nail loss, tendons, wounds, vascular injury, complex injuries. Thirty six percent of the diagnoses were coded as wrist/hand/finger contusion and 30% superficial lacerations of forearm/wrist/hand. The largest fracture group was of phalangeal fractures (7%) followed by single/multiple metacarpal (6%) and wrist (5%) fractures (Table 3). The cause of the injury was also coded according to the Derby hand codes. The largest injury groups resulted from falls on to the hand, sports, other cutting/piercing or the hand being caught in a door/window (Table 4). When cause of injury was related to hand dominance and side of injury it was evident that in some groups the cause of injury had a significant influence on the side of injury in relation to hand dominance. In the knife injury group the ratio of dominant to non-dominant injury is more than 1: 3. Increased likelihood of injury to the dominant hand is seen in injury from opening a tin and injury from putting the hand through a window or door (Table 5). Patterns of disposal after initial attendance revealed that 86% were discharged home and 13% referred to another specialty. Of the group discharged home 48% had no follow-up arranged, 27% were referred to their Table 2---Dominance and side of injury
Side of injury WRIST
Number of injuries (%)
12%
Fig 2
Anatomical area of injury. The area of the h a n d injured was not specified in 11% of cases. In a further 10% of cases multiple fingers were injured.
1132 (55)
Right hand dominant
Right Left
922 (45)
Left h a n d dominant
Left Right
174 (58) 124 (42)
198
THE JOURNALOF HAND SURGERYVOL.23B No. 2 APRIL 1998
Table 3--Diagnosis (%). This list represents our majo r diagnosis groups to allow comparison with previous studies. The Derby hand codes offer a large variety of diagnostic codes and a diversity which would not allow clear presentation of the data and which would make comparisons with previous reports difficult
Diagnosis'
No. (%)
Contusion wrist/hand/finger Laceration arm/wrist/hand Fractured phalanx Fractured metacarpal single/multiple Fractured wrist Crushed arm/hand/finger Abrasion hand/finger Dislocated finger Animal bite Mallet finger Human bite
1745 (36) 1483 (30) 337 (7) 295 (6) 241 (5) 96 (2) 81 (2) 61 (1) 55 (1) 32 (< 1) 20 (< 1)
general practitioner and 25% were reviewed at the accident and emergency d e p a r t m e n t . O f the group referred to specialties 80% were to orthopaedics, 8.2% to plastic surgery and 5.6% to general surgery. In the remaining 6.2% the patient was referred to a n o t h e r specialty or the referred specialty was uncertain. A b r e a k d o w n o f the diagnoses o f the patients referred to these specialties is shown in Table 6. Fractures represented 82% o f the referrals to o r t h o p a e d i c surgery, whereas lacerations of the h a n d / w r i s t / a r m including nerve and flexor tendon injuries represented 87.3% o f referrals to plastic surgery. DISCUSSION H a n d injuries are c o m m o n and have implications for patients, employers, the economy, the health service and both personal and corporate insurance (O'Sullivan and Colville, 1993; Smith et al, 1985).
Table 4--Cause of injury, frequency, and percentage. The table excludes all causes of frequency less than 1%. These were agricultural injury, lawnmower, gunshot, electrical burn, suicidal/self-inflicted, opening a tin, road traffic accident, hand through window/door, human bit, high pressure injection, power saw, other power tools, household appliance, frost bite and insect bite. Also excluded is the 'others' group, ie diagnosis not within coded categories [836 patients (14%)l and the group in which a cause was not stated [515 patients (8.9%)]
Cause of injury
Frequency
(%)
Fall on hand Sports related Caught in door/window Other cutting/piercing Knife injury Injury at work/machinery Broken glass Hand caught between objects Assault Burn-other (i.e. excluding electrical) Animal bite
736 732 326 322 262 261 249 237 127 79 68
(15) (15) (6.7) (6.6) (5.4) (5.4) (5.1) (4.9) (2.6) (1.6) (1.4)
T h e contribution of h a n d and wrist injuries to the w o r k l o a d o f accident and emergency d e p a r t m e n t s is variously reported as between 5.7% and 21% (Campbell, 1985; O'Sullivan and Colville, 1983; Smith et al, 1985; Usal and Beattie, 1993). In the present study the rate was 6.6% for isolated injuries to the h a n d and wrist and includes all age groups and injury types. It can be seen f r o m the previously reported studies that the incidence of injury to the h a n d is lower in young children (Wilson, 1986; Usal and Beattie, 1993). In the studies reporting a high incidence of hand injury children are often excluded (Clark et al, 1985) thus increasing the overall incidence of h a n d injury. The male to female ratio in the study group was 2.2: 1. This is in keeping with the findings of previous studies within the British Isles (Edwards, 1975; Clark et al, 1985; Wilson, 1986) however the ratio was
Table ~-Influence of cause of injury on hand injured (dominance)
Causes of injury (no.)
Injury to dominant
Injury to non-dominant
Ratio dominant: non-dominant
Knife injury (262) Broken glass (249) Opening a tin (42) Fall on hand (736) Hand caught between objects (237) Hand through window/door (30) Injury at work/machinery (261)
34 75 17 211 69
100 36 4 156 61
1:3.4 2.1:1 4.3:1 1.4:1 1.1:1
11
3
3.6:1
87
84
1:1
REGIONAL AUDIT OF INJURIES
199
Table 6--Diagnosis of injury in relation to frequency (%) of specialty referral. For the sake of clarity certain diagnoses which had a individual code representing them within the Derby hand keywords have been represented by their major grouping within this table, eg Dislocations Diagnosis'
Plastic surgery (n=59)
Orthopaedic surgery (n=579)
General surgery (n=49)
Laceration arm/wrist/hand
25 (45.5)
5 (0.9)
6 (15.8)
Digital nerve
8 (14.5)
0
0
Flexor tendon palm/digit
5 (9.1)
0
0
Extensor tendon hand/digit
3 (5.5)
1 (0.2)
8 (21.1)
Ulnar nerve
3 (5.5)
0
0
Amputation finger tip
1 (1.8)
0
0
Amputation digit/digits
2 (3.6)
1 (0.2)
0
Infections
1 (1.8)
2 (0.4)
0
Burns
1 (1.8)
0
0
Dislocations
1 (1.8)
21 (3.9)
1 (2.6)
Contusions
1 (1.8)
58 (10.9)
3 (7.9)
Skin/nail loss
1 (1.8)
0
1 (2.6)
Complex injury
1 (1.8)
0
0
Fractured phalanx/phalanges
2 (3.6)
116 (21.8)
2 (5.3)
Fractured metacarpal/s
0
153 (28.7)
1 (2.6)
Fractured wrist
0
164 (30.8)
15 (39.5)
Vascular injury-radial
0
0
1 (2.6)
Mallet finger
0
8 (1.5)
0
much lower in the recent large study from Denmark (1.6: 1) (Angermann and Lohmann, 1993). This may reflect cultural and/or employment differences. The effect of age group and gender on incidence of injury can be seen in Figure 1. This demonstrates a large increase between the 6 10 years group and the 11-15 years group, where the sudden increase may be related to the large number of sports related hand and wrist injuries at this age (Bhende et al, 1993). This may also be reflected by greater increase in the number of male patients injured. A second peak can be seen in the 21-25 years age group, which is likely to be related to work injuries; this is supported by previous studies looking specifically at work related hand injuries (Page, 1975). The mean age of injury for women is 29.2 years and 26.4 years for men, though it can be seen" that increased longevity in the female population has an effect on hand injuries as in all age groups over 70 years women outnumber men. The mode represents a more accurate distribution of hand injuries in relation to age and sex. The modal age for injury is 14 years for male patients (n=113) and 13 years for female patients (n=59). When the ages are grouped in 5 years intervals as in Figure 1 the modal group is 21-25 years for male patients and 11 15 years for female patients. These findings are reflected in Figure 1. A breakdown of the occupations of those injured indicated that 30.2% were students (those in any educational program including primary, secondary and fur-
ther) and 38.4% were in employment. This pattern is not a reflection of the population in Northern Ireland as 21.8% of the population are in education and 20.9% in employment (Department of Health and Social Services, Registrar General Northern Ireland, 1992). It indicates an increased incidence of hand injury amongst the employed and student groups relative to the remaining population. When further analysis of hand injuries in relation to work was undertaken it became clear that whilst the occupation and cause of injury were recorded in most cases, it was often unclear whether the injury had occurred at work or home. This may explain why in the current study only 5.4% of hand and wrist injuries were recorded as being work/machinery related compared with previous reported incidences of between 21% and 32% of all hand injuries (Angermann and Lohmann, 1993; Edwards, 1975; Wilson, 1986). The right and left hands were injured with similar frequency, 51.8% and 45.4% respectively, in keeping with the findings of previous reports (Edwards, 1975; Page, 1975; Smith et al, 1985; Wilson, 1985). Few studies have looked at the incidence of injury to dominant versus non-dominant hands (Clark et al, 1985; Edwards, 1975; Smith et al, 1985). In only one case was a difference found in the incidence of injury between dominant and non-dominant hands. In the present study we found that the dominant hand was more likely to suffer injury; this was statistically significant for both right (P<0.001) and
200
left (P<0.01) hand dominance (Table 2) which supports Clark et al (1985). Analysis of the anatomical site of injury has shown in previous studies that the index finger, then the thumb are most commonly injured (Page, 1975; Smith et al, 1985; Wilson, 1986). We would support this finding (Fig 2) and the suggestion that this is related to the importance of thumbs in fine motor function. After the index and thumb we found the little finger to be most commonly injured as reported by Smith et al (1985). This is likely to relate to its exposed position along a 'border' of the hand. In previous studies there has been little or no standardization in the diagnosis groupings of injuries (Clark et al, 1985; Edwards, 1975; Page, 1975; Wilson, 1986). We have attempted to introduce a comprehensive and standardized method of recording diagnoses of hand and wrist injuries using the Derby hand codes. This produces a good database for further audit and research; however at the present time it is necessary to combine some groups or individual code groups to allow comparison with the results of other studies (Table 3). When the results from previous reports are combined into similar broad diagnostic groups lacerations/sharp injuries are reported as between 36% and 50% of total injuries, contusions/blunt injuries as between 23% and 53% of total injuries and fractures between 8% and 19% of total injuries (Clark et al, 1985; Edwards, 1975; Page, 1975; Wilson, 1986). The results of the current study are in agreement with these findings (Table 3). The cause of injury is not widely reported and again there is no apparent standardization (Campbell, 1985; Edwards, 1975; Smith et al, 1985). Falls both at home and at work have been acknowledged as a major cause of injury but the incidence has not previously been reported. When the cause of injury is related to hand dominance it appears that the non-dominant hand is particularly vulnerable to knife injury, whereas the dominant hand is vulnerable to injury from opening a tin or putting the hand through a window or door. These findings may not be surprising but this relationship has not been previously reported and previous reports have said that there is no significant difference in the incidence of injury between dominant and non-dominant hands (Edwards, 1975; Smith et al, 1985). Patterns of disposal of patients with hand injuries have been reported and are likely to have been influenced by inclusion criteria in each study and local practice in terms of treatment and referral (Angermann and Lohmann, 1993; Clark et al, 1985; Edwards, 1975; Smith et al 1985; Wilson, 1986). In the current study 13.6% of patients were referred immediately to another specialty (orthopaedic surgery, plastic surgery and general surgery). Of those discharged 62% had a review arranged with their general practitioner or at the accident and emergency department. The rate of review appears high but reflects the fact that patients with minor hand injuries can have persistent symptoms
THE J O U R N A L OF H A N D SURGERY VOL. 23B No. 2 A P R I L 1998
(Edwards, 1975) and warrant further attention. It also reflects the policy of most accident and emergency units to review patients with equivocal signs or symptoms within 2448 hours. The group referred to specialties shows only 8.2% (n=55) of referrals were made to plastic surgery. This is not in keeping with the findings of Wilson (1986) whose study from an accident and emergency department included in the present study showed that of the group that required referral for further treatment, 30% were referred to plastic surgery. Wilson's study excluded wrist and carpal injuries; however taking this into account and by looking at our number of emergency operations for the period of the study it was clear that the 8.2% of referrals in the present study was not representative of our emergency workload for hands in a plastic surgery department. Looking at the cases notes of our emergency cases for the period of the study provided three reasons for this apparent shortfall: emergency referrals from hospitals not participating in the study; emergency referrals made following review of a patient at accident and emergency; and a small number of cases that had escaped inclusion in the study. Similar factors causing underestimation of workload have been described (Angermann and Lohmann, 1993).
Acknowledgements The authors gratefully acknowledge the work of the department of clinical audit at The Ulster Hospital in the collection and initial collation of the data. We would also like to thank the staff of the accident and emergency units who participated in the study.
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