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ORIGINAL ARTICLE
Year : 2022 | Volume
: 30
| Issue : 3 | Page : 63-68
Evaluation of hand injuries admitted to emergency department of a tertiary care center: Analysis of 10352 patients
Mehmet Besir Oner1, Can Ege Yalcin1, Semih Baghaki1, Anil Demiroz1, Ibrahim Ikizceli2, Oguz Cetinkale1
1 Department of Plastic, Reconstructive and Aesthetic Surgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
2 Department of Emergency Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
Correspondence Address:
Dr. Mehmet Besir Oner
Department of Plastic, Reconstructive and Aesthetic Surgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul 34093
Turkey
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/tjps.tjps_18_21
Background: In this study, we aimed to evaluate the characteristics of patients who were admitted to the emergency department for a hand injury and to make preventive inferences for hand injuries in terms of public health. Materials and Methods: We conducted a retrospective analysis of 10,352 patients admitted to the emergency department between August 2016 and July 2020. Results: The average age was 28.4. Injuries mostly occurred in the 25–34 age interval (18.7%). Men predominated in the patient group (70.27%), and injuries were almost equally distributed between right and left sides, with fingers being the most frequently affected region. Common etiologies included falling, occupational injury, and home accidents, leading most frequently to fracture/dislocations, skin-nail injuries, and tendon injuries. Amputations comprised 6.3% of the injuries. Complicated injuries mostly occurred in young males and were mostly due to work accidents. Conclusions: Hand injuries can be devastating, and increased individual and social awareness and improved occupational standards are required for prevention (level of evidence: III).
Keywords: Accident, epidemiology, hand injuries, safety measures
The hand is an integral part of the upper extremity that has a critical function to fulfill their daily activities. The fact that the hand is the most frequently used organ in daily life makes it vulnerable to injuries.[1] Between 6.6% and 28.6% of the patients admitted to the emergency services suffer from upper extremity injuries.[2],[3],[4],[5] Previous reports suggest that the major causes of hand injuries are occupational injuries, home accidents, injuries occurring out of working hours, traffic accidents, and sports injuries,[3],[4],[5],[6] mostly affecting the young working male population.[1],[7]
Hand injuries range from simple soft-tissue injuries to complicated injuries, fractures, and amputation.[8] Despite being generally nonlife threatening, these injuries have great importance as the consequences may include labor losses, high treatment costs, and permanent disability and morbidity.[1],[5],[9],[10] As the severity of injury increases, the treatment and rehabilitation process of the patient extends accordingly.[11] Such injuries may prevent the patient from going back to work and social life.[1],[5] These injuries impose an economic burden in addition to its effects on patients' health and daily life.[9],[12],[13] The treatment aims to ensure that the extraordinary functions of the hand are brought back to normal as close as possible, thus facilitating the patient's early return to their former job and social life without functional loss.[1],[5]
This study aims to evaluate the etiology of injury, injured regions, injured anatomical structures, treatment data, and demographical characteristics of patients admitted to the emergency department with complaints of hand and upper extremity injuries and to deliver messages to take timely measures and prevent negative consequences.
Materials and MethodsIn this retrospective study, records of the patients admitted to the emergency department of our medical center with complaints of hand and upper extremity injury during a 4-year period between the years of 2016 and 2020 were analyzed. The cases with hand injury admitted to the outpatient clinic late after the injury, burns, humerus fractures, and hand infections were excluded from the study.
The data on age, gender, injured region, injured finger, cause and site of injury, injured structures, and patient demographics were analyzed, and the cases were grouped according to these criteria. Injuries happening at home during daily activities were categorized as home accidents and the ones occurring at workspaces during business hours were categorized as occupational injuries. The remaining etiologies were stratified as detailed as possible. This study was approved by Istanbul University-Cerrahpasa Ethical Committee on September 3, 2019. The results obtained were analyzed by performing the student t-test and Chi-square test on age, gender, and injury localization groups. The level of significance was taken as P < 0.05.
ResultsIn total, 10,352 patients were included. The rate of upper extremity injury cases among all the patients (n = 228.309) admitted to the emergency department was 4.5%. The average age was 28.4 (0–98, standard deviation: 17.5). While the average age was lower in home accidents and punching glass/wall cases (26.2 and 25.4, respectively), it was higher in occupational injuries (37.4) and injuries mostly occurred between 25 and 34 years of age (18.7%) [Table 1]. The majority of the patients were male (70.27%).
Table 1: Characteristics of patients included in the study with the gender distribution and age groupsThe total number of patient-based daily average was 7.2/day. The average number of admitted patients per day was 13.2/day during Eid al-Adha, 7.7/day during Ramadan, 8.9/day during national holidays, and 7.1/day during nonholiday days. Thirty percent of patients (n = 3130) were admitted on the weekend and 70.0% (n = 7222) were admitted on the weekdays. There was a statistically significant increase in the number of patient admissions on the weekends throughout the year (P = 0.035; P < 0.05), most common in summer (27.8%) and autumn (25.4%) [Table 2].
Table 2: Distribution of patients by time of presentation, including season, weekday, and weekendThe details on the localization of the injury were obtained in 4958 cases. Of those, 49.2% (n = 2442) had an injury on the right upper extremity and 49.7% (n = 2464) on the left upper extremity, and in 1.1% (n = 52), both extremities were affected. Of those whose dominant hand is known, 53.6% (n = 1443) had injuries on the dominant, 45.6% (n = 1227) on the nondominant, and 0.8% (n = 21) on both the dominant and nondominant hands. Specific injury sites could be determined in 4438 (42.87%) cases. The multiple-region injury occurred in 385 (8.68%) cases, with the most frequently affected region being the digits (n = 2322). 85.5% (n = 2247) of finger injury cases were single and 14.5% (n = 381) were multiple-finger injury. The second (23.0%) and third fingers (22.5%) were the most frequently injured fingers while the least frequently injured one was the fourth finger (17.4%).
Cases (5602) suffering from a simple hand injury that can be treated primarily by an emergency physician were excluded from further analysis due to insufficient level of information, which left 4750 patients in total. Injuries arose most commonly after falls (25.8%, n = 1228), occupational injuries (19.7%, n = 935), and home accidents (19.5%, n = 926). Punching glass/wall (7.7%, n = 367) is a distinctive cause [Table 3]. The most common causes of injury in males were occupational injuries (24.39%), falling (21.77%), and home accidents (15.70%). In females, the most common cause of injury was falling (37.87%).
Bone fracture/dislocations (45.5%), isolated skin (32.7%), and tendon (11.7%) injuries comprised the majority of cases [Figure 1]. There were 673 patients suffering from complex injuries in which two or more of the tendon, nerve, vessel, bone, and ligament/capsule structures were injured together. Tendon injuries were mostly accompanied by nerve and vessel injuries, and most frequently occupational with male predominance (79.2%).
Isolated flexor and extensor tendon injuries constituted 42.8% (n = 239) and 48.9% (n = 273) of tendon injuries, affecting both sides in 8.2% (n = 46) of the cases. Flexor tendon injuries occurred most commonly on the second and third fingers, on the right hand and in flexor zones 2 and 5. Most frequently, fifth flexor digitorum profundus and flexor digitorum superficialis tendon injuries occurred. Tendon injuries in the dorsal region occurred most frequently on the extensor zone 3 and extensor zone 6. Most frequently, the third extensor digitorum communis tendon was damaged.
Isolated nerve injuries constituted 4.8% (n = 16) of 330 (6.4%) nerve injury cases [Table 4]. In general, nerve injury was accompanied by a vessel injury. Most frequently, digital nerves of the second (23.7%) and third fingers (20.0%) were affected. Nerve injuries mostly resulted from home accidents, occupational injuries, and sharp object injuries. There were vessel injuries in 297 patients (6.25%). There were nail bed injuries in 516 (10.8%) patients, and the total number of injured nail beds was 548. Multiple fingers were affected in 32 patients.
Bone fracture and/or dislocation was observed in 45.5% (n = 2162) of the patients [Table 3]. In total, 2419 bone fractures were observed. The most common causes of injury for bone fracture/dislocation were falling (45.9%), work accidents (13.4%), and home accidents (11.2%). The fifth metacarpal was the most frequently affected, commonly secondary to self-inflicted injury (hitting a wall or another object) or falling [Figure 2]. Among the phalangeal bones, the most common one was the distal phalanx, and it mostly resulted from work accidents and home accidents. Fingertip injures were generally caused by closing the finger in a door or similarly getting it smashed between two objects.
Figure 2: Distribution of injured hand, wrist, and forearm bones. Each number shows how many patients have a fracture on that bone, please note the possibility of multiple bone fractures in some patientsIn 6.35% (n = 302) of patients, subtotal/total amputation occurred, and, most commonly, the second and third fingers are involved at the level of the distal phalanx. The main reasons are home and occupational accidents (57.2% and 27.7%, respectively), more specifically due to saw, spiral, pit saw, and press machines in work accidents and doors in home accidents.
Complex injuries, defined as the injury of two or more of the tendon, nerve, vessel, bone, and ligament structures, were observed in 673 (14.1%) patients, more frequently in male patients (79.0%), and were mostly due to occupational injuries and home accidents. Treatment was mainly conservative by applying splints, casts, or bandages (29.8%). The most common surgical procedures were tendon and nail bed repairs. Nineteen patients underwent replantation, and 26 patients underwent revascularization [Table 4]. Soft-tissue defects were present in 317 cases, requiring either surgical reconstruction or healing by secondary intention.
DiscussionUpper extremity injuries comprise a significant part of emergency department patients. In some studies, this rate ranges from 6.6% to 28.6%.[2],[3],[4],[5] The relatively lower rate (4.5%) we reported may be a result of inclusion of patients from trauma centers in previous studies and differences in our exclusion and inclusion criteria. These injuries impose an economic burden by leading to labor loss in addition to its effects on patients' health and daily life.[13] Hand injuries are highly common and crucial traumas due to their functional significance and serious rates of morbidity.[14]
The demographical studies on work accidents indicate that up to 50% of hand injuries may result in permanent disability. Previous cohort studies focusing on the outcomes of hand injures reported that the risk of permanent disability and inability to work may be as high as 36% and 25%, respectively following digit amputations or median and/or nerve injuries.[15]
Hand injuries are common in working male, young adult, and adult groups, ranging between 62% and 89%,[2],[3],[4],[14],[16],[17],[18] similar to the rate we found in this study. In the previous studies, the rate of pediatric patients was reported as 14%–33%, concurring with our data.[5],[16],[19] The average age is 28.4 in this study, and it is consistent with previous studies.[2],[3],[4],[8],[14],[18],[19],[20],[21],[22] Injuries occurred slightly more frequently on the left upper extremity, and previous studies revealed inconsistent results.[17],[19],[22],[23],[24]
Digits, which are responsible for fine and detailed movement and integral to our daily life, are most vulnerable to trauma and may be involved in up to 86.5% of patients in some series. Although variations exist between the studies, similar to our findings, the third (22.5%–43.8%) and the second fingers (23.0%–31.4%) are generally affected.[19],[23] Angerman and Lohmann reported in their study intended for evaluation of hand and wrist injuries that injuries mostly occurred in fingers (62%).[3] Studies focusing on work accidents revealed that the most frequently injured fingers were the second finger (27.8%) and third finger (27.1%). Most frequently, there were finger injuries (52.3%), forearm injuries (25.8%), and hand injuries (10.93%).[23]
Previous studies demonstrated an increased number of admissions of patients with a hand injury in the summer season and on the weekends throughout the year.[2],[16],[18] We think that the similar distribution of cases in our study is due to the increase in touristic, work-related or recreational activities during weekends and holidays as a result of our center being located in a metropolis.
In general, the cause of hand injury is failing to comply with the standard occupational safety rules.[4] However, according to Tan et al., it is impossible to exclude unforeseen human errors leading up to 90% of minor hand injuries. Hand injuries arising from occupational accidents generally result in amputation and/or complex injuries affecting more than one tissue.[25] For this reason, the duration of treatment is long and difficult, and besides disability, it also causes socioeconomic losses due to the prolongation of the period required to return to work.[22] Work accidents were determined as the major cause in 18%–26% of th e patients with hand trauma.[3],[4],[6],[18],[19],[26] In this study, the rate of work accidents was 19.7%, similarly. Occupational injuries are more common in males, and the rate of males in this study was similar.[3],[16] Complex injuries are more common in occupational injuries, and the rate in this study was similar.[4],[16]
The rate of home accidents in terms of hand injuries was reported between 19% and 45.2%.[3],[4],[10],[18],[21] Our result was 19.5%, similarly. In terms of home accidents, the rate of female cases is higher than work accidents. In the previous studies, the rate of female cases in home accidents was reported between 38% and 44%.[3],[16] In this study, this rate was determined as 39.8%, similarly.
In our series, falls were the most common cause of hand trauma, affecting 25.8% of our patients in this study. Similar rates (23%–46%) were reported in the literature.[3],[10] Punching glass, which is one of the typical injury mechanisms in the hand, often causes complicated injuries and requires complex treatment.[4] Karasoy et al. reported that 13.6% of cases were those arising from punching a glass and it was more common in males; this rate was reported as 8.5% in the study performed by Sakrak et al. and 2.5% in the study performed by Şahin et al.[8],[14],[16] Uysal et al. reported that this rate was 40% in their study intended for analysis of injuries of volar side. In this study, the cases with injuries arising from hitting a glass or hard surface were determined at the rate of 7.7% and more common in males. It was thought that the higher rate in Uysal's study was because it was a specific study.[27] Sakrak et al. stated that the number of cases of punching glass were important markers for social stress and behavioral disorder.[14]
Bone fracture-dislocations comprised the majority of cases with a rate of 45.5%, followed by isolated skin and nail injuries and tendon injuries. Incidence of isolated skin and nail injuries shows variations between studies, ranging between 18.4% and 45%.[3],[5],[16],[22] In this study, it was the second most common type of injury with 36.9%. Our results for fracture-dislocations are comparable to the previous studies, where a frequency between 20% and 55.5% was reported, with the most commonly involved bones being radius and/or ulna, phalanges, and metacarpal bones.[3],[6],[8],[10],[22],[28],[29] Angerman and Lohmann reported that the most common causes were home and work accidents; they were home accidents and traffic accidents according to the study performed by Ribak et al. and falling and assault according to the study intended for evaluation of hand and forearm fractures performed by Chung and Spilson.[2],[3],[29] In our opinion, the reason for such differences might be due to differences in sample classification, stratification, and selection.
Tendons are essential structures for hand function as the fine grabbing, grasping and adjusting movements of the hand are dependent on their integrity.[7] In developed countries, tendon injuries occur in 2%–5% of patients.[3],[5],[26] However, rates as high as 29% were reported in selected patient populations as well.[3] This rate may rise to 60% in less developed and/or developing countries, especially where the industrial activities are intense.[28],[30] It was reported between 13.5% and 32.7% in the studies performed in our country.[18],[19],[22] In this study, the rate of tendon injury was 11.7%. In similar studies, the most common causes were cited as punching a glass and stab wounds.[1],[7],[27] Although the rates in this study were comparable to the previous studies, we believe that minor differences were based on the economic development, occupational training and occupational safety, whether sufficient protective equipment is provided or not, and regional variability. Similarly, it was stated that the reason for the high rate in the male gender may be partly due to the nature of occupational and entertainment activities.[27] It was thought that the reason for the high rate of cases of punching glass in etiology was due to alcohol consumption or wildness due to any discussion.
Nerves are one of the most frequently injured structures, and the rate of injury varies in the literature. A rate between 0.1% and 1.2% was reported in developed countries.[3],[26] In the study performed in the industrial region of India, this rate was determined as 27%.[28] In our country, reported rates vary between 10% and 12%.[1],[8],[16] In this study, nerve injuries were observed at the rate of 6.4%. Like nerve injuries, vessel injuries were reported at a low rate (<1%)[2],[3],[26] in Western countries but higher in similar studies in our country (around 4.5%).[1],[16] It was determined as 6.25% in this study. The most common causes of both nerve and artery injuries were home accidents, work accidents, and sharp object injuries. It may depend on the use of kitchenware, occupational safety and training, and lack of protective measures. It was emphasized that major nerve and tendon damages cannot be noticed due to a superficial examination of the hand, especially in patients with psychological disorders and those with limited cooperation due to the use of drugs or alcohol.[26]
In the previous studies, the rate of complex hand injuries is 10.2% and 15% and more common in the working-class male population.[16],[22] Complex hand injuries were determined as 14.1% in this study. It mostly resulted from occupational injuries and home accidents. It was more frequently (79.0%) observed in male patients. Panagopoulou et al. reported that the rate of amputation cases in 57986 patients over the age of 14 with hand injury was 1.3% and it was more common in young male workers.[32] In previous studies, it has been reported that the amputation rate varies between 1% and 10.1%, the most common causes of amputations are work accidents, and it mostly occurs in the male gender.[2],[3],[22],[23],[24] In this study, the rate of cases accompanied by amputation was 6.35%. The most common cause was work accidents. It was more common in male patients, and our results were compatible with the previous studies. The costly and long-lasting nature of the treatment period of such injuries has the risk to create a socioeconomic burden on both the patient and the society.
The retrospective nature of our study is a limitation since only the patients whose records were duly kept were included. However, since the number of these patients was as high as 4750 (10352), the data obtained were considered to be valuable.
ConclusionsHand injuries are traumas that are both critical and common. In this study, hand injuries mostly resulted from falling and work accidents. Serious injuries mostly occurred in young male workers due to work accidents. The rate of amputation was considerable. As a result, disability, labor loss, psychosocial problems, and serious economic losses may occur. Epidemiological studies are crucial to minimize the injuries and prevent them with regulations and measures taken accordingly. Considering our finding that serious injuries such as amputations occur more commonly at work, preventive measures should be applied meticulously at workspaces.
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Nil.
Conflicts of interest
There are no conflicts of interest.
References
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