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A review of digital injuries
A REVIEW OF k ~ I T A L INJURIES By P. W. BROWN, F.R.C.S.Ed. 1
Plastic and Facio-maxillary Unit, Bangour General Hospital, West Lothian, Scotland DIGITAL injuries are a major sotlrce of casualty attendance and are responsible for enormous economic losses to the nation. The method of treatment of these injuries is determined not only by the degree of injury but also by the age and occupation of the patient and the experience of the surgeon (Moynihan, 1961). A variety of procedures have been recommended because of their cosmetic and functional results as well as their ability to allow the patient to return to work quickly. However, there are many conflicting claims regarding the relative merits of each form of treatment (Robins, 1954; Tempest, 1955; McCash, 1959; Brody et al., 196o ; Moynihan, 1961 ; McCormack, I964), A review has been undertaken of all patients with acute digital injuries admitted to this Unit during the two years April 1964 to March 1966, with special reference to the results of various types of treatment in terms of duration of stay in hospital and length of time off work. Series.--One hundred and thirty cases of acute digital injuries were admitted to this Unit during these two years. Many cases where more serious injuries to the hand or other parts of the body also occurred have been excluded as these would give inaccurate results for the duration of stay in hospital and time off work. Ninety-one per cent. of the cases were referred from the hospital casualty department where digital injuries not requiring in-patient treatment were dealt with by the general surgeons. The remaining 9 per cent. of cases were referred as emergency admissions from nearby hospitals. The 13° cases constituted 18.1 per cent. (13o/698) of all emergency admissions and 5"5 per cent. (13o/2365) of all admissions to the unit over the same period. Monthly Incidence (Fig. I).--The obvious peak in December is not a solitary finding. An increased incidence occurs each December and is very difficult to account for. It cannot be related to the cold or dark as the incidence of injuries in November and January when similar conditions apply is no greater than in summer months. Daily Incidence (Fig. 2).--This shows an equal distribution throughout the working week and relates to the fact that 83"8 per cent. (lO9/13o) of the patients sustained the injury at work; miners (26 cases), plant operators (I9), general labourers (I4) , joiners (9) and engineers (9) accounting for the majority of occupations. Sex Incidence.--Only 9 out of the 13o patients were female. Age Incidence (Fig. 3).--This shows that there is a large number of patients under the age of 20 years ; a finding similar to that of Brody et al. (196o) who considered it to be due to lack of skill. In the present series there were a considerable number of apprentices and others recently starting work on machines with which they were not familiar. Digit Injured.--In all 207 digits were involved. The incidence of individual digital injuries is shown in Figure 4 and is comparable to the length of each finger. 1 Present address: Senior Surgical Registrar, Royal Infirmary, Edinburgh. 387
388
BRITISH JOURNAL OF PLASTIC SURGERY
T h e left and right hand were almost equally involved, 6 4 : 6 8 , and similarly the dominance of the hand made little difference, 555 per cent. of the injuries occurring in the dominant hand. 27
30 25
=20
25 • 21. 22
16
22
~20
~10 APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR MOF;THS
FIG. I Monthly number of digital injuries, 1964-1966.
~0
G2
50
30
10'
FIG. 2 Day of injury.
701 3~
~, 20'
NON TUE WED THLI FRI SAT SUN
50
23iH
1,5
37
~o2
,~30~ 20lO.
V-3 1
0-9 10-19 20-29 30-39 t,O-Z,9 50-59 60-69 :='70 AGE
FIG. 3 Age of patient.
TH. IND.
MID. RING DIGIT INJURED
LIT.
FIG. 4 Digit injured.
TREATMENT AND RESULTS T h e various forms of treatment employed are shown in the Table, along with the length of time in hospital and off work. The column showing the number of cases is divided into two, the first figure is the number of cases receiving that form of treatment as the sole or major form of treatment. The second figure is the total number of cases treated that way and includes multiple injuries where different digits have received different forms of treatment. The time in hospital and off work has been calculated only from the first figures in order to get an accurate figure for each form of treatment. T h e overall time spent in hospital in the first year of the review was 12.83 days. tn the following year when adequate out-patient facilities were provided the overall time spent in hospital dropped to 7"5 2 days--a saving of five in-patient days per patient ; in fact 42'3 per cent. of the patients were in hospital for under 48 hours. T h e number of patients requiring out-patient physiotherapy was 3o per cent. (39/13o) . Readmission--Excluding the eight patients who were readmitted for division of a flap, 18 (13.1 per cent.) patients had to be readmitted for the following reasons : 4 cases for excision of nail bed. 5 cases requiring further amputation. 2 cases for thinning of flaps.
A R E V I E W OF D I G I T A L
2 I I I I
389
INJURIES
cases for failure of split-skin grafts. case for excision of terminal scar. case for excision of neuroma. case for further arthrodesis. case for tendon graft.
Three of the five patients who needed further amputation were admitted because previous amputations had not been adequate or had broken down ; the fourth patient TABLE
No. o f cases A B All cases S h o r t e n i n g a n d closure Split-skin graft Cross finger Cross a r m Pectoral flap Extensor tendon suture Arthrodesis A m p u t a t i o n with filleting Direct closure F u l l - t h i c k n e s s graft
I3o
43 23 7 12 4
T i m e in hospital in days
T i m e o f work in weeks
9'73
--
3'9 6.8
7"6 5"4 5'7 9"3 14-o 6.6 9.0
65 36 7 13
][2 "0 3O'2
13
26 "6 2'6 4'25
had to have an amputation of a stiff arthrodesed finger and the fifth removal of a metacarpal head to improve function. Of the two split-skin graft failures, the defect in one was covered with a free skin graft and in the other with a cross-arm flap. Change of Job.--Three people were not followed up ; one, an alcoholic vagrant, was not seen following amputation of a digit, two others lived too far away to be followed but had good movement in their injured hands four and nine weeks respectively after injury. Three out of the remaining IZ7 patients did not return to their original job but in only one was this because of the accidentqa man with three fingers badly damaged who required a cross-arm flap and found his labouring job too heavy. DISCUSSION
The object of this paper has been to assess the results of different treatments of digital injuries in terms of duration of time off work. No attempt has been made to judge the sensory or joint movement results of the various procedures as these have recently been thoroughly reviewed by Sturman and Duran (I963). The extent of avulsion of a tactile pad is too variable to expect one method of repair to be employed exclusively. Frequently cases present with gross bone damage and contamination or with large areas of bone protruding and in these amputation is obviously best. However, many cases present with skin and pulp loss with small amounts of exposed intact bone where the choice lies between shortening and direct closure, shortening with split-skin grafting or the use of some form of pedicled flap. 4D
390
,BRITISH JOURNAL
OF PLASTIC SURGERY
It is in these cases that it is frequently stated that shortening and direct closure will enable a manual labourer to get back to his work more quickly. It will be seen in this review that the average time off work following amputation is 7.6 weeks. Barclay (I956) found I I '6 weeks to be the average time off work and Brody et al. (I96o) found 11 weeks. This delay is not one of healing because of inadequate bone removal, but is considered by Barclay to be due to the fact that the stumps are too tender to enable heavy work to be carried out for three months and also because the digit may be clumsy and the patient reluctant to return to work until he has regained confidence in it. Brody also pointed out that patients receiving compensation took an average of I I days longer to r,'turn to work than those not receiving compensation. In the few self-employed patients in this series return to work was dramatically quicker than in the others. Split-skin grafting directly on to pulp or after bone has been shortened and covered with adjacent pulp is recommended by many authors (Barclay, I955; Brody et al., I96o ; Moynihan, I96I). However, others strongly condemn this form of treatment and prefer full-thickness grafting (Tempest, I955 ; McCash, I959). In the present review patients with split-skin grafting returned to work after 5'4 weeks which is comparable to 5"2 weeks in Brody's patients and also to Moynihan's finding that 67 per cent. of cases return to work within four weeks, and is an improvement on Reid's seven to eight weeks (Reid, I956) and Barclay's nine weeks (Barclay, I955). While a split-skin graft is frequently condemned because it may leave a painful adherent scarred tip this is by no means necessarily so, and the fact that the graft contracts up to half its original size results in minimising the final area of sensory defect. No comparison is possible in this series with treatment with full-thickness grafting as only three cases underwent this treatment. Two of these three grafts failed and had to be replaced with split-skin grafts. The third case developed a superficial black adherent slough which eventually separated to show a well-healed surface. Although a full-thickness graft probably offers the best functional result it is the most difficult graft to take, requiring a soft base, complete ha:mostasis and absence of infection. It is because of poor results with this graft in the past that it is not often used in this unit for treating acute digital injuries. Patients treated with pedicle flaps have usually sustained more extensive injuries than just a tip avutsion; usually circumferential skin loss has occurred. These patients remain in hospital longer than those undergoing other forms of treatment, and those with cross-arm and pectoral flaps are off work much longer. It will be seen that the limited number of cases in this series undergoing cross-finger flaps returned to work earlier than those patients undergoing simple amputation. Stiffness in the donor finger following a cross-finger flap is not a common finding in younger patients. SUMMARY
A review of acute finger injuries presenting at a Plastic Unit over a two-year period is presented. The length of time off work has been compared in the various forms of treatment and it has been found that following amputation patients are off work longer than those treated by split-skin grafts or cross-finger flaps. The average length of time in hospital can be reduced by adequate out-patient facilities for dressings and physiotherapy. I should like to thank Miss A. B. Sutherland, M.D., F.R.C.S.E.,/or her help in preparing this paper.
A REVIEW OF D I G I T A L
INJURIES
REFERENCES BARCLAY, T. L. (1955)- Br. J. plast. Surg., 8, 38. BRODY, G. S., CLOUTIER, A. McL., and WOOLHOUSE, P. M. (196o). Plastic reconstr. Surg., 26, 80. McCASH, C. R. (1959). Br. J. plast. Surg., I I , 3 ~ . McCoRMACK, R. (1964). I n : " Modern Trends in Plastic Surgery ", ed. Gibson, T. London : Butterworth. MOYNIHAN, F. J. (1961). Br. med. J., 2, 8oz. REID, D. A. C. (1956). Br.J. plast. Surg., 9, II. ROBINS, R. H. C. (1954). Br. J. Surg., 41, 515. STURMAN, M. J., and DURAN, R. J. (1963). J. Bone Jt Surg., 45-A, 289. TEMPEST, M. N. (1954). Br. J. plast. Surg., 7, 153.
391
Plastic and Facio-maxillary Unit, Bangour General Hospital, West Lothian, Scotland DIGITAL injuries are a major sotlrce of casualty attendance and are responsible for enormous economic losses to the nation. The method of treatment of these injuries is determined not only by the degree of injury but also by the age and occupation of the patient and the experience of the surgeon (Moynihan, 1961). A variety of procedures have been recommended because of their cosmetic and functional results as well as their ability to allow the patient to return to work quickly. However, there are many conflicting claims regarding the relative merits of each form of treatment (Robins, 1954; Tempest, 1955; McCash, 1959; Brody et al., 196o ; Moynihan, 1961 ; McCormack, I964), A review has been undertaken of all patients with acute digital injuries admitted to this Unit during the two years April 1964 to March 1966, with special reference to the results of various types of treatment in terms of duration of stay in hospital and length of time off work. Series.--One hundred and thirty cases of acute digital injuries were admitted to this Unit during these two years. Many cases where more serious injuries to the hand or other parts of the body also occurred have been excluded as these would give inaccurate results for the duration of stay in hospital and time off work. Ninety-one per cent. of the cases were referred from the hospital casualty department where digital injuries not requiring in-patient treatment were dealt with by the general surgeons. The remaining 9 per cent. of cases were referred as emergency admissions from nearby hospitals. The 13° cases constituted 18.1 per cent. (13o/698) of all emergency admissions and 5"5 per cent. (13o/2365) of all admissions to the unit over the same period. Monthly Incidence (Fig. I).--The obvious peak in December is not a solitary finding. An increased incidence occurs each December and is very difficult to account for. It cannot be related to the cold or dark as the incidence of injuries in November and January when similar conditions apply is no greater than in summer months. Daily Incidence (Fig. 2).--This shows an equal distribution throughout the working week and relates to the fact that 83"8 per cent. (lO9/13o) of the patients sustained the injury at work; miners (26 cases), plant operators (I9), general labourers (I4) , joiners (9) and engineers (9) accounting for the majority of occupations. Sex Incidence.--Only 9 out of the 13o patients were female. Age Incidence (Fig. 3).--This shows that there is a large number of patients under the age of 20 years ; a finding similar to that of Brody et al. (196o) who considered it to be due to lack of skill. In the present series there were a considerable number of apprentices and others recently starting work on machines with which they were not familiar. Digit Injured.--In all 207 digits were involved. The incidence of individual digital injuries is shown in Figure 4 and is comparable to the length of each finger. 1 Present address: Senior Surgical Registrar, Royal Infirmary, Edinburgh. 387
388
BRITISH JOURNAL OF PLASTIC SURGERY
T h e left and right hand were almost equally involved, 6 4 : 6 8 , and similarly the dominance of the hand made little difference, 555 per cent. of the injuries occurring in the dominant hand. 27
30 25
=20
25 • 21. 22
16
22
~20
~10 APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR MOF;THS
FIG. I Monthly number of digital injuries, 1964-1966.
~0
G2
50
30
10'
FIG. 2 Day of injury.
701 3~
~, 20'
NON TUE WED THLI FRI SAT SUN
50
23iH
1,5
37
~o2
,~30~ 20lO.
V-3 1
0-9 10-19 20-29 30-39 t,O-Z,9 50-59 60-69 :='70 AGE
FIG. 3 Age of patient.
TH. IND.
MID. RING DIGIT INJURED
LIT.
FIG. 4 Digit injured.
TREATMENT AND RESULTS T h e various forms of treatment employed are shown in the Table, along with the length of time in hospital and off work. The column showing the number of cases is divided into two, the first figure is the number of cases receiving that form of treatment as the sole or major form of treatment. The second figure is the total number of cases treated that way and includes multiple injuries where different digits have received different forms of treatment. The time in hospital and off work has been calculated only from the first figures in order to get an accurate figure for each form of treatment. T h e overall time spent in hospital in the first year of the review was 12.83 days. tn the following year when adequate out-patient facilities were provided the overall time spent in hospital dropped to 7"5 2 days--a saving of five in-patient days per patient ; in fact 42'3 per cent. of the patients were in hospital for under 48 hours. T h e number of patients requiring out-patient physiotherapy was 3o per cent. (39/13o) . Readmission--Excluding the eight patients who were readmitted for division of a flap, 18 (13.1 per cent.) patients had to be readmitted for the following reasons : 4 cases for excision of nail bed. 5 cases requiring further amputation. 2 cases for thinning of flaps.
A R E V I E W OF D I G I T A L
2 I I I I
389
INJURIES
cases for failure of split-skin grafts. case for excision of terminal scar. case for excision of neuroma. case for further arthrodesis. case for tendon graft.
Three of the five patients who needed further amputation were admitted because previous amputations had not been adequate or had broken down ; the fourth patient TABLE
No. o f cases A B All cases S h o r t e n i n g a n d closure Split-skin graft Cross finger Cross a r m Pectoral flap Extensor tendon suture Arthrodesis A m p u t a t i o n with filleting Direct closure F u l l - t h i c k n e s s graft
I3o
43 23 7 12 4
T i m e in hospital in days
T i m e o f work in weeks
9'73
--
3'9 6.8
7"6 5"4 5'7 9"3 14-o 6.6 9.0
65 36 7 13
][2 "0 3O'2
13
26 "6 2'6 4'25
had to have an amputation of a stiff arthrodesed finger and the fifth removal of a metacarpal head to improve function. Of the two split-skin graft failures, the defect in one was covered with a free skin graft and in the other with a cross-arm flap. Change of Job.--Three people were not followed up ; one, an alcoholic vagrant, was not seen following amputation of a digit, two others lived too far away to be followed but had good movement in their injured hands four and nine weeks respectively after injury. Three out of the remaining IZ7 patients did not return to their original job but in only one was this because of the accidentqa man with three fingers badly damaged who required a cross-arm flap and found his labouring job too heavy. DISCUSSION
The object of this paper has been to assess the results of different treatments of digital injuries in terms of duration of time off work. No attempt has been made to judge the sensory or joint movement results of the various procedures as these have recently been thoroughly reviewed by Sturman and Duran (I963). The extent of avulsion of a tactile pad is too variable to expect one method of repair to be employed exclusively. Frequently cases present with gross bone damage and contamination or with large areas of bone protruding and in these amputation is obviously best. However, many cases present with skin and pulp loss with small amounts of exposed intact bone where the choice lies between shortening and direct closure, shortening with split-skin grafting or the use of some form of pedicled flap. 4D
390
,BRITISH JOURNAL
OF PLASTIC SURGERY
It is in these cases that it is frequently stated that shortening and direct closure will enable a manual labourer to get back to his work more quickly. It will be seen in this review that the average time off work following amputation is 7.6 weeks. Barclay (I956) found I I '6 weeks to be the average time off work and Brody et al. (I96o) found 11 weeks. This delay is not one of healing because of inadequate bone removal, but is considered by Barclay to be due to the fact that the stumps are too tender to enable heavy work to be carried out for three months and also because the digit may be clumsy and the patient reluctant to return to work until he has regained confidence in it. Brody also pointed out that patients receiving compensation took an average of I I days longer to r,'turn to work than those not receiving compensation. In the few self-employed patients in this series return to work was dramatically quicker than in the others. Split-skin grafting directly on to pulp or after bone has been shortened and covered with adjacent pulp is recommended by many authors (Barclay, I955; Brody et al., I96o ; Moynihan, I96I). However, others strongly condemn this form of treatment and prefer full-thickness grafting (Tempest, I955 ; McCash, I959). In the present review patients with split-skin grafting returned to work after 5'4 weeks which is comparable to 5"2 weeks in Brody's patients and also to Moynihan's finding that 67 per cent. of cases return to work within four weeks, and is an improvement on Reid's seven to eight weeks (Reid, I956) and Barclay's nine weeks (Barclay, I955). While a split-skin graft is frequently condemned because it may leave a painful adherent scarred tip this is by no means necessarily so, and the fact that the graft contracts up to half its original size results in minimising the final area of sensory defect. No comparison is possible in this series with treatment with full-thickness grafting as only three cases underwent this treatment. Two of these three grafts failed and had to be replaced with split-skin grafts. The third case developed a superficial black adherent slough which eventually separated to show a well-healed surface. Although a full-thickness graft probably offers the best functional result it is the most difficult graft to take, requiring a soft base, complete ha:mostasis and absence of infection. It is because of poor results with this graft in the past that it is not often used in this unit for treating acute digital injuries. Patients treated with pedicle flaps have usually sustained more extensive injuries than just a tip avutsion; usually circumferential skin loss has occurred. These patients remain in hospital longer than those undergoing other forms of treatment, and those with cross-arm and pectoral flaps are off work much longer. It will be seen that the limited number of cases in this series undergoing cross-finger flaps returned to work earlier than those patients undergoing simple amputation. Stiffness in the donor finger following a cross-finger flap is not a common finding in younger patients. SUMMARY
A review of acute finger injuries presenting at a Plastic Unit over a two-year period is presented. The length of time off work has been compared in the various forms of treatment and it has been found that following amputation patients are off work longer than those treated by split-skin grafts or cross-finger flaps. The average length of time in hospital can be reduced by adequate out-patient facilities for dressings and physiotherapy. I should like to thank Miss A. B. Sutherland, M.D., F.R.C.S.E.,/or her help in preparing this paper.
A REVIEW OF D I G I T A L
INJURIES
REFERENCES BARCLAY, T. L. (1955)- Br. J. plast. Surg., 8, 38. BRODY, G. S., CLOUTIER, A. McL., and WOOLHOUSE, P. M. (196o). Plastic reconstr. Surg., 26, 80. McCASH, C. R. (1959). Br. J. plast. Surg., I I , 3 ~ . McCoRMACK, R. (1964). I n : " Modern Trends in Plastic Surgery ", ed. Gibson, T. London : Butterworth. MOYNIHAN, F. J. (1961). Br. med. J., 2, 8oz. REID, D. A. C. (1956). Br.J. plast. Surg., 9, II. ROBINS, R. H. C. (1954). Br. J. Surg., 41, 515. STURMAN, M. J., and DURAN, R. J. (1963). J. Bone Jt Surg., 45-A, 289. TEMPEST, M. N. (1954). Br. J. plast. Surg., 7, 153.
391