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The hand injury severity scoring system
THE HAND INJURY SEVERITY SCORING SYSTEM D. A. C A M P B E L L and S. P. J . KAY
From the Departments of Orthopaedic Surgery and Plastic, Reconstructive and Hand Surgery, St James's University Hospital, Leeds, UK
A descriptive severity scoring system for injuries to the hand, distal to the carpus, has been designed. Each ray of the hand is assessed separately. Each ray's score is then multiplied by a ~veighting factor for that ray and added to the scores of the other rays to obtain a total score for the injury. This system has been tested on a series of specimen injuries and compared with the opinion of experienced hand surgeons. A retrospective study of hand injuries has also been conducted, and the Hand Injury Severity Score ( H I S S ) has been found to closely correlate with return to work. Four grades of increasing severity of hand injury have been described. Although this system has been designed as a research tool, it is envisaged that it would be a useful immediate measure of severity and a guide to likely outcome.
Journal of Hand Surgery (British and European Volume, 1996) 21B." 3:295-298 Scoring systems have been successfully employed for many years in the management of trauma (Baker et al, 1974). The information which is provided is invaluable when assessing prognosis, but can also give an important measure for auditing the allocation and performance of health services (Boyd et al, 1987; Anderson et al, 1988). Hand injuries form a regular part of the workload of all accident and emergency departments (Clark et al, 1985; Packer and Shaheen, 1993) and have a major economic impact because they can dramatically affect the ability to carry out useful employment (Smith et al, 1985; O'Sullivan and Colville, 1993). The education and training of hand surgeons in the UK is traditionally via either a "Plastic" or "Orthopaedic" route (Tonkin, 1992) and consequently more emphasis may be unwittingly placed on those aspects of hand injury particular to the mother specialty. It is essential when assessing a hand injury to look at the entire organ and all its constituent components. This scoring system for hand injuries allows all types of injury to be classified and thus compared for severity.
absolute values which require no further modification. The absolute values apply in areas where assignation to a particular ray would not be possible, (e.g. the motor branches of median and ulnar nerves, and skin loss on the dorsal and palmar aspects of the metacarpals). A reference sheet (Fig 1) detailing the ISMN score is completed for each ray. These values are used to fill in the overall scoring chart (Fig2), and a final Hand Injury Severity Score (HISS) is obtained. Modifications to allow for appropriate scoring of contaminated wounds have been added to the Integument and Skeletal categories. If a wound is crushed, dirty or contaminated or in any way different from a clean incised wound, the Integument score should be doubled. Similarly, if a Skeletal injury is open, this value should also be doubled. A fracture which is both open and contaminated will therefore receive appropriate points by doubling both the Integument and Skeletal values. Both of these modifications should take place before multiplying by the weighting factor. Amputations should take all damaged structures into account, as in any other injury.
MATERIALS AND METHODS System validation
System development
Although points for specific injuries were awarded in a controlled and considered fashion, their actual values were regarded as arbitrary until satisfactorily validated. The system was validated in two ways. Five specimen hand injuries (Table 2) containing a mixture of soft tissue and bony cases, were produced and mailed to 25 experienced hand surgeons in the UK.
The separate anatomical components of the hand distal to the carpus were divided into the broad constituent categories of: integument, skeletal, motor and neural (ISMN). Each category wgs examined in detail to cover all possible injury patterns, and each specific injury was assigned a value based on its notional importance. Each ray should be separately examined for injury in the four ISMN categories. After this examination, the total ISMN score is multiplied by a weighting factor for that particular ray (Table 1), since the same injury in different rays can be regarded as more severe in the functionally more important ray. In each ISMN category there are two types of points to be scored. There are those which must be multiplied by the weighting factor for that ray, and those assigned
Table 1--The individual digit weighting factors
Digit Thumb Index Long Ring Little
295
Weightingfactor x x x x x
6 2 3 3 2
296
THE JOURNAL OF HAND SURGERY VOL. 21B No. 3 JUNE 1996
INTEGUMENT INTEGUMENT
Skin loss
Absolute values (hand)."
< 1 cm 2 > 1 cm 2 > 5 cm z
5 10 20
Palm
Dorsum x 2
....
Dorsum
< > < >
Dorsum
SKELETON
I
THUMB
L I
INDEX
Weighted values (digit):
Pulp
1 cm 2 1 cm 2 25% 25%
2 3 3 5
MOTOR
I[
NEUROLOGICAL
TOTAL
[
xO.
]
×2.
LONG
x3-
RING
xS-
LITTLE
Skin laceration < 1 cm l > 1 cm 2 (If, extends across more than one ray, include in both rays score)
FINALSEVEa~rY SCORE Fig 2
The Hand Injury Severity Scoring chart.
Nail. damage Table 2--Five specimen hand injuries
SKELETAL
Fractures
Dislocations Ligament injury
Simple shaft Comminuted shaft Intraarticular DIPJ Intraarticular PIPJ/IPJ of thumb Intraarticular MCPJ
1 2 3 5 4
Open
4
Closed
2
Sprain Rupture
2 3
MOTOR Extensor tendon Flexor profundus
Proximal to PIPJ Distal to PIPJ Zone 1 Zone 2 Zone 3
Flexor superficialis Intrinsics
1 3 6 6 5
5 2
NEURAL
Absolute values
Recurrent branch median nerve Deep branch ulnar nerve
Weighted values
Digital nerve x 1 Digital nerve x 2
Fig 1
30 30 3 4
The injury scoring system.
Table 2 gives the broad type of injury described, but not the exact details of that specimen injury. The surgeons were instructed to rate these injuries in order of severity, 1 to 5, with 1 being the most severe. The information given to them was that the injury had been sustained by a male blue collar worker in his thirties. No information was given on side of injury or dominance. These opinions from experienced colleagues were then collated and compared with the results which would have been achieved by using the Scoring System. A level of significance was obtained using a Z2 test. Several minor modifications were then made to the HISS, so that the
Case
Injuries
A B C D E
Minor Minor Major Major Minor
bony injury soft tissue injury bony injury soft tissue injury fingertip amputation
(Only broad type of injury is specified here)
results using the HISS concurred with the "gold standard" of experienced surgical opinion. The modified HISS was then applied retrospectively to 100 consecutive hand injuries in patients under 50 years of age who had presented to the Regional Hand Service. The aim was to compare the amount of time off work with the HISS, to see if the more severe injuries (as described by the H I S S ) t o o k longer to return to work. Spearman's rank correlation coefficient was used to assess the relationship between severity of injury (HISS) and time off work. RESULTS Specimen cases
Twenty-four replies were received from 25 letters sent. One reply was spoilt, giving 23 replies for analysis, a response rate of 92%. The "votes cast" were collated (Table 3) and a clear picture emerged of the opinions Table 3--Votes cast for specimen hand injuries Ranking
1
2
3
4
5
Case Case Case Case Case
0 0 8 15 0
0 1 14 8 0
2 18 1 0 2
11 3 0 0 9
10 1 0 0 12
A B C D E
(l=Most severe; 5=Least severe)
INJURY SEVERITY SCORE
297 Table 5--Patient study group
2oVo~s
Case D
i(h
1st
Ranking
~d
4-- --5"--
20Votes
2nd
Case C
20 TM
3rd
Case B
Votes
10
1
2
3
4
Case A
4th =
Case E
4th =
5
2 0 Vows
No. of patients Mean age (range) M : F ratio Dominant hand injuries Mean follow up (range) Mean time off work (range) HISS mean (range)
48 31 yrs (21 47) 41 : 7 28 (58%) 17.6 weeks (6-58) 8.8 weeks (0 52) 21 points (6-80)
Retrospective patient study One hundred consecutive hand injuries in individuals of working age were analysed. Forty-eight of these patients were traced and interviewed (48%) (Table 5). Forty-two were classed as semi-skilled workers. A scatter diagram of HISS against number of weeks before return to work was constructed (Fig 4). Using Spearman's rank correlation coefficient, a coefficient of 0.57 was obtained. With a sample size of 48, a significant relationship between HISS and time off work was noted (P 40.002). There were 32 patients with a HISS of less than 20 points, (Fig 4); 27 of them (84%) were fit to return to work after 8 weeks. There were 16 patients with a HISS greater than 20 points and of these only six (38%) were fit for work after 8 weeks. Using these results, a HISS of below 20 points can be regarded as an injury of "Minor" severity. It is suggested that all injuries with a HISS between 21 and 50 be assigned to the "Moderate" category. A HISS between 51 and 100 is "Severe", and 101 and above is "Major" (Table 6). !
DISCUSSION Fig 3
Results of peer ranking of five specimen hand injuries.
of experienced hand surgeons on these cases (Fig 3). Case D was widely seen as being the most severe, with 15 votes (63%) (P<0.001). The ranking of these cases differed slightly from the ranking produced by the original HISS (which was developed from values regarded as arbitrary). The HISS was revised by increasing the weighting factors for thumb and index rays, and by adjusting the values of simple shaft fractures and tendon division, to give values which were comparable to the survey results (Table 4). Table 4--Relationship of specimen cases to HISS showing effects of score modification
Severity ranking 1 2 3 4 5
Surgeon survey D C B A/E A/E
HISS (original) D C A E B
(123 pts) (92 pts) (30 pts) (25 pts) (21 pts)
HISS (revised) D C B A E
(176 pts) (107 pts) (42 pts) (35 pts) (25 pts)
Scoring systems are now well established in the management of trauma. Systems such as the Injury Severity Score (ISS; Baker et al, 1974) and the Glasgow Coma Scale (GCS; Teasdale and Jennett~ 1974) have now been in use for over 20 years, and play a major role in predicting outcome. In the hand, scoring systems can either be functional or descriptive. Many different factors must be considered in a functional system, such as handedness, occupation, treatment and the patient's psychological profile. A descriptive system merely outlines the exact structural damage at the time of injury. At present this has no direct bearing on prognosis but may ultimately yield such information after the audit of large numbers of hand injuries. Table 6 - - T h e grading of severity of hand injury
Grade
HISS (pts)
I Minor II--Moderate III-- Severe IV--Major
< 20 21 50 51- 100 > 100
298
T H E J O U R N A L OF H A N D SURGERY VOL. 21B No. 3 JUNE 1996 HISS
100
80
60
40 i
20
--
-'l--"41-'-
1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
i
•
0
m
i i i
]
I
~
p
10
20
30
40
I
50 Time
Fig 4
i
off
work
60 (weeks)
Scatter diagram of HISS against time off work.
The Hand Injury Severity Scoring system is a descriptive system which is of help in grading injuries into broad categories, such as Minor, Moderate, Severe and Major. This allows all types of hand trauma to be compared, like with like, with regard to severity. Inevitably, it will be functional assessments which validate descriptive systems and these take time to verify. However an accurate descriptive scoring system allows hand injuries to be broadly categorized immediately after injury, and so helps with decisions about further referral and resource management. The acute care and assessment of an injured hand is an important first step towards a successful outcome (Smith and Jones, 1985). Use of this system will ensure that a thorough assessment is made by all personnel involved in the care of hand trauma, including the most inexperienced. This Hand Injury Severity Scoring System is the first stage in the evolution of a quantitative measurement of hand trauma.
(1988). A retrospective study of 1,000 deaths from injury in England and Wales. British Medical Journal, 296:1305 1308. B A K E R S P, O ' N E I L L B, H A D D O N W and L O N G W B (1974). The injury severity score: a method for describing patients with multiple injuries and evaluating care. Journal of Trauma, 14: 187-196. BOYD C R, TOLSON M A and COPES W S (1987). Evainating trauma care: the TRISS method. Journal of Trauma, 27:370 378. C L A R K D P, SCOTT R N and A N D E R S O N I W R (1985). Hand problems in an accident and emergency department. Journal of H a n d Surgery, 10B: 297-299. O'SULLIVAN M E and COLVILLE J (1993). The economic impact of hand injuries. Journal of H a n d Surgery, 18B: 395-398. PACKER G J and S H A H E E N M A (1993). Patterns of hand fractures and dislocations in a district general hospital. Journal of Hand Surgery, 18B: 5ll-514. SMITH M E, AUCH1NLOSS J M and ALI M S (1985). Causes and consequences of hand injury. Journal of H a n d Surgery, 10B: 288-292. SMITH P J and JONES B M (1985). Care of the acutely injured hand. British Medical Journal, 290: 178-179. TEASDALE G and JENNETT B (1974). Assessment of coma and impaired consciousness: a practical scale. Lancet, 2: 81-84. T O N K I N M (1992). H a n d surgery: The skin and its contents. Journal of Hand Surgery, 17B: 381-382.
References
Accepted: 11 December 1995 S P J Kay, Department of Plastic, Reconstructive and Hand Surgery, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK.
A N D E R S O N I D, W O O D F O R D M, DE D O M B A L F T and IRVING M
© 1996 The British Society for Surgery of the Hand
From the Departments of Orthopaedic Surgery and Plastic, Reconstructive and Hand Surgery, St James's University Hospital, Leeds, UK
A descriptive severity scoring system for injuries to the hand, distal to the carpus, has been designed. Each ray of the hand is assessed separately. Each ray's score is then multiplied by a ~veighting factor for that ray and added to the scores of the other rays to obtain a total score for the injury. This system has been tested on a series of specimen injuries and compared with the opinion of experienced hand surgeons. A retrospective study of hand injuries has also been conducted, and the Hand Injury Severity Score ( H I S S ) has been found to closely correlate with return to work. Four grades of increasing severity of hand injury have been described. Although this system has been designed as a research tool, it is envisaged that it would be a useful immediate measure of severity and a guide to likely outcome.
Journal of Hand Surgery (British and European Volume, 1996) 21B." 3:295-298 Scoring systems have been successfully employed for many years in the management of trauma (Baker et al, 1974). The information which is provided is invaluable when assessing prognosis, but can also give an important measure for auditing the allocation and performance of health services (Boyd et al, 1987; Anderson et al, 1988). Hand injuries form a regular part of the workload of all accident and emergency departments (Clark et al, 1985; Packer and Shaheen, 1993) and have a major economic impact because they can dramatically affect the ability to carry out useful employment (Smith et al, 1985; O'Sullivan and Colville, 1993). The education and training of hand surgeons in the UK is traditionally via either a "Plastic" or "Orthopaedic" route (Tonkin, 1992) and consequently more emphasis may be unwittingly placed on those aspects of hand injury particular to the mother specialty. It is essential when assessing a hand injury to look at the entire organ and all its constituent components. This scoring system for hand injuries allows all types of injury to be classified and thus compared for severity.
absolute values which require no further modification. The absolute values apply in areas where assignation to a particular ray would not be possible, (e.g. the motor branches of median and ulnar nerves, and skin loss on the dorsal and palmar aspects of the metacarpals). A reference sheet (Fig 1) detailing the ISMN score is completed for each ray. These values are used to fill in the overall scoring chart (Fig2), and a final Hand Injury Severity Score (HISS) is obtained. Modifications to allow for appropriate scoring of contaminated wounds have been added to the Integument and Skeletal categories. If a wound is crushed, dirty or contaminated or in any way different from a clean incised wound, the Integument score should be doubled. Similarly, if a Skeletal injury is open, this value should also be doubled. A fracture which is both open and contaminated will therefore receive appropriate points by doubling both the Integument and Skeletal values. Both of these modifications should take place before multiplying by the weighting factor. Amputations should take all damaged structures into account, as in any other injury.
MATERIALS AND METHODS System validation
System development
Although points for specific injuries were awarded in a controlled and considered fashion, their actual values were regarded as arbitrary until satisfactorily validated. The system was validated in two ways. Five specimen hand injuries (Table 2) containing a mixture of soft tissue and bony cases, were produced and mailed to 25 experienced hand surgeons in the UK.
The separate anatomical components of the hand distal to the carpus were divided into the broad constituent categories of: integument, skeletal, motor and neural (ISMN). Each category wgs examined in detail to cover all possible injury patterns, and each specific injury was assigned a value based on its notional importance. Each ray should be separately examined for injury in the four ISMN categories. After this examination, the total ISMN score is multiplied by a weighting factor for that particular ray (Table 1), since the same injury in different rays can be regarded as more severe in the functionally more important ray. In each ISMN category there are two types of points to be scored. There are those which must be multiplied by the weighting factor for that ray, and those assigned
Table 1--The individual digit weighting factors
Digit Thumb Index Long Ring Little
295
Weightingfactor x x x x x
6 2 3 3 2
296
THE JOURNAL OF HAND SURGERY VOL. 21B No. 3 JUNE 1996
INTEGUMENT INTEGUMENT
Skin loss
Absolute values (hand)."
< 1 cm 2 > 1 cm 2 > 5 cm z
5 10 20
Palm
Dorsum x 2
....
Dorsum
< > < >
Dorsum
SKELETON
I
THUMB
L I
INDEX
Weighted values (digit):
Pulp
1 cm 2 1 cm 2 25% 25%
2 3 3 5
MOTOR
I[
NEUROLOGICAL
TOTAL
[
xO.
]
×2.
LONG
x3-
RING
xS-
LITTLE
Skin laceration < 1 cm l > 1 cm 2 (If, extends across more than one ray, include in both rays score)
FINALSEVEa~rY SCORE Fig 2
The Hand Injury Severity Scoring chart.
Nail. damage Table 2--Five specimen hand injuries
SKELETAL
Fractures
Dislocations Ligament injury
Simple shaft Comminuted shaft Intraarticular DIPJ Intraarticular PIPJ/IPJ of thumb Intraarticular MCPJ
1 2 3 5 4
Open
4
Closed
2
Sprain Rupture
2 3
MOTOR Extensor tendon Flexor profundus
Proximal to PIPJ Distal to PIPJ Zone 1 Zone 2 Zone 3
Flexor superficialis Intrinsics
1 3 6 6 5
5 2
NEURAL
Absolute values
Recurrent branch median nerve Deep branch ulnar nerve
Weighted values
Digital nerve x 1 Digital nerve x 2
Fig 1
30 30 3 4
The injury scoring system.
Table 2 gives the broad type of injury described, but not the exact details of that specimen injury. The surgeons were instructed to rate these injuries in order of severity, 1 to 5, with 1 being the most severe. The information given to them was that the injury had been sustained by a male blue collar worker in his thirties. No information was given on side of injury or dominance. These opinions from experienced colleagues were then collated and compared with the results which would have been achieved by using the Scoring System. A level of significance was obtained using a Z2 test. Several minor modifications were then made to the HISS, so that the
Case
Injuries
A B C D E
Minor Minor Major Major Minor
bony injury soft tissue injury bony injury soft tissue injury fingertip amputation
(Only broad type of injury is specified here)
results using the HISS concurred with the "gold standard" of experienced surgical opinion. The modified HISS was then applied retrospectively to 100 consecutive hand injuries in patients under 50 years of age who had presented to the Regional Hand Service. The aim was to compare the amount of time off work with the HISS, to see if the more severe injuries (as described by the H I S S ) t o o k longer to return to work. Spearman's rank correlation coefficient was used to assess the relationship between severity of injury (HISS) and time off work. RESULTS Specimen cases
Twenty-four replies were received from 25 letters sent. One reply was spoilt, giving 23 replies for analysis, a response rate of 92%. The "votes cast" were collated (Table 3) and a clear picture emerged of the opinions Table 3--Votes cast for specimen hand injuries Ranking
1
2
3
4
5
Case Case Case Case Case
0 0 8 15 0
0 1 14 8 0
2 18 1 0 2
11 3 0 0 9
10 1 0 0 12
A B C D E
(l=Most severe; 5=Least severe)
INJURY SEVERITY SCORE
297 Table 5--Patient study group
2oVo~s
Case D
i(h
1st
Ranking
~d
4-- --5"--
20Votes
2nd
Case C
20 TM
3rd
Case B
Votes
10
1
2
3
4
Case A
4th =
Case E
4th =
5
2 0 Vows
No. of patients Mean age (range) M : F ratio Dominant hand injuries Mean follow up (range) Mean time off work (range) HISS mean (range)
48 31 yrs (21 47) 41 : 7 28 (58%) 17.6 weeks (6-58) 8.8 weeks (0 52) 21 points (6-80)
Retrospective patient study One hundred consecutive hand injuries in individuals of working age were analysed. Forty-eight of these patients were traced and interviewed (48%) (Table 5). Forty-two were classed as semi-skilled workers. A scatter diagram of HISS against number of weeks before return to work was constructed (Fig 4). Using Spearman's rank correlation coefficient, a coefficient of 0.57 was obtained. With a sample size of 48, a significant relationship between HISS and time off work was noted (P 40.002). There were 32 patients with a HISS of less than 20 points, (Fig 4); 27 of them (84%) were fit to return to work after 8 weeks. There were 16 patients with a HISS greater than 20 points and of these only six (38%) were fit for work after 8 weeks. Using these results, a HISS of below 20 points can be regarded as an injury of "Minor" severity. It is suggested that all injuries with a HISS between 21 and 50 be assigned to the "Moderate" category. A HISS between 51 and 100 is "Severe", and 101 and above is "Major" (Table 6). !
DISCUSSION Fig 3
Results of peer ranking of five specimen hand injuries.
of experienced hand surgeons on these cases (Fig 3). Case D was widely seen as being the most severe, with 15 votes (63%) (P<0.001). The ranking of these cases differed slightly from the ranking produced by the original HISS (which was developed from values regarded as arbitrary). The HISS was revised by increasing the weighting factors for thumb and index rays, and by adjusting the values of simple shaft fractures and tendon division, to give values which were comparable to the survey results (Table 4). Table 4--Relationship of specimen cases to HISS showing effects of score modification
Severity ranking 1 2 3 4 5
Surgeon survey D C B A/E A/E
HISS (original) D C A E B
(123 pts) (92 pts) (30 pts) (25 pts) (21 pts)
HISS (revised) D C B A E
(176 pts) (107 pts) (42 pts) (35 pts) (25 pts)
Scoring systems are now well established in the management of trauma. Systems such as the Injury Severity Score (ISS; Baker et al, 1974) and the Glasgow Coma Scale (GCS; Teasdale and Jennett~ 1974) have now been in use for over 20 years, and play a major role in predicting outcome. In the hand, scoring systems can either be functional or descriptive. Many different factors must be considered in a functional system, such as handedness, occupation, treatment and the patient's psychological profile. A descriptive system merely outlines the exact structural damage at the time of injury. At present this has no direct bearing on prognosis but may ultimately yield such information after the audit of large numbers of hand injuries. Table 6 - - T h e grading of severity of hand injury
Grade
HISS (pts)
I Minor II--Moderate III-- Severe IV--Major
< 20 21 50 51- 100 > 100
298
T H E J O U R N A L OF H A N D SURGERY VOL. 21B No. 3 JUNE 1996 HISS
100
80
60
40 i
20
--
-'l--"41-'-
1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
i
•
0
m
i i i
]
I
~
p
10
20
30
40
I
50 Time
Fig 4
i
off
work
60 (weeks)
Scatter diagram of HISS against time off work.
The Hand Injury Severity Scoring system is a descriptive system which is of help in grading injuries into broad categories, such as Minor, Moderate, Severe and Major. This allows all types of hand trauma to be compared, like with like, with regard to severity. Inevitably, it will be functional assessments which validate descriptive systems and these take time to verify. However an accurate descriptive scoring system allows hand injuries to be broadly categorized immediately after injury, and so helps with decisions about further referral and resource management. The acute care and assessment of an injured hand is an important first step towards a successful outcome (Smith and Jones, 1985). Use of this system will ensure that a thorough assessment is made by all personnel involved in the care of hand trauma, including the most inexperienced. This Hand Injury Severity Scoring System is the first stage in the evolution of a quantitative measurement of hand trauma.
(1988). A retrospective study of 1,000 deaths from injury in England and Wales. British Medical Journal, 296:1305 1308. B A K E R S P, O ' N E I L L B, H A D D O N W and L O N G W B (1974). The injury severity score: a method for describing patients with multiple injuries and evaluating care. Journal of Trauma, 14: 187-196. BOYD C R, TOLSON M A and COPES W S (1987). Evainating trauma care: the TRISS method. Journal of Trauma, 27:370 378. C L A R K D P, SCOTT R N and A N D E R S O N I W R (1985). Hand problems in an accident and emergency department. Journal of H a n d Surgery, 10B: 297-299. O'SULLIVAN M E and COLVILLE J (1993). The economic impact of hand injuries. Journal of H a n d Surgery, 18B: 395-398. PACKER G J and S H A H E E N M A (1993). Patterns of hand fractures and dislocations in a district general hospital. Journal of Hand Surgery, 18B: 5ll-514. SMITH M E, AUCH1NLOSS J M and ALI M S (1985). Causes and consequences of hand injury. Journal of H a n d Surgery, 10B: 288-292. SMITH P J and JONES B M (1985). Care of the acutely injured hand. British Medical Journal, 290: 178-179. TEASDALE G and JENNETT B (1974). Assessment of coma and impaired consciousness: a practical scale. Lancet, 2: 81-84. T O N K I N M (1992). H a n d surgery: The skin and its contents. Journal of Hand Surgery, 17B: 381-382.
References
Accepted: 11 December 1995 S P J Kay, Department of Plastic, Reconstructive and Hand Surgery, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK.
A N D E R S O N I D, W O O D F O R D M, DE D O M B A L F T and IRVING M
© 1996 The British Society for Surgery of the Hand