- Email: [email protected]
Time off work after hand injury
IWv.
12.417-424
417
Printedin GreatBritain
Time off work after hand injury A. M. Johns Department
of Orthopaedics and Traumatology, Cardiff Royal Infirmary
Summary
The aim of the present study is to identify the principal factors which determine time off work following hand injury. Information was obtained from a series of 182 cases drawn from the genera1 population, with a broad spectrum of injuries of all degrees of severity. Median time off work for the series was 3 weeks: one third of the cases had no time off work, one third were off work for up to 6 weeks and one third for over 6 weeks. Certain types of injury were associated with long periods off work, particularly those involving nerve and tendon damage, or traumatic amputation of digits. Time off work, however, was more closely related to the severity than to the type of injury. Injuries to dominant hands were common in patients off work for over 6 weeks. Errors of treatment delayed return to work in only 4 per cent of cases. Morbidity was related to time off work, but it seemed to depend mainly on the severity of the injury. Manual workers stay off work for considerably longer than other workers; this is the case whether one considers all injuries or only those of comparable severity. The pursuit of compensation claims is much more common among manual workers, and is associated with a significant increase in time off work. Its incidence is related more to the circumstances of injury than to the morbidity which results. Even if one considers workers with no compensation claims and with injuries of comparable severity, there is still a significant difference in time off work between manual and other workers. This is probably due to the greater physical demands of most manual jobs. It is concluded that the major factors determining time off work are: The nature and severity of injury. The pursuit of compensation claims. The physical demands ofthe patient’s work. INTRODUCTION
EVERYyear between
3 and 4 million working days are lost as a result of hand injuries (DHSS,
personal
communication).
Those
injuries
account for nearly a quarter of the periods off work for which injury benefit is claimed (Rank and Wakefield, 1953; HMSO, 1974). During the year 197415 the cost to the taxpayer in sickness, injury and invalidity benefit was in the region of ten million pounds at the rates then current (HMSO, 1974). In addition to these costs borne by the exchequer, one has to consider sick pay, compensation payments and loss of productive capacity, borne by the employer, and loss of earnings to the employee. The last figure varies according to circumstances. In their study of the cost of incapacity due to fractures of the wrist and hand, Gardner et al. (1968) found an average total loss to the patient of f54. It can be imagined how this sum has increased in the interim. All these costs are proportionate to the period of time off work. It is therefore relevant to identify those factors which determine its duration, and to consider whether they can be modified in any way, so as to reduce both the cost and the inconvenience of the injury to all concerned. In their study, Gardner et al. (1968) found that personal, psychological and social factors were less important in delaying return to work than had been commonly supposed. They stressed the importance of the type of injury, the presence of complications and the physical demands of the patient’s job in prolonging time off work. Goldwyn and Day (1969) reviewed a large series of hand injuries of lesser severity, and they also found that time off work was related more to the nature of the injury than to personal factors. The present study is based on a comprehensive range of hand injuries, of all degrees of
Injury: the British Journal of Accident Surgery Vol. 1 Z/No.
418
5
severity. It considers the nature of the injuries, their treatment, the resulting morbidity, the occupation of the patient and the effect of compensation claims. No attempt has been made to assess the psychological state of the patients, nor to detail their financial loss. The aim is to identify the principal factors which determine the duration of time off work after hand injury. PATIENTS
AND
METHODS
The series under study comprised 198 patients with hand injuries treated by the Trauma Service in the Cardiff Royal Infirmary, between 1972 and 1974. Information on time off work was available in 182 cases. The patients had an age range of IO-65 years, and included 27 children at schools. The ratio of male to female was 4 : 1. The principal occupational groups were as follows: 55% Manual workers 21% Clerical/professional workers 15% School children Other workers 9% The term ‘manual worker’ corresponds with ‘blue-collar worker’, whereas the ‘clerical/professional’ group corresponds with ‘white-collar worker’. It should be remembered that not all injuries occur at work: in fact the circumstances of injury were as follows: 42% At work In public places 36% 22% At home The ‘public’ group includes sporting injuries, assaults and road traffic accidents. The range of injuries includes all the common types encountered, except bums, which were treated elsewhere. It also includes wounds of the wrist, which were of special interest to the author, but not fractures of the wrist. Simple wounds are under represented, since many of these are never referred to the Trauma Service. Former patients were identified through the records system, and were summoned by post to attend special review clinics. On attendance, a detailed history was taken, embracing the following points: nature and extent of injury; nature and duration of treatment; morbidity (including complications, persistent symptoms and loss of function); compensation claims and time off work. In recognition of the ultimate importance of function, morbidity has been assessed on the basis of functional deficits persisting to the time of examination. For the sake of simplicity, five basic functions have been considered: power
0
O-3
3-6
6-9
9-12
>I2
Weeks Time off work Median time off warlc 3wks. Mean time aff wak: 7.9wks
Fig. 1. Time off work results for the whole series.
grip; precision grip; sensation; finger mobility; wrist mobility. The resulting score of persistent functional deficits (PFD) varies from zero to a maximum of five. As can be seen from Fig. 5, there is a general relationship between the PFD score and the severity of injury, but the same score may be found following injuries of all degrees of severity. The severity of injury was assessed according to the criteria shown in Table I. RESULTS
The incidence of time off work for the whole series is shown in Fig. 1. It will be seen that approximately one third had no time off work, a third were off work for up to 6 weeks, and a third for over 6 weeks. The median time off work for the whole series was 3 weeks. Type and severity of injury
In Fig. 2 the series is broken down into the types of injury encountered, with distinctive markings to indicate the severity of each injury. If we group injuries by their severity we can plot the percentage of each group off work at various times after injury (see Fig. 3). The correlation between severity of injury and time off work is clearly shown in the three groups. Dominance
If we compare injuries to dominant and nondominant hands in the same way (see Fig. 4), we find that the percentages off work at 6 weeks are very similar. Thereafter, the percentage of dominant hands is somewhat greater. This is probably because the dominant group contains more moderate and fewer trivial injuries than the non-dominant group (see Table ZZ).
419
Johns:Time off Work
Fig. 2. Time off work with various types of injury. 0, trivial; 0, moderate;
severe.
Table/. Classification of injuries by severity Severity
Type of injury
Trivial
Closed dislocations of I P or M P joints Mallet fmgers Fractures of the neck of the fifth metacarpal Other fractures of phalanges or metacarpals without displacement Uncomplicated wounds
Moderate
Displaced fractures into IP or MP joints Bennett’s fracture Open injuries of IP joints Comminuted or displaced fractures of phalanges and metacarpals (including less severe compound fractures). Traumatic amputation affecting the terminal phalanx Solitary flexor tendon injury Solitary nerve injury Extensor tendon injuries (excepting mallet fmger)
Severe
Multiple fractures of phalanges or metacarpals. The more severe open fractures Severe wounds involving several flexor tendons and/or nerves Traumatic amputation of whole or multiple digits.
0,
420
Injury:the British Journal of Accident Surgery Vol. 1~/NO. 5 loo-
60‘ xofwhpmg OH wwk
60. K ofeachgmp off work
40
40’
Sewe
0
3
6 keks
Fig.
9
12
26
20.
Fig. 4. Time off work related to dominance.
after injury
3. Time off work related to severity of injury.
Tab/e //. Severity of injury related to dominance
Dominant Non-dominant
Trivial (%I
Moderate (%I
Severe (%I
33 46
2
6 5
Treatment
There were 13 cases in which the initial treatment could be judged inappropriate, but in only 3 cases did this delay return to work. These cases were: an unrecognized open injury to the distal interphalangeal joint; an unrecognized fracturedislocation of a proximal interphalangeal joint and an animal bite of an index finger which was primarily sutured and became infected. Repeated operation delayed return to work in 5 cases, 3 secondary amputations of non-viable digits and 2 revisions of unsuccessful tendon repairs. One of the latter underwent six procedures in all, culminating in amputation. Morbidity
The incidence of persistent functional deficit (PFD), has been used as an index of morbidity. The relation of PFD to time off work is shown in Fig. 5, again with distinctive marking showing the severity of injury. It can be seen that the majority of cases off work for over 9 weeks were those with three or more functional deficits. The relationship of the PFD score to severity of injury is shown in Fig. 6. Occupational group
The bulk of patients
off work after injury are
Fig. 5. Persistent functional deficit related to time off work. 0, trivial; 6, moderate; 0, severe. Mean PFD (for whole series) = 1.9.
manual workers, and this group includes all except 8 of those off work for more than 6 weeks (see Fig. 7). This is partly owing to the greater severity of their injuries (see Fig. 8). All the severe injuries, and most of the moderate injuries, are to be found in this group. However, even if we compare cases of comparable severity (see Fig. 9), there is still a marked difference between manual workers and others. What else, then, sets this group apart from the rest? Compensation
claims
In the whole series there were 42 claims for compensation, 34 by manual workers and 8 by others. All but two of the claims by manual workers were against their employer, whereas all claims by other workers were against other mainly in connection with road parties, accidents.
Johns: Time off Work
421 100
BC
80
60 X of each QOUP off work
60 %
40
I I
40
20 0 I
0 No
2
of penislent
-
sewre
m m
moderate trivial
3 functional
4
3
6 We&r
5 htsdmn times
deficlts
off vork
9
12
26
from anjury htanw, Othsrr
6WkI Owhs
Fig. 7. Time off work of manual workers compared with all others (all injuries).
Fig. 6. Persistent functional deficit related to severity
of injury.
50 %
%0‘
each Off Work
of each group 30
Mama I
Clerical
m
severe moderate
m
trivial
II
Fig. 9. Time off work of manual workers compared with all others (moderate injuries only).
Fig. 8. Severity of injury v. occupational group.
The incidence of time off work among these with claims is shown in Fig. 10. Their median time off work (10 weeks), is over three times that for the whole series. If we eliminate severity of injury as a factor, by considering only manual workers with moderate injury, we can still demonstrate a striking difference in time off work between those with claims and those without (see Fig. 11). Comparison of their mean times off work (see Table ZZr)reveals that this difference is probably significant (P
42 patients
and others, which again is probably significant, (PC 0.05) (see Table IZI). There thus appears to be another factor, in addition to compensation, contributing to the difference between the two groups. Physical demands occupation
of the patient’s
When those workers with moderate injury and no claims are classifted according to the demands of their work (see Table II/), a difference at once appears between manual workers and the rest. All those with ‘heavy’ jobs are found in the former category, and all sedentary
422
Injury:the British Journal of Accident Surgery Vol. 1~/NO. 5
16 No.
IO
60
x
of *(I* Off WoIk
group 40
0
O-3
3-6
6-12 l2- 26
~26
Weeks Median time off: Mean time off:
IOwks. 20.6wks.
0
3
6
9
12
26
W&m from in&
Fig. 10. Compensation (42 cases).
claims related to time off work Fig. 11. Manual workers with moderate injury: time off work in relation to compensation claims.
Tab/e I//. Mean (and median) times off work related to occupational weeks) (all cases with moderate injury)
Occupational group Manual workers
No. 27
Claim Mean (and median) 16,4 (10.0)
4
Others
workers in the latter. The ‘light’ workers in both groups have very similar mean times off work, suggesting that only they are truly comparable in this respect. Employment status
A small group of 13 cases were self employed (see Table v). Over half their injuries were trivial, but their mean score for PFD was 2.2 (slightly above the mean for the series). The median time off work was one third that for the series and none stayed off work for more than 12 weeks. The sole compensation claim was in connection with a road accident. DISCUSSION
The patients attending the injuries. The when patients for interview. been omitted reviewed are
studied were typical of all those Cardiff Royal Infirmary with hand only element of selection occurred who were sent for did not attend Also, the extremes of age have from consideration. The injuries less severe than those studied by
No.
group and compensation
No claim Mean (and median)
No. 61
34 ,E, 4.5 (1.0)
35
claims (in
All cases Mean (and median) 12.0 (8.0)
39
Table IV. Physical demands of job: a comparison of all cases with moderate injury and no claims Manual
0 thers
Heavy work Light work Sedentary work
Mean times off work (weeks) in brackets.
Wilkes (1956), whose paper was concerned exclusively with industrial injury. This is reflected in the shorter median time off work for this series (3 weeks), compared with that found by Wilkes (7 weeks). However, the injuries are more severe than those studied by Gardner et al. (1968) and by Goldwyn and Day (1969). In general, certain types of injury tend to be associated with longer times off work than
Johns: Time off Work
423
Tab/e V. Self-employed Severity of injury: Occupational
group:
workers (13 cases) Trivial Moderate Manual Professional Other
Median time off work: Mean PFD Compensation claims
others (see Fig. 2). This is particularly true of traumatic amputations and wounds dividing nerves and tendons. However, most types of injury include a wide range of severity, and severity correlates much more closely with time off work (see Fig. 3). Even among injuries of comparable severity, there is considerable variation in time off work, suggesting that other factors affect it. As might be expected, injuries to dominant hands tended to be more severe; indeed 14 per cent of patients off work over 12 weeks suffered injury to the dominant hand. Furthermore, most jobs make greater demands on the dominant hand, and return to work is likely to be delayed when it is injured. In this series, errors of treatment increased time off work in only 4 per cent of cases. However, the mean time off work in these cases was 24 weeks (compared with a series mean of only 3 weeks). The elimination of errors would therefore have a greater impact on the total of working days lost than this small percentage would suggest. There is a general relationship between morbidity (as indicated by the PFD score) and time off work (see Fig. 5). However, it seems likely that morbidity depends mainly on the severity of injury (see Fig. 6), and may be considered secondary to it in determining time off work. The marked predominance of manual workers among those with long periods of time off work is not unexpected. Seventy-one per cent of their accidents occurred at work: the hazards of their type of work not only subjects them to more severe injury, but also result in a high incidence of compensation claims (in 40 per cent of accidents occurring at work). There is little doubt that the pursuit of compensation claims in itself significantly increases time off work. The median time off work shown in Fig. 3 demonstrates this, even in workers with comparable degrees of injury. This view is reinforced by the low median time off work
: 1 1 week 2.2 1 (v. other party)
found among the self-employed, a group virtually devoid of claims. Finally, the physical demands of most manual jobs require a greater degree of functional recovery before the patient is fit to resume work. The importance of the psychological element of injury in delaying return to work has not been investigated. It is of interest, however, that Gardner et al. (1968) and Goldwyn and Day (1969) have both discounted it as a major factor. What, then, can be done to reduce the four million working days lost each year as a result of hand injuries? It has already been suggested that improvements in the standard of treatment are unlikely to produce a substantial reduction. The provision of sheltered employment, on the other hand, would make an earlier return to work possible in many cases. This would reduce the physical demands of the job in the early stages, and would provide a graduated return to full activity. However, it is not always practicable, particularly for the small employer. A change in the system for assessing compensation, with greater emphasis on the severity of injury, and less on the time off work, could have considerable impact. Employees should not, of course, be penalized for time taken off work, but payments could be increased in recognition of early return to work. This should not be taken to the point of inducing patients to return to work before they are really fit, nor of burdening employers with staff who are largely unproductive. There is no means, however, of altering the nature and severity of an injury, and the principal effort must continue to lie in the field of accident prevention.
Acknowledgements
I am indebted to Mrs M. D. V. Hart for secretarial assistance, and to Miss J. Seaton for typing the manuscript.
424
Injury: the British
REFERENCES
Gardner D. C., Goodwill C. J. and Bridges P. K. (1968) Cost of incapacity due to fractures of the wrist and hand. J. Occup. Med. 10,114. Gardner D. C., Goodwill C. J. and Bridges P. K. (1968) Absence from work after fractures of the wrist and hand. J. Occup. Med. 10,118. Goldwyn R. M. and Day L. H. (1969) Acute industrial hand injuries: a socio-medical study. Plastic Reconstr. Surg. 44,567.
Journal of Accident Surgery Vol. 1 ~/NO. 5
Rank B. K. and Wakefield A. R. (1953) Surgery of Repair as Applied to Hand Injuries. Edinburgh, Livingstone. Social Security Statistics (1974) HMSO, London. Wilkes R. (1956) A social and occupational study of injured hands. Br. J. Ind. Med. 13,119.
Requests@ reprints should be nddressed to: A. M. Johns, Consultant, Department
of Orthopaedics,
Burton District Hospital
Centre, Belvedere Road, Burton-on-Trent.
DEVELOPMENTS
IN ACCIDENT
AND EMERGENCY
MEDICINE
A two-day Symposium arranged jointly by the University of Manchester (Hope Hosnital) and the MRC Trauma Unit entitled ‘Develonments in Accident and Emergency Medicine’ was held in Manchester in September 1980. Our present understanding of the pathophysiological and metabolic responses to trauma was discussed in the context of practical problems in the initial management of serious injury and acute illness. It was most encouraging to witness the lively discussions between scientists and clinicians. The many accident and emergency senior registrars and consultants at the Meeting realized the potential for research in their departments, and it is to be hoped that similar meetings will be arranged in Manchester and elsewhere in the future to maintain their interest and enthusiasm.
12.417-424
417
Printedin GreatBritain
Time off work after hand injury A. M. Johns Department
of Orthopaedics and Traumatology, Cardiff Royal Infirmary
Summary
The aim of the present study is to identify the principal factors which determine time off work following hand injury. Information was obtained from a series of 182 cases drawn from the genera1 population, with a broad spectrum of injuries of all degrees of severity. Median time off work for the series was 3 weeks: one third of the cases had no time off work, one third were off work for up to 6 weeks and one third for over 6 weeks. Certain types of injury were associated with long periods off work, particularly those involving nerve and tendon damage, or traumatic amputation of digits. Time off work, however, was more closely related to the severity than to the type of injury. Injuries to dominant hands were common in patients off work for over 6 weeks. Errors of treatment delayed return to work in only 4 per cent of cases. Morbidity was related to time off work, but it seemed to depend mainly on the severity of the injury. Manual workers stay off work for considerably longer than other workers; this is the case whether one considers all injuries or only those of comparable severity. The pursuit of compensation claims is much more common among manual workers, and is associated with a significant increase in time off work. Its incidence is related more to the circumstances of injury than to the morbidity which results. Even if one considers workers with no compensation claims and with injuries of comparable severity, there is still a significant difference in time off work between manual and other workers. This is probably due to the greater physical demands of most manual jobs. It is concluded that the major factors determining time off work are: The nature and severity of injury. The pursuit of compensation claims. The physical demands ofthe patient’s work. INTRODUCTION
EVERYyear between
3 and 4 million working days are lost as a result of hand injuries (DHSS,
personal
communication).
Those
injuries
account for nearly a quarter of the periods off work for which injury benefit is claimed (Rank and Wakefield, 1953; HMSO, 1974). During the year 197415 the cost to the taxpayer in sickness, injury and invalidity benefit was in the region of ten million pounds at the rates then current (HMSO, 1974). In addition to these costs borne by the exchequer, one has to consider sick pay, compensation payments and loss of productive capacity, borne by the employer, and loss of earnings to the employee. The last figure varies according to circumstances. In their study of the cost of incapacity due to fractures of the wrist and hand, Gardner et al. (1968) found an average total loss to the patient of f54. It can be imagined how this sum has increased in the interim. All these costs are proportionate to the period of time off work. It is therefore relevant to identify those factors which determine its duration, and to consider whether they can be modified in any way, so as to reduce both the cost and the inconvenience of the injury to all concerned. In their study, Gardner et al. (1968) found that personal, psychological and social factors were less important in delaying return to work than had been commonly supposed. They stressed the importance of the type of injury, the presence of complications and the physical demands of the patient’s job in prolonging time off work. Goldwyn and Day (1969) reviewed a large series of hand injuries of lesser severity, and they also found that time off work was related more to the nature of the injury than to personal factors. The present study is based on a comprehensive range of hand injuries, of all degrees of
Injury: the British Journal of Accident Surgery Vol. 1 Z/No.
418
5
severity. It considers the nature of the injuries, their treatment, the resulting morbidity, the occupation of the patient and the effect of compensation claims. No attempt has been made to assess the psychological state of the patients, nor to detail their financial loss. The aim is to identify the principal factors which determine the duration of time off work after hand injury. PATIENTS
AND
METHODS
The series under study comprised 198 patients with hand injuries treated by the Trauma Service in the Cardiff Royal Infirmary, between 1972 and 1974. Information on time off work was available in 182 cases. The patients had an age range of IO-65 years, and included 27 children at schools. The ratio of male to female was 4 : 1. The principal occupational groups were as follows: 55% Manual workers 21% Clerical/professional workers 15% School children Other workers 9% The term ‘manual worker’ corresponds with ‘blue-collar worker’, whereas the ‘clerical/professional’ group corresponds with ‘white-collar worker’. It should be remembered that not all injuries occur at work: in fact the circumstances of injury were as follows: 42% At work In public places 36% 22% At home The ‘public’ group includes sporting injuries, assaults and road traffic accidents. The range of injuries includes all the common types encountered, except bums, which were treated elsewhere. It also includes wounds of the wrist, which were of special interest to the author, but not fractures of the wrist. Simple wounds are under represented, since many of these are never referred to the Trauma Service. Former patients were identified through the records system, and were summoned by post to attend special review clinics. On attendance, a detailed history was taken, embracing the following points: nature and extent of injury; nature and duration of treatment; morbidity (including complications, persistent symptoms and loss of function); compensation claims and time off work. In recognition of the ultimate importance of function, morbidity has been assessed on the basis of functional deficits persisting to the time of examination. For the sake of simplicity, five basic functions have been considered: power
0
O-3
3-6
6-9
9-12
>I2
Weeks Time off work Median time off warlc 3wks. Mean time aff wak: 7.9wks
Fig. 1. Time off work results for the whole series.
grip; precision grip; sensation; finger mobility; wrist mobility. The resulting score of persistent functional deficits (PFD) varies from zero to a maximum of five. As can be seen from Fig. 5, there is a general relationship between the PFD score and the severity of injury, but the same score may be found following injuries of all degrees of severity. The severity of injury was assessed according to the criteria shown in Table I. RESULTS
The incidence of time off work for the whole series is shown in Fig. 1. It will be seen that approximately one third had no time off work, a third were off work for up to 6 weeks, and a third for over 6 weeks. The median time off work for the whole series was 3 weeks. Type and severity of injury
In Fig. 2 the series is broken down into the types of injury encountered, with distinctive markings to indicate the severity of each injury. If we group injuries by their severity we can plot the percentage of each group off work at various times after injury (see Fig. 3). The correlation between severity of injury and time off work is clearly shown in the three groups. Dominance
If we compare injuries to dominant and nondominant hands in the same way (see Fig. 4), we find that the percentages off work at 6 weeks are very similar. Thereafter, the percentage of dominant hands is somewhat greater. This is probably because the dominant group contains more moderate and fewer trivial injuries than the non-dominant group (see Table ZZ).
419
Johns:Time off Work
Fig. 2. Time off work with various types of injury. 0, trivial; 0, moderate;
severe.
Table/. Classification of injuries by severity Severity
Type of injury
Trivial
Closed dislocations of I P or M P joints Mallet fmgers Fractures of the neck of the fifth metacarpal Other fractures of phalanges or metacarpals without displacement Uncomplicated wounds
Moderate
Displaced fractures into IP or MP joints Bennett’s fracture Open injuries of IP joints Comminuted or displaced fractures of phalanges and metacarpals (including less severe compound fractures). Traumatic amputation affecting the terminal phalanx Solitary flexor tendon injury Solitary nerve injury Extensor tendon injuries (excepting mallet fmger)
Severe
Multiple fractures of phalanges or metacarpals. The more severe open fractures Severe wounds involving several flexor tendons and/or nerves Traumatic amputation of whole or multiple digits.
0,
420
Injury:the British Journal of Accident Surgery Vol. 1~/NO. 5 loo-
60‘ xofwhpmg OH wwk
60. K ofeachgmp off work
40
40’
Sewe
0
3
6 keks
Fig.
9
12
26
20.
Fig. 4. Time off work related to dominance.
after injury
3. Time off work related to severity of injury.
Tab/e //. Severity of injury related to dominance
Dominant Non-dominant
Trivial (%I
Moderate (%I
Severe (%I
33 46
2
6 5
Treatment
There were 13 cases in which the initial treatment could be judged inappropriate, but in only 3 cases did this delay return to work. These cases were: an unrecognized open injury to the distal interphalangeal joint; an unrecognized fracturedislocation of a proximal interphalangeal joint and an animal bite of an index finger which was primarily sutured and became infected. Repeated operation delayed return to work in 5 cases, 3 secondary amputations of non-viable digits and 2 revisions of unsuccessful tendon repairs. One of the latter underwent six procedures in all, culminating in amputation. Morbidity
The incidence of persistent functional deficit (PFD), has been used as an index of morbidity. The relation of PFD to time off work is shown in Fig. 5, again with distinctive marking showing the severity of injury. It can be seen that the majority of cases off work for over 9 weeks were those with three or more functional deficits. The relationship of the PFD score to severity of injury is shown in Fig. 6. Occupational group
The bulk of patients
off work after injury are
Fig. 5. Persistent functional deficit related to time off work. 0, trivial; 6, moderate; 0, severe. Mean PFD (for whole series) = 1.9.
manual workers, and this group includes all except 8 of those off work for more than 6 weeks (see Fig. 7). This is partly owing to the greater severity of their injuries (see Fig. 8). All the severe injuries, and most of the moderate injuries, are to be found in this group. However, even if we compare cases of comparable severity (see Fig. 9), there is still a marked difference between manual workers and others. What else, then, sets this group apart from the rest? Compensation
claims
In the whole series there were 42 claims for compensation, 34 by manual workers and 8 by others. All but two of the claims by manual workers were against their employer, whereas all claims by other workers were against other mainly in connection with road parties, accidents.
Johns: Time off Work
421 100
BC
80
60 X of each QOUP off work
60 %
40
I I
40
20 0 I
0 No
2
of penislent
-
sewre
m m
moderate trivial
3 functional
4
3
6 We&r
5 htsdmn times
deficlts
off vork
9
12
26
from anjury htanw, Othsrr
6WkI Owhs
Fig. 7. Time off work of manual workers compared with all others (all injuries).
Fig. 6. Persistent functional deficit related to severity
of injury.
50 %
%0‘
each Off Work
of each group 30
Mama I
Clerical
m
severe moderate
m
trivial
II
Fig. 9. Time off work of manual workers compared with all others (moderate injuries only).
Fig. 8. Severity of injury v. occupational group.
The incidence of time off work among these with claims is shown in Fig. 10. Their median time off work (10 weeks), is over three times that for the whole series. If we eliminate severity of injury as a factor, by considering only manual workers with moderate injury, we can still demonstrate a striking difference in time off work between those with claims and those without (see Fig. 11). Comparison of their mean times off work (see Table ZZr)reveals that this difference is probably significant (P
42 patients
and others, which again is probably significant, (PC 0.05) (see Table IZI). There thus appears to be another factor, in addition to compensation, contributing to the difference between the two groups. Physical demands occupation
of the patient’s
When those workers with moderate injury and no claims are classifted according to the demands of their work (see Table II/), a difference at once appears between manual workers and the rest. All those with ‘heavy’ jobs are found in the former category, and all sedentary
422
Injury:the British Journal of Accident Surgery Vol. 1~/NO. 5
16 No.
IO
60
x
of *(I* Off WoIk
group 40
0
O-3
3-6
6-12 l2- 26
~26
Weeks Median time off: Mean time off:
IOwks. 20.6wks.
0
3
6
9
12
26
W&m from in&
Fig. 10. Compensation (42 cases).
claims related to time off work Fig. 11. Manual workers with moderate injury: time off work in relation to compensation claims.
Tab/e I//. Mean (and median) times off work related to occupational weeks) (all cases with moderate injury)
Occupational group Manual workers
No. 27
Claim Mean (and median) 16,4 (10.0)
4
Others
workers in the latter. The ‘light’ workers in both groups have very similar mean times off work, suggesting that only they are truly comparable in this respect. Employment status
A small group of 13 cases were self employed (see Table v). Over half their injuries were trivial, but their mean score for PFD was 2.2 (slightly above the mean for the series). The median time off work was one third that for the series and none stayed off work for more than 12 weeks. The sole compensation claim was in connection with a road accident. DISCUSSION
The patients attending the injuries. The when patients for interview. been omitted reviewed are
studied were typical of all those Cardiff Royal Infirmary with hand only element of selection occurred who were sent for did not attend Also, the extremes of age have from consideration. The injuries less severe than those studied by
No.
group and compensation
No claim Mean (and median)
No. 61
34 ,E, 4.5 (1.0)
35
claims (in
All cases Mean (and median) 12.0 (8.0)
39
Table IV. Physical demands of job: a comparison of all cases with moderate injury and no claims Manual
0 thers
Heavy work Light work Sedentary work
Mean times off work (weeks) in brackets.
Wilkes (1956), whose paper was concerned exclusively with industrial injury. This is reflected in the shorter median time off work for this series (3 weeks), compared with that found by Wilkes (7 weeks). However, the injuries are more severe than those studied by Gardner et al. (1968) and by Goldwyn and Day (1969). In general, certain types of injury tend to be associated with longer times off work than
Johns: Time off Work
423
Tab/e V. Self-employed Severity of injury: Occupational
group:
workers (13 cases) Trivial Moderate Manual Professional Other
Median time off work: Mean PFD Compensation claims
others (see Fig. 2). This is particularly true of traumatic amputations and wounds dividing nerves and tendons. However, most types of injury include a wide range of severity, and severity correlates much more closely with time off work (see Fig. 3). Even among injuries of comparable severity, there is considerable variation in time off work, suggesting that other factors affect it. As might be expected, injuries to dominant hands tended to be more severe; indeed 14 per cent of patients off work over 12 weeks suffered injury to the dominant hand. Furthermore, most jobs make greater demands on the dominant hand, and return to work is likely to be delayed when it is injured. In this series, errors of treatment increased time off work in only 4 per cent of cases. However, the mean time off work in these cases was 24 weeks (compared with a series mean of only 3 weeks). The elimination of errors would therefore have a greater impact on the total of working days lost than this small percentage would suggest. There is a general relationship between morbidity (as indicated by the PFD score) and time off work (see Fig. 5). However, it seems likely that morbidity depends mainly on the severity of injury (see Fig. 6), and may be considered secondary to it in determining time off work. The marked predominance of manual workers among those with long periods of time off work is not unexpected. Seventy-one per cent of their accidents occurred at work: the hazards of their type of work not only subjects them to more severe injury, but also result in a high incidence of compensation claims (in 40 per cent of accidents occurring at work). There is little doubt that the pursuit of compensation claims in itself significantly increases time off work. The median time off work shown in Fig. 3 demonstrates this, even in workers with comparable degrees of injury. This view is reinforced by the low median time off work
: 1 1 week 2.2 1 (v. other party)
found among the self-employed, a group virtually devoid of claims. Finally, the physical demands of most manual jobs require a greater degree of functional recovery before the patient is fit to resume work. The importance of the psychological element of injury in delaying return to work has not been investigated. It is of interest, however, that Gardner et al. (1968) and Goldwyn and Day (1969) have both discounted it as a major factor. What, then, can be done to reduce the four million working days lost each year as a result of hand injuries? It has already been suggested that improvements in the standard of treatment are unlikely to produce a substantial reduction. The provision of sheltered employment, on the other hand, would make an earlier return to work possible in many cases. This would reduce the physical demands of the job in the early stages, and would provide a graduated return to full activity. However, it is not always practicable, particularly for the small employer. A change in the system for assessing compensation, with greater emphasis on the severity of injury, and less on the time off work, could have considerable impact. Employees should not, of course, be penalized for time taken off work, but payments could be increased in recognition of early return to work. This should not be taken to the point of inducing patients to return to work before they are really fit, nor of burdening employers with staff who are largely unproductive. There is no means, however, of altering the nature and severity of an injury, and the principal effort must continue to lie in the field of accident prevention.
Acknowledgements
I am indebted to Mrs M. D. V. Hart for secretarial assistance, and to Miss J. Seaton for typing the manuscript.
424
Injury: the British
REFERENCES
Gardner D. C., Goodwill C. J. and Bridges P. K. (1968) Cost of incapacity due to fractures of the wrist and hand. J. Occup. Med. 10,114. Gardner D. C., Goodwill C. J. and Bridges P. K. (1968) Absence from work after fractures of the wrist and hand. J. Occup. Med. 10,118. Goldwyn R. M. and Day L. H. (1969) Acute industrial hand injuries: a socio-medical study. Plastic Reconstr. Surg. 44,567.
Journal of Accident Surgery Vol. 1 ~/NO. 5
Rank B. K. and Wakefield A. R. (1953) Surgery of Repair as Applied to Hand Injuries. Edinburgh, Livingstone. Social Security Statistics (1974) HMSO, London. Wilkes R. (1956) A social and occupational study of injured hands. Br. J. Ind. Med. 13,119.
Requests@ reprints should be nddressed to: A. M. Johns, Consultant, Department
of Orthopaedics,
Burton District Hospital
Centre, Belvedere Road, Burton-on-Trent.
DEVELOPMENTS
IN ACCIDENT
AND EMERGENCY
MEDICINE
A two-day Symposium arranged jointly by the University of Manchester (Hope Hosnital) and the MRC Trauma Unit entitled ‘Develonments in Accident and Emergency Medicine’ was held in Manchester in September 1980. Our present understanding of the pathophysiological and metabolic responses to trauma was discussed in the context of practical problems in the initial management of serious injury and acute illness. It was most encouraging to witness the lively discussions between scientists and clinicians. The many accident and emergency senior registrars and consultants at the Meeting realized the potential for research in their departments, and it is to be hoped that similar meetings will be arranged in Manchester and elsewhere in the future to maintain their interest and enthusiasm.