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The spectrum of hand injuries
The Spectrum of Hand ln]uries--D. H. Edwards
THE SPECTRUM
OF HAND
INJURIES
D. H. E D W A R D S , Oxford This paper presents an analysis of the patients with hand injuries attending the Accident Service at the Radcliffe Infirmary, Oxford. The purpose of the study was to assess the size and nature of the problem and so to assist in planning the service needs in this area, which has an estimated population of 445,000 (Edwards and Scott, 1971). Two periods of one month each, in summer and in winter, were chosen for study. 1,071 patients were registered as attending with hand injuries in this time. The notes of four out-patients were not traced after a thorough search for them had been made. On review of the notes, 141 patients had injuries of the wrist joint or carpal bones and these were excluded. There remained 926 patients available for study. Three months after injury they were sent a postal questionnaire to determine the incidence of persistent symptoms, and to assess time lost from work. Replies were received from 596 patients, of whom 318 were in employment at the time of their injury. CAUSES OF INJURY
The survey included hand injuries of all degrees of severity, no matter how trivial or severe, which the patient or his general practitioner considered to need hospital treatment. Half the injuries were caused by accidents which do not fit in to other categories. The next largest group were injuries due to accidents at work, which were responsible for 21%; accidents in the home caused 14%, sports 8%, road accidents 4% and agricultural accidents 3% of injuries. TYPES OF INJURY
The types of injury which occurred are summarised in Table 1. Soft tissue injuries in which the skin was broken--including clean cuts, untidy lacerations and compression injuries--accounted for 41%. Other soft tissue injuries in which the skin was intact--dislocations, sprains and contusions--were the next largest group (23%). Fractures, both closed and compound, occurred in 19%. Foreign bodies, bites, burns and hand infections accounted for the remainder. The age and sex incidence are shown in Fig. 1. In both sexes there were many injuries in the working age-group. Males predominated by 2.2 to 1. TABLE I
TYPES OF INJURY Cuts, lacerations, and "bursting" injuries ... Dislocations, sprains and contusions . . . . . . Fractures ............... Foreign bodies . . . . . . . . . . . . . . . Bites .................. Burns .................. Primary hand infections ......... 46
41% 23% 19% 6% 5% 3% 3%
The H a n d - - V o l . 7
No. 1
1975
The Spectrum of Hand Injuries--L). H. Edwards 926 H&NI3ITIjU~IES i00
~"
5O
0
0
0
0
5
6
7
;,A>//W>TY,
80
90
Fig. 1. Age and sex graph.
'
f
'~ 0\
i
/
~\
Fig. 2. Sites of fracture.
DO~NA]qT
Fig. 3. Sites of soft tissue wounds.
SITES OF I N J U R Y , A N D H A N D
DOMINANCE
90% of the patients were right-handed, 9% left-handed, 1% said they were ambidextrous. Overall, the dominant hand appeared to be injured slightly more often than the non-dominant hand, though the difference was not statistically significant (Table 2). The numbers of fractures of the metacarpals and phalanges followed the same trend, there being more fractures in the dominant hand; the sites of fractures are shown in Figure 2. The soft tissue wounds were distributed differently, there being more injuries in the non-dominant index and thumb; whereas the dominant middle finger was the more prone to injury (Fig. 3). EFFECTS OF I N J U R Y
The effects of hand injuries may be considered from the point of view of the hospital, the individual patient, or his place of work, (1) T h e Hospital The total number of attendances of all these patients at all clinics are indicated iri Table III. Separate clinics are held for the more complex hand injuries, for burns, and for infections since special facilities are required to deal with them. I t is'noteworthy, though, that the soft tissue injuries result in a larger number of attendances than all these special groups put together. The average The Hand--Vol. 7
No. 1
1975
47
The Spectrum of Hand lnjuries--D. H. Edwards TABLE 11
Dominant ... Non-dominant Both Hands
All Injuries
Fractures
305 (52.2%) 274 (47.0%)
58 (60%) 41 (40%)
5 (0.8%) T A B L E III
ATTENDANCES Total attendances
Tidy cut ... ...... Untidy laceration . . . . . . Crush ... ...... Other soft tissue . . . . . . Fracture ......... Infection ........ Burn . . . . . . . . . . . . Foreign body ...... Bite . . . . . . . . . . . .
,
TOTAL
223 259 166 267 336 158 89 70 62 1,630
Average number o/ attendances per patient
1.7 1.6 1.6 1.0 2.4 3.0 3.4 1.25 1.2 1.7
number of attendances per patient, taken overall, is 1.7. Fractures, infections and burns require more visits per patient than the other groups. (2) T h e Place o f W o r k The economic effects of hand injuries are considerable. Several assessments have been made of the effects of severe hand injuries, for example the studies of Wilkes (1956); Gardner, Goodwill and Bridges (1968); Goldwyn and Day (1969); and Rank, Wakefield and Hueston (1973). In this survey a deliberate attempt was made to assess the overall time lost from work by all patients with hand injuries which were bad enough to require hospital treatment, whether as inpatients or outpatients; the trivial injuries are included as well as the severe ones. The results are shown in Table IV. The overall average time away from work was just over one week. Tidy skin wounds kept the patient off work for about half this time, and fractures for about twice this time. (3) T h e Patients" Residual S y m p t o m s Part of the questionnaire asked the patient to state if he was suffering any residual symptoms three months after injury. In Fig. 4, the proportions of patients who replied to the follow-up letter are shaded, and the proportions who had symptoms are shown in the solid bars. It could be argued that the patients who had symptoms would be more likely to return the questionnaire than those who did not. However, the presence of symptoms was not the only question asked, and a high proportion of patients replied to report that they had no symptoms. Nevertheless, it is striking that no fewer than 30% of the patients experience symptoms three months later. One would expect those with fractures to do so--43% of this group had persistent symptoms, stiffness and pain being the commonest complaints. The fact that one-third of the patients with simple 48
The Hand--Vol. 7
No. 1
1975
The Spectrum of Hand lnjuries--D. H, Edwards SYMPTOMSAT 3 MONTHS
UNTIDY
\\'~,\\\,"-.~ "~.'%"X\.]
TIDY CRUSH
i\\\
SPLINTER RITE
E~'-\I
FRACTURE ~
I
-
'
\
INFECTION m \ \ \ l BURN OTHER
I
\N
I
~ i
|"-.'q I
\\\\1
\\\\\
[
I
O
I
100
20O
PERSISTANT SYMPTOMS ~ ~
REPLIEDTO QUESTIONNAIRE "
RQ REPLIES TO QUESTIONNAIRE
Fig. 4. Persistent symptoms. T A B L E IV
TIME OFF WORK
Tidy. cut ......... Laceration ......... Crush ...... Other soft tissue'-.. . . . . Fracture ......... Infection ......... Burn ............ Other . . . . . . . . . . . . TOTAL
Total Working days lost
Days off per worker
164 427 249 381 72t 147 154 125
4 5.7 7.6 7.1 13.4 7.0 7.7 7.0
2,368
Average: 7.5
tidy cuts still have trouble at this time was an u n e x p e c t e d finding; half of t h e m complained of numbness and half of t h e m had tenderness in the scar, which suggests that the cutaneous nerves m a y be divided m o r e often than is recognised. I n only five of the patients in this group, was nerve injury detected at the time of injury. One particular group of patients is of interest. These are people with injuries which the casualty officer did not consider needed to be seen again at follow-up clinics, and who were discharged to the c a r e of their general practitioners after a single visit to the A c c i d e n t Service. T h e r e were 86 such patients in the series w h o replied to the questionnaire, and 14.4% of t h e m still had s y m p t o m s three m o n t h s later. Most of these were in the miscellaneous g r o u p of soft tissue injuries which included sprains and dislocations of the m e t a c a r p o p h a l a n g e a l and interphalangeal joints. SUMMARY
(1) A survey is presented of all injuries of the h a n d presenting to an A c c i d e n t Service working in a c a t c h m e n t area of 445,000 people. The Hand--Vol. 7
No. 1
1975
49
The Spectrum o[ Hand lniuries--D. H. Edwards
(2) In this area, provision needs to be made for the treatment of 6,000 patients with hand injuries each year." (3) These patients require 9,000 attendances at the Accident Service and its related clinics. (4) 2,700 of these patients are in employment at the time of injury, and the average time away from work as a result of injury is 1 week. (5) Three months after injury, 30% of these patients still have symptoms relating to their accident. ACKNOWLEDGEMENTS
I would like to thank Mr. J. C. Scott and the surgeons of the Accident Service at the Radcliffe Infirmary, Oxford, for permission to study patients in their care, and Mrs. Olive Kingsworth for secretarial help. REFERENCES
EDWARDS, D. H. and SCOTT, J. C. (1971) Work Load and Medical Staffing in an Accident Service. Injury, 2: 199-204. GARDNER, D. C., GOODWILL, C. J., and BRIDGES, P. K. (1968) (a) Absence from Work after Fracture of the Wrist and Hand. Journal of Occupational Medicine, 10: 114-117. (b) Cost of Incapacity Due to Fractures of the Wrist and Hand. Journal of Occupational Medicine, 10: 118-120. GOLDWYN, R. M., and DAY, L. H. (1969) Acute Industrial Hand Injuries: A Socio-Medical Study. Plastic and Reconstructive Surgery, 44: 567. RANK, B. K. WAKEFIELD, A. R., and HUESTON, J. T. (1973) Surgery of Repair as applied to Hand Surgery. Edinburgh. Churchill Livingstone. WILKES, R. (1956) A Social and Occupational Study of Injured Hands. British Journal of Industrial Medicine, 13: 119-130.
50
"1he H a n d - - V o l . 7
No. 1
1975
THE SPECTRUM
OF HAND
INJURIES
D. H. E D W A R D S , Oxford This paper presents an analysis of the patients with hand injuries attending the Accident Service at the Radcliffe Infirmary, Oxford. The purpose of the study was to assess the size and nature of the problem and so to assist in planning the service needs in this area, which has an estimated population of 445,000 (Edwards and Scott, 1971). Two periods of one month each, in summer and in winter, were chosen for study. 1,071 patients were registered as attending with hand injuries in this time. The notes of four out-patients were not traced after a thorough search for them had been made. On review of the notes, 141 patients had injuries of the wrist joint or carpal bones and these were excluded. There remained 926 patients available for study. Three months after injury they were sent a postal questionnaire to determine the incidence of persistent symptoms, and to assess time lost from work. Replies were received from 596 patients, of whom 318 were in employment at the time of their injury. CAUSES OF INJURY
The survey included hand injuries of all degrees of severity, no matter how trivial or severe, which the patient or his general practitioner considered to need hospital treatment. Half the injuries were caused by accidents which do not fit in to other categories. The next largest group were injuries due to accidents at work, which were responsible for 21%; accidents in the home caused 14%, sports 8%, road accidents 4% and agricultural accidents 3% of injuries. TYPES OF INJURY
The types of injury which occurred are summarised in Table 1. Soft tissue injuries in which the skin was broken--including clean cuts, untidy lacerations and compression injuries--accounted for 41%. Other soft tissue injuries in which the skin was intact--dislocations, sprains and contusions--were the next largest group (23%). Fractures, both closed and compound, occurred in 19%. Foreign bodies, bites, burns and hand infections accounted for the remainder. The age and sex incidence are shown in Fig. 1. In both sexes there were many injuries in the working age-group. Males predominated by 2.2 to 1. TABLE I
TYPES OF INJURY Cuts, lacerations, and "bursting" injuries ... Dislocations, sprains and contusions . . . . . . Fractures ............... Foreign bodies . . . . . . . . . . . . . . . Bites .................. Burns .................. Primary hand infections ......... 46
41% 23% 19% 6% 5% 3% 3%
The H a n d - - V o l . 7
No. 1
1975
The Spectrum of Hand Injuries--L). H. Edwards 926 H&NI3ITIjU~IES i00
~"
5O
0
0
0
0
5
6
7
;,A>//W>TY,
80
90
Fig. 1. Age and sex graph.
'
f
'~ 0\
i
/
~\
Fig. 2. Sites of fracture.
DO~NA]qT
Fig. 3. Sites of soft tissue wounds.
SITES OF I N J U R Y , A N D H A N D
DOMINANCE
90% of the patients were right-handed, 9% left-handed, 1% said they were ambidextrous. Overall, the dominant hand appeared to be injured slightly more often than the non-dominant hand, though the difference was not statistically significant (Table 2). The numbers of fractures of the metacarpals and phalanges followed the same trend, there being more fractures in the dominant hand; the sites of fractures are shown in Figure 2. The soft tissue wounds were distributed differently, there being more injuries in the non-dominant index and thumb; whereas the dominant middle finger was the more prone to injury (Fig. 3). EFFECTS OF I N J U R Y
The effects of hand injuries may be considered from the point of view of the hospital, the individual patient, or his place of work, (1) T h e Hospital The total number of attendances of all these patients at all clinics are indicated iri Table III. Separate clinics are held for the more complex hand injuries, for burns, and for infections since special facilities are required to deal with them. I t is'noteworthy, though, that the soft tissue injuries result in a larger number of attendances than all these special groups put together. The average The Hand--Vol. 7
No. 1
1975
47
The Spectrum of Hand lnjuries--D. H. Edwards TABLE 11
Dominant ... Non-dominant Both Hands
All Injuries
Fractures
305 (52.2%) 274 (47.0%)
58 (60%) 41 (40%)
5 (0.8%) T A B L E III
ATTENDANCES Total attendances
Tidy cut ... ...... Untidy laceration . . . . . . Crush ... ...... Other soft tissue . . . . . . Fracture ......... Infection ........ Burn . . . . . . . . . . . . Foreign body ...... Bite . . . . . . . . . . . .
,
TOTAL
223 259 166 267 336 158 89 70 62 1,630
Average number o/ attendances per patient
1.7 1.6 1.6 1.0 2.4 3.0 3.4 1.25 1.2 1.7
number of attendances per patient, taken overall, is 1.7. Fractures, infections and burns require more visits per patient than the other groups. (2) T h e Place o f W o r k The economic effects of hand injuries are considerable. Several assessments have been made of the effects of severe hand injuries, for example the studies of Wilkes (1956); Gardner, Goodwill and Bridges (1968); Goldwyn and Day (1969); and Rank, Wakefield and Hueston (1973). In this survey a deliberate attempt was made to assess the overall time lost from work by all patients with hand injuries which were bad enough to require hospital treatment, whether as inpatients or outpatients; the trivial injuries are included as well as the severe ones. The results are shown in Table IV. The overall average time away from work was just over one week. Tidy skin wounds kept the patient off work for about half this time, and fractures for about twice this time. (3) T h e Patients" Residual S y m p t o m s Part of the questionnaire asked the patient to state if he was suffering any residual symptoms three months after injury. In Fig. 4, the proportions of patients who replied to the follow-up letter are shaded, and the proportions who had symptoms are shown in the solid bars. It could be argued that the patients who had symptoms would be more likely to return the questionnaire than those who did not. However, the presence of symptoms was not the only question asked, and a high proportion of patients replied to report that they had no symptoms. Nevertheless, it is striking that no fewer than 30% of the patients experience symptoms three months later. One would expect those with fractures to do so--43% of this group had persistent symptoms, stiffness and pain being the commonest complaints. The fact that one-third of the patients with simple 48
The Hand--Vol. 7
No. 1
1975
The Spectrum of Hand lnjuries--D. H, Edwards SYMPTOMSAT 3 MONTHS
UNTIDY
\\'~,\\\,"-.~ "~.'%"X\.]
TIDY CRUSH
i\\\
SPLINTER RITE
E~'-\I
FRACTURE ~
I
-
'
\
INFECTION m \ \ \ l BURN OTHER
I
\N
I
~ i
|"-.'q I
\\\\1
\\\\\
[
I
O
I
100
20O
PERSISTANT SYMPTOMS ~ ~
REPLIEDTO QUESTIONNAIRE "
RQ REPLIES TO QUESTIONNAIRE
Fig. 4. Persistent symptoms. T A B L E IV
TIME OFF WORK
Tidy. cut ......... Laceration ......... Crush ...... Other soft tissue'-.. . . . . Fracture ......... Infection ......... Burn ............ Other . . . . . . . . . . . . TOTAL
Total Working days lost
Days off per worker
164 427 249 381 72t 147 154 125
4 5.7 7.6 7.1 13.4 7.0 7.7 7.0
2,368
Average: 7.5
tidy cuts still have trouble at this time was an u n e x p e c t e d finding; half of t h e m complained of numbness and half of t h e m had tenderness in the scar, which suggests that the cutaneous nerves m a y be divided m o r e often than is recognised. I n only five of the patients in this group, was nerve injury detected at the time of injury. One particular group of patients is of interest. These are people with injuries which the casualty officer did not consider needed to be seen again at follow-up clinics, and who were discharged to the c a r e of their general practitioners after a single visit to the A c c i d e n t Service. T h e r e were 86 such patients in the series w h o replied to the questionnaire, and 14.4% of t h e m still had s y m p t o m s three m o n t h s later. Most of these were in the miscellaneous g r o u p of soft tissue injuries which included sprains and dislocations of the m e t a c a r p o p h a l a n g e a l and interphalangeal joints. SUMMARY
(1) A survey is presented of all injuries of the h a n d presenting to an A c c i d e n t Service working in a c a t c h m e n t area of 445,000 people. The Hand--Vol. 7
No. 1
1975
49
The Spectrum o[ Hand lniuries--D. H. Edwards
(2) In this area, provision needs to be made for the treatment of 6,000 patients with hand injuries each year." (3) These patients require 9,000 attendances at the Accident Service and its related clinics. (4) 2,700 of these patients are in employment at the time of injury, and the average time away from work as a result of injury is 1 week. (5) Three months after injury, 30% of these patients still have symptoms relating to their accident. ACKNOWLEDGEMENTS
I would like to thank Mr. J. C. Scott and the surgeons of the Accident Service at the Radcliffe Infirmary, Oxford, for permission to study patients in their care, and Mrs. Olive Kingsworth for secretarial help. REFERENCES
EDWARDS, D. H. and SCOTT, J. C. (1971) Work Load and Medical Staffing in an Accident Service. Injury, 2: 199-204. GARDNER, D. C., GOODWILL, C. J., and BRIDGES, P. K. (1968) (a) Absence from Work after Fracture of the Wrist and Hand. Journal of Occupational Medicine, 10: 114-117. (b) Cost of Incapacity Due to Fractures of the Wrist and Hand. Journal of Occupational Medicine, 10: 118-120. GOLDWYN, R. M., and DAY, L. H. (1969) Acute Industrial Hand Injuries: A Socio-Medical Study. Plastic and Reconstructive Surgery, 44: 567. RANK, B. K. WAKEFIELD, A. R., and HUESTON, J. T. (1973) Surgery of Repair as applied to Hand Surgery. Edinburgh. Churchill Livingstone. WILKES, R. (1956) A Social and Occupational Study of Injured Hands. British Journal of Industrial Medicine, 13: 119-130.
50
"1he H a n d - - V o l . 7
No. 1
1975