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Hand injuries at work
Hand lnjuries at W o r k - - R . E. Page
H A N D INJURIES AT WORK (An analysis: of patients attending hospital) R. E. PAGE, Leeds INTRODUCTION Of 6,175 new patients attending the Accident Department of the Leeds General Infirmary in a four-week period, 303 or 4.9% of patients were suffering from a hand injury sustained whilst at work. Sixty per cent of these patients required at least one further consultation. Industrial hand injuries thus provide much of the work of an accident department serving an industrial area and can be responsible for considerable loss of time from work. Although the incidence and treatment of specific hand injuries has received extensive attention the epidemiology of the industrial hand injury has not, in western literature, been well documented. Wilkes (1956) reported on the social and occupational aspects of injured hands in two hundred and ninety-seven men working mainly in heavy industry. More recen.tly Insufov (1971) published an account of finger and hand injuries in workers in glass factories, and Sarton (1971) reported on industrial injuries of the fingers and hands, but the latter two publications related to industrial conditions in Eastern Europe. The aim of this survey is to elucidate the epidemiology of those industrial hand injuries which are bad enough to need hospital treatment. METHOD Any patient who had injured a hand at work was included in the series. In the case of superficial injuries, only those distal to the ventral wrist crease were considered; and of bone injuries, only those distal to the radio-carpal joint were included. The following details were recorded for each of the 303 patients:-(a) Age and occupation, including place of employment with date of initial attendance. (b) A clinical description of the injury, noting the type of trauma involved --whether sharp trauma, blunt trauma, foreign body or burn. Where necessary, X-ray films were taken and the findings recorded. (c) The type of treatment--whether a minor procedure under a local anaesthetic or a major procedure under a general anaesthetic. (d) The period of follow-up. (e) The existence of nerve or tendon damage. (f) Whether in the patient's opinion the accident was avoidable or unavoidable. The information was then tabulated and in part statistically analysed. RESULTS Of the 303 patients 33 were female and 270 males. The age distribution of the patient is shown in Figure I and this is compared with the age distribution of industrial employees in Leeds City Borough. The collective attendances for each day of the week is indicated in Table I, and Table II shows the distribution and nature of the injuries to the digits and hands. Injuries distal to the metacarpophalangeal joints are classified a s digital and those proximal as hand or wrist injuries. Damage to tendon and nerve was found in only 3 patients, and two of these had suffered major injuries of the hand, which required brief in-patient treatment. Only 35 of the patients considered their injuries to have been avoidable, whereas 828 patients thought that their injuries were unavoidable. The Hand--Vol. 7
No. 1
1975
51
Hand Injuries at W o r k I R . E. Page
25-
distribution of patients attending with hand Injuries
I
-
Age
Age distribution of workers in similar employment in the Leeds City Borough
-
20in i.,. o
•~ I O Q
I'~elowZtl Zl-Zs I 26-30 1 3I-3s 1 36-401 4I-4s 146-S01 sl-5sl 56-6016t-6s lOver 6sl
Age in years Fig. 1. The age distribution of patients with hand injuries compared with that of workers in similar employment in Leeds City Borough. TABLE I
DAILY ATTENDANCE Day
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Number
60 71 57 49 49 17 0
Two patients required major operative procedures under general anaesthesia, and 144 minor procedures under local analgesia, of which 106 needed sutures of a laceration caused by sharp trauma, 26 suturing or manipulation for an injury produced by blunt trauma, and 12 had foreign bodies removed. Excluding the two patients with major injuries, the average follow-up period for the remaining 301 patients was 4.1 days. However, 95 patients were asked to return after 7 days for removal of sutures, 120 patients did not require follow-up or failed to attend as requested, and 24 patients were referred to their own General Practitioner. 52
The Hand--Vol. 7
No. 1
1975
Hand Injuries at W o r k - - R . E. Page
T A B L E II D I S T R I B U T I O N A N D N A T U R E OF I N J U R I E S 303 P A T I E N T S
149 P. Injuries to L side (2 patients with bilat, injuries)
Total Injuries Burn Sharp Trauma Blunt Foreign Body Fracture
Thumb
Index
Middle
Ring
Little
Wrist Hand
Total
23 2 13 6 2 4
41 1 26 9 5 0
18 0 7 10 1 3
14 0 6 7 1 2
9 0 6 3 0 1
45 4 17 23 1 2
150 7 75 58 10 12
157 P. Injuries to R. side (2 patients with bilat, injuries) Thumb
Total Injuries Burn Sharp Trauma Blunt Foreign Body Fracture
30 0 13 16 1 4
Index
Middle
Ring
Little
Wrist Hand
Total
41 1 22 12 6 0
22 0 13 6 3 0
11 0 5 6 0 2
17 0 7 10 0 3
44 2 20 22 0 4
165 3 80 72 10 13
DISCUSSION
There is no significant difference between the total number of injuries to the left hand and to the right. Left-sided cerebral dominance resulting in greater usage of the right hand, is present in 93 per cent of the population (Curtis, Jacobson, Marcus, 1972). It was the preconceived idea of the author that injuries to the hand would be distributed in approximately the same ratio as cerebral dominance, but this does not appear to be the case. The dominant hand will undoubtedly be used more but must be more adept at escape from injury than its non-dominant and less used partner. It is interesting to note that in a series of one hundred and thirty patients that had undergone digital amputation Gruneberg and Spence (1974) found the dominant side to be injured in less than 55 per cent of cases. The index fingers are injured with equal frequency and are the digits most often injured. The two thumbs are injured with nearly the same frequency and are the second most likely digits to be damaged. Injuries to the index fingers and thumbs are significantly higher than those to the remaining digits. As it is the thumb and index which produce the "pinch-grip", it is not surprising that they are more prone to injury. Wrist and hand injuries divide themselves equally to each side and occur with the same frequency as those of the index fingers. Injuries to the ring finger on the left hand account for a significantly larger proportion "of left-sided digital injuries than do right ring finger injuries in the total of right-hand digital injuries. Of the 14 patients with left ring finger injuries, 10 were female: It m a y be pertinent to point out that injury to this digit may have some connection with wearing a wedding ring. The Hand--Vol. 7
No. 1
1975
53
Hand Injuries at W o r k - - R . E. Page
Analysis of the types of injury show that blunt trauma is significantly greater to both hands and wrists than to the digits. However, it is interesting to note that eight fractures were found in the thumbs and only six in both hands and wrists. The commonest area damaged by sharp trauma is the left index. A possible explanation for this is the use of the dominant right hand to hold or guide an instrument towards an article being held or supported by the left hand. Foreign bodies present with greater frequency in the index fingers, whereas burns appear more commonly on the hands and wrists but in the latter two categories insufficient patients were collected for statistical analysis. In assessing the age distribution of patients presenting with hand injuries (Fig. 1), it appears that the younger age groups, particularly those below 21 years of age are prone to injury. By comparing the age distribution of workers in the Leeds City Borough with that of patients in the series, it is revealed that patients below the age of 30 years are more likely to sustain an injury, and those over 51 years of age are less likely to injure their hand. Examination of the age distribution in heavy and manufacturing industries (figures taken from the Department of Employment G a z e t t e - - J u n e 1972) shows that there are fewer workers below the age of 20 and an equal number in the age groups 20 to 39 years, and 40 to 64 years. Thus the impression that younger people are in the majority in the manufacturing and heavy industries undertaking more strenuous forms of work, and therefore more exposed to injury, is not borne out by current statistics. The explanation for the increased frequency of injury in young people perhaps lies only in their lack of exeprience and care. Figures published by the Department of Employment in 1971 showed the sex distribution of workers over the age of 15 years in the catchment area for the Leeds General Infirmary to be 60% male and 40% female. Even allowing for slight variations in the pattern of employment which may have taken place in the last two years, it is significant that of the 303 patients collected in this study, only ten per cent were female. The concept of women being more concerned about their appearance and, therefore, taking greater precautions against injury appears to be a superficial explanation. More relevant is the fact that women tend to work in the lighter forms of industry and, although the potential for it remains, trauma is less severe and may not necessitate a visit to hospital. Of the weekdays, significantly more injuries take place on Tuesdays and fewer on Thursday and Friday. At the weekend considerably fewer injuries present. The Department of Employment cannot give figures for absenteeism, but it was the opinion of their representative that Monday (miner's Monday) and Friday are the common days. The purpose of asking if an accident could have been avoided was to assess whether, in the patient's opinion, any further care or protective measures could have led to prevention of their accident. It is interesting to note that 268 patients thought their accident was unavoidable. "It was just one of those things," was a common response. The majority of workers appear to accept accidents with an air of fatalism, an attitude which, perhaps, warrants attention. SUMMARY
An analysis of hand injuries sustained at work by 303 patients attending an Accident Department over a four-week period showed:-(a) The left side and right side to be injured at the same frequency. (b) The index fingers to be the most commonly injured digit, followed by the thumbs. (c) Hand and wrist injuries to be equally divided to left and right sides and to have the same frequency as injuries to the index fingers. 54
The Hand--Vol. 7
No. 1
1975
Hand Iniuries at W o r k - - R . E. Page
(d) Young people to be more prone to injury. (e) W o m e n to be less likely to sustain injuries. I would like to thank Mr. D. H. Wilson, Consultant Surgeon to the Accident and Emergency Department at the General Infirmary at Leeds for permission to involve his patients in this trial and for his helpful advice in preparing this communication. My thanks are due also to Mr. F. T. de Dombal, Reader in Clinical Science, The University Department of Surgery at the General Infirmary at Leeds, for his help in analysing the results. REFERENCES
CURTIS, B. A., JACOBSON, S., and MARCUS, E. M. (1972) An introduction to the Neurosciences 21: p. 525. Philadelphia, London and Toronto, V. B. Saunders & Co, Department of Employment Gazette. June 1972, p. 531-539. GRUNEBERG, R. and SPENCE, A. J. (1974) Finger amputations and ability to work. The Hand, 6" 236-242. INSUFOV, G. G. (1971) Finger and Hand Injuries in Workers in a Glass Factory. Ortopediya Travmatologiyai Protezirovanie, 32: 73-74. SARTON, V. A. (1971)" Industrial Injuries of the Finger and Hands. Ortopediya Travmatologiyai Protezirovanie, 32: 65-68. WILKES, R. (1956) A Social and Occupational Study of Injured Hands. British Journal of Industrial Medicine, 13: 119-130.
The Hand--Vol. 7
No. 1
1975
55
H A N D INJURIES AT WORK (An analysis: of patients attending hospital) R. E. PAGE, Leeds INTRODUCTION Of 6,175 new patients attending the Accident Department of the Leeds General Infirmary in a four-week period, 303 or 4.9% of patients were suffering from a hand injury sustained whilst at work. Sixty per cent of these patients required at least one further consultation. Industrial hand injuries thus provide much of the work of an accident department serving an industrial area and can be responsible for considerable loss of time from work. Although the incidence and treatment of specific hand injuries has received extensive attention the epidemiology of the industrial hand injury has not, in western literature, been well documented. Wilkes (1956) reported on the social and occupational aspects of injured hands in two hundred and ninety-seven men working mainly in heavy industry. More recen.tly Insufov (1971) published an account of finger and hand injuries in workers in glass factories, and Sarton (1971) reported on industrial injuries of the fingers and hands, but the latter two publications related to industrial conditions in Eastern Europe. The aim of this survey is to elucidate the epidemiology of those industrial hand injuries which are bad enough to need hospital treatment. METHOD Any patient who had injured a hand at work was included in the series. In the case of superficial injuries, only those distal to the ventral wrist crease were considered; and of bone injuries, only those distal to the radio-carpal joint were included. The following details were recorded for each of the 303 patients:-(a) Age and occupation, including place of employment with date of initial attendance. (b) A clinical description of the injury, noting the type of trauma involved --whether sharp trauma, blunt trauma, foreign body or burn. Where necessary, X-ray films were taken and the findings recorded. (c) The type of treatment--whether a minor procedure under a local anaesthetic or a major procedure under a general anaesthetic. (d) The period of follow-up. (e) The existence of nerve or tendon damage. (f) Whether in the patient's opinion the accident was avoidable or unavoidable. The information was then tabulated and in part statistically analysed. RESULTS Of the 303 patients 33 were female and 270 males. The age distribution of the patient is shown in Figure I and this is compared with the age distribution of industrial employees in Leeds City Borough. The collective attendances for each day of the week is indicated in Table I, and Table II shows the distribution and nature of the injuries to the digits and hands. Injuries distal to the metacarpophalangeal joints are classified a s digital and those proximal as hand or wrist injuries. Damage to tendon and nerve was found in only 3 patients, and two of these had suffered major injuries of the hand, which required brief in-patient treatment. Only 35 of the patients considered their injuries to have been avoidable, whereas 828 patients thought that their injuries were unavoidable. The Hand--Vol. 7
No. 1
1975
51
Hand Injuries at W o r k I R . E. Page
25-
distribution of patients attending with hand Injuries
I
-
Age
Age distribution of workers in similar employment in the Leeds City Borough
-
20in i.,. o
•~ I O Q
I'~elowZtl Zl-Zs I 26-30 1 3I-3s 1 36-401 4I-4s 146-S01 sl-5sl 56-6016t-6s lOver 6sl
Age in years Fig. 1. The age distribution of patients with hand injuries compared with that of workers in similar employment in Leeds City Borough. TABLE I
DAILY ATTENDANCE Day
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Number
60 71 57 49 49 17 0
Two patients required major operative procedures under general anaesthesia, and 144 minor procedures under local analgesia, of which 106 needed sutures of a laceration caused by sharp trauma, 26 suturing or manipulation for an injury produced by blunt trauma, and 12 had foreign bodies removed. Excluding the two patients with major injuries, the average follow-up period for the remaining 301 patients was 4.1 days. However, 95 patients were asked to return after 7 days for removal of sutures, 120 patients did not require follow-up or failed to attend as requested, and 24 patients were referred to their own General Practitioner. 52
The Hand--Vol. 7
No. 1
1975
Hand Injuries at W o r k - - R . E. Page
T A B L E II D I S T R I B U T I O N A N D N A T U R E OF I N J U R I E S 303 P A T I E N T S
149 P. Injuries to L side (2 patients with bilat, injuries)
Total Injuries Burn Sharp Trauma Blunt Foreign Body Fracture
Thumb
Index
Middle
Ring
Little
Wrist Hand
Total
23 2 13 6 2 4
41 1 26 9 5 0
18 0 7 10 1 3
14 0 6 7 1 2
9 0 6 3 0 1
45 4 17 23 1 2
150 7 75 58 10 12
157 P. Injuries to R. side (2 patients with bilat, injuries) Thumb
Total Injuries Burn Sharp Trauma Blunt Foreign Body Fracture
30 0 13 16 1 4
Index
Middle
Ring
Little
Wrist Hand
Total
41 1 22 12 6 0
22 0 13 6 3 0
11 0 5 6 0 2
17 0 7 10 0 3
44 2 20 22 0 4
165 3 80 72 10 13
DISCUSSION
There is no significant difference between the total number of injuries to the left hand and to the right. Left-sided cerebral dominance resulting in greater usage of the right hand, is present in 93 per cent of the population (Curtis, Jacobson, Marcus, 1972). It was the preconceived idea of the author that injuries to the hand would be distributed in approximately the same ratio as cerebral dominance, but this does not appear to be the case. The dominant hand will undoubtedly be used more but must be more adept at escape from injury than its non-dominant and less used partner. It is interesting to note that in a series of one hundred and thirty patients that had undergone digital amputation Gruneberg and Spence (1974) found the dominant side to be injured in less than 55 per cent of cases. The index fingers are injured with equal frequency and are the digits most often injured. The two thumbs are injured with nearly the same frequency and are the second most likely digits to be damaged. Injuries to the index fingers and thumbs are significantly higher than those to the remaining digits. As it is the thumb and index which produce the "pinch-grip", it is not surprising that they are more prone to injury. Wrist and hand injuries divide themselves equally to each side and occur with the same frequency as those of the index fingers. Injuries to the ring finger on the left hand account for a significantly larger proportion "of left-sided digital injuries than do right ring finger injuries in the total of right-hand digital injuries. Of the 14 patients with left ring finger injuries, 10 were female: It m a y be pertinent to point out that injury to this digit may have some connection with wearing a wedding ring. The Hand--Vol. 7
No. 1
1975
53
Hand Injuries at W o r k - - R . E. Page
Analysis of the types of injury show that blunt trauma is significantly greater to both hands and wrists than to the digits. However, it is interesting to note that eight fractures were found in the thumbs and only six in both hands and wrists. The commonest area damaged by sharp trauma is the left index. A possible explanation for this is the use of the dominant right hand to hold or guide an instrument towards an article being held or supported by the left hand. Foreign bodies present with greater frequency in the index fingers, whereas burns appear more commonly on the hands and wrists but in the latter two categories insufficient patients were collected for statistical analysis. In assessing the age distribution of patients presenting with hand injuries (Fig. 1), it appears that the younger age groups, particularly those below 21 years of age are prone to injury. By comparing the age distribution of workers in the Leeds City Borough with that of patients in the series, it is revealed that patients below the age of 30 years are more likely to sustain an injury, and those over 51 years of age are less likely to injure their hand. Examination of the age distribution in heavy and manufacturing industries (figures taken from the Department of Employment G a z e t t e - - J u n e 1972) shows that there are fewer workers below the age of 20 and an equal number in the age groups 20 to 39 years, and 40 to 64 years. Thus the impression that younger people are in the majority in the manufacturing and heavy industries undertaking more strenuous forms of work, and therefore more exposed to injury, is not borne out by current statistics. The explanation for the increased frequency of injury in young people perhaps lies only in their lack of exeprience and care. Figures published by the Department of Employment in 1971 showed the sex distribution of workers over the age of 15 years in the catchment area for the Leeds General Infirmary to be 60% male and 40% female. Even allowing for slight variations in the pattern of employment which may have taken place in the last two years, it is significant that of the 303 patients collected in this study, only ten per cent were female. The concept of women being more concerned about their appearance and, therefore, taking greater precautions against injury appears to be a superficial explanation. More relevant is the fact that women tend to work in the lighter forms of industry and, although the potential for it remains, trauma is less severe and may not necessitate a visit to hospital. Of the weekdays, significantly more injuries take place on Tuesdays and fewer on Thursday and Friday. At the weekend considerably fewer injuries present. The Department of Employment cannot give figures for absenteeism, but it was the opinion of their representative that Monday (miner's Monday) and Friday are the common days. The purpose of asking if an accident could have been avoided was to assess whether, in the patient's opinion, any further care or protective measures could have led to prevention of their accident. It is interesting to note that 268 patients thought their accident was unavoidable. "It was just one of those things," was a common response. The majority of workers appear to accept accidents with an air of fatalism, an attitude which, perhaps, warrants attention. SUMMARY
An analysis of hand injuries sustained at work by 303 patients attending an Accident Department over a four-week period showed:-(a) The left side and right side to be injured at the same frequency. (b) The index fingers to be the most commonly injured digit, followed by the thumbs. (c) Hand and wrist injuries to be equally divided to left and right sides and to have the same frequency as injuries to the index fingers. 54
The Hand--Vol. 7
No. 1
1975
Hand Iniuries at W o r k - - R . E. Page
(d) Young people to be more prone to injury. (e) W o m e n to be less likely to sustain injuries. I would like to thank Mr. D. H. Wilson, Consultant Surgeon to the Accident and Emergency Department at the General Infirmary at Leeds for permission to involve his patients in this trial and for his helpful advice in preparing this communication. My thanks are due also to Mr. F. T. de Dombal, Reader in Clinical Science, The University Department of Surgery at the General Infirmary at Leeds, for his help in analysing the results. REFERENCES
CURTIS, B. A., JACOBSON, S., and MARCUS, E. M. (1972) An introduction to the Neurosciences 21: p. 525. Philadelphia, London and Toronto, V. B. Saunders & Co, Department of Employment Gazette. June 1972, p. 531-539. GRUNEBERG, R. and SPENCE, A. J. (1974) Finger amputations and ability to work. The Hand, 6" 236-242. INSUFOV, G. G. (1971) Finger and Hand Injuries in Workers in a Glass Factory. Ortopediya Travmatologiyai Protezirovanie, 32: 73-74. SARTON, V. A. (1971)" Industrial Injuries of the Finger and Hands. Ortopediya Travmatologiyai Protezirovanie, 32: 65-68. WILKES, R. (1956) A Social and Occupational Study of Injured Hands. British Journal of Industrial Medicine, 13: 119-130.
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No. 1
1975
55