Hand trauma

1. Presentation and Outcome of Hand Trauma in a Plastic Surgical Unit Muhammad Saaiq et al
Ann. Pak. Inst. Med. Sci. 2009; 5(3): 131-135 131
Original Article
Presentation and Outcome of Hand
Trauma in a Plastic Surgical Unit
Objective: To determine the frequency of various causes of hand trauma and the
pattern of outcome in terms of traumatic amputation of fingers / hand, duration of
hospital stay, complications/ morbidity and mortality.
Study Design: Case series study.
Place and duration: This study was carried out in the Department of Plastic and
Reconstructive Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad during
the period from August 16, 2008 to May 31, 2009.
Materials and Methods: All hand injured patients of either gender over 14 years of age,
receiving treatment indoor or at outpatient department or managed in emergency
department were included in the study by consecutive sampling technique. The
sociodemographic profile of the patients, cause of injury, type of injury, type of surgical
procedure undertaken, any complications and morbidity etc. were all recorded on a
proforma. A follow-up of two months was done to document any late complications. The
data were subjected to statistical analysis.
Results: Out of a total of 138 patients, 84.78 % ( n=117 ) were males while 15.21 %
( n=21 ) were females. The mean age was 28 ±±±± 11.35 years. Majority of the patients (69.56 %)
were in their 2nd and 3rd decades of life. Two patients had left hand dominance while the
remainder had right hand dominance. Occupation-wise 38.40% (n=53) patients were
machine operators, 12.31%( n=17) were labourers / manual workers, while the remainder
belonged to various other professions. Majority of the patients 63.04% (n=87) were
socioeconomically poor.
Machines constituted the commonest cause of hand trauma (38.40%), followed by road
traffic accidents (15.94 %). Bone fracture was the most common injury (45.65 %), followed
by cuts / lacerations (18.11 %) and fingertip losses (17.39 %). The rate of traumatic
amputation of hand was 5.07 %. The rate of hospitalization was 11.59 %( n=16). The average
hospital stay was 10.7 ±±±± 5.40 days. There was no in-hospital mortality.
Conclusion: Hand trauma predominantly affects young males who have occupational
exposure to different machines. It is associated with a high rate of traumatic amputation of
hand and digits. Most of the cases result from avoidable occupational hazards.
Key Words: Hand trauma. Hand injuries. Hand fractures.
Muhammad Saaiq*
Hameed-Ud-Din**
Muhammad Ibrahim Khan***
Saud Majid Chaudhery****
* Postgraduate Resident,
**Assistant Professor And Head,
*** Senior Registrar
****Postgraduate Resident
Department of Plastic Surgery,
Pakistan Institute of Medical Sciences
(PIMS), Islamabad.
Address for Correspondence:
Muhammad Saaiq,
Postgraduate Resident,
Department of Plastic Surgery,
PIMS, Islamabad.
E-mail: msaaiq@yahoo.uk.com
Introduction
The hand is a highly perfect and intricate tool
with which man has been endowed with by his creator. It
receives information from the outside world and then the
individual acts upon it. It also translates human intellect
into meaningful communications in the form writings and
fine skilled voluntary movements involved in a variety of
professions. Indeed following brain, hand is the second
most frequently used organ of human body. Owing to its
function it is vulnerable to various traumatic insults. In
the developed countries, hand injuries account for up to
10% of all emergency department presentations.
1-3
Hand trauma refers to trauma that involves any
or all the components of hand and wrist. The
components include the skeleton and soft tissues. The
hand injuries are thus classified into skeletal and soft
tissue injuries. Their clinical presentation ranges from
minor complaints of pain to traumatic amputation of the
hand.
1, 2, 4
The outcome of hand trauma depends not only
on the severity of injury but also on the adequacy of
timely instituted treatment.
1-3
In the developed countries
effective hand injury preventive measures have greatly
reduced the incidence as well as severity of these
disabling injuries.
5, 6
The present study was undertaken to determine
the frequency of various causes of hand trauma and the

2. Presentation and Outcome of Hand Trauma in a Plastic Surgical Unit Muhammad Saaiq et al
Ann. Pak. Inst. Med. Sci. 2009; 5(3): 131-135 132
pattern of outcome in terms of traumatic amputation of
fingers / hand, duration of hospital stay, complications
and mortality.
Materials and Methods
This Case series study was carried out in the
Department of Plastic Surgery, Pakistan Institute of
Medical Sciences (PIMS), Islamabad from August 16,
2008 to May 31, 2009. Informed consent was taken
from all the patients. Permission was sought from the
hospital ethics committee for conducting the study. All
hand injured patients of either gender over 14 years of
age, receiving treatment indoor or at outpatient
department or managed in the emergency department
were all included in the study by consecutive sampling
technique. Hand trauma patients who were either
referred from or for whom plastic surgery consultation
was sought by other departments were also included in
the study. Patients who had already received treatment
at some other health care facility and those not
consenting to participate in the study were excluded.
The patients were initially assessed by
adequate history, thorough examination and
investigations (Plain X-Rays hand in all patients and
other investigations such as those required for
evaluation of fitness for general anesthesia, where
indicated). Patients with simple hand trauma were
discharged home after necessary treatment in
emergency department while those requiring
hospitalization were admitted for indoor management.
The sociodemographic profile of the patients, cause of
injury, type of injury, type of surgical procedure
undertaken, complications and morbidity etc. were all
recorded on a proforma. A follow-up of two months was
undertaken to document any late complications. The
data were subjected to statistical analysis to measure
the objectives.
Statistical Analysis
The data were analysed through SPSS version
10 and various descriptive statistics were used to
calculate frequencies, percentages, means and
standard deviation. The numerical data such as age
and duration of hospitalization were expressed as Mean
± Standard deviation while the categorical data such as
the causes of hand trauma, different types of hand
injuries, interventional procedures employed and
complications observed were expressed as frequency
and percentages.
Results
Out of a total of 138 patients, 84.78 % (n=117)
were males while 15.21 % (n=21) were females. The
mean age was 28 ± 11.35 years. Majority of the patients
(69.56 %) were in their 2nd and 3rd decades of life.
(Figure I)
41
52
25
13
7
0
10
20
30
40
50
60
No. of
PATIENTS
11--20 21-30 31-40 41-50 51-60
AGE ( YEARS )
Figure I: Age Distribution of the Patients.
(n= 138)
Two patients had left hand dominance while the
remainder had right hand dominance. Majority of the
patients belonged to the twin cities of Islamabad and
Rawalpindi (n=117), seven were from Azad Jammu
Kashmir and the remainder were from other cities.
Occupation-wise 38.40 % (n=53) patients were machine
operators, 12.31 %( n=17) were labourers / manual
workers, while the remainder belonged to various other
professions. Majority of the patients 63.04 % (n=87)
were socioeconomically poor.
Machines constituted the commonest cause of
hand trauma (38.40%). (Table I) Bone fracture was the
most common injury (45.65 %). (Table II) The rate of
traumatic amputation of hand was 5.07 %. The
associated injuries found among the patients included
head injury 2.17% (n=3), fracture radius 1.44% (n=2),
and fracture humerus 0.72% (n=1).
The surgical procedures undertaken included k-
wire fixations 11.59% (n=16), tendon repairs 10.14%
(n=14), flap covers 5.79% (n=8), skin grafts 5.07% (n=
7), nerve repairs 3.62% (n=5), fasciotomies for hand
2.17% (n= 3) and other miscellaneous procedures such
as wound excision, foreign body removal, and wound
closures etc. 55.79% (n=77). Complications
encountered included wound infection 7.97% ( n=11 )
and hand stiffness 5.07% ( n=7 ). The rate of
hospitalization was 11.59 %( n=16). The average
hospital stay was 10.7 ± 5.40 days. (range 1-18 days)
There was no in-hospital mortality.

3. Presentation and Outcome of Hand Trauma in a Plastic Surgical Unit Muhammad Saaiq et al
Ann. Pak. Inst. Med. Sci. 2009; 5(3): 131-135 133
Table I: Causes of Hand Injury. (n =138)
S.
No.
Causes
No. OF
PATIENTS ( % )
1 Machines
Ara machine (powered saw )
Chara cutting machine
Press machine
Wool machine
Factory machinery
Gunna machine
Sewing machine
Automobile machine
Washing machine
53 (38.40%)
2 Road traffic accidents 22 ( 15.94 % )
3 Sporting injuries 13 ( 9.42 % )
4 Glass injuries 10 (7.24 % )
5 Household injuries 8 ( 5.79 % )
6 Assaults/ fights 8 ( 5.79 % )
7 Falls 6 ( 4.34 % )
8 Firecrackers 5 ( 3.62 % )
9 Electrical injuries 3 ( 2.17 % )
10 Fire arm injuries 2 ( 1.44 % )
11 Dog bites 2 ( 1.44 % )
12 Burns 2 ( 1.44 % )
13 Blast injuries 2 ( 1.44 % )
14 Door entrapments 2 ( 1.44 % )
Discussion
Predominant involvement of males was found in
our study. A gender difference in hand injury patterns
has been reported in the published literature as well.
5
Khan AZ
7
reported a series of occupational hand
trauma patients in which all patients were males.
Subramanian A et al
8
found that injuries to the hands
and fingers were more common in men, while wrist
injuries were more common in women.
Majority of our patients were young. Other
published studies have also reported more frequent
involvement of relatively younger patients.
5, 6, 9
The risk
of various injuries including amputations tend to decline
with increasing age. This decline can be attributed to the
growing experience of the workers with resultant caution
exercised while at work.
Machines constituted the leading cause of hand
injuries in our study. Among these machines,
electrically powered saws, Chara cutting machines and
press machines were most frequently involved. Trybus
M et al
10
also reported mechanical equipment as the
leading cause of hand injuries. Several other published
studies have reported electrically powered metal
machinery used in a variety of sectors, as the major
source of disabling hand trauma.
11-14
Table II: Distribution of the Hand Injuries.
(n =138)
S.
No.
INJURIES
No. OF
PATIENTS
( % )
1 Bone Fractures 63 (45.65 %)
2 Superficial cuts, lacerations etc 25 (18.11 %)
3 Fingertip losses 24 (17.39 %)
4 Finger amputations 17 (12.31 %)
5 Tendon injuries 14 (10.14 %)
6 Degloving / Skin loss 10 (7.24 %)
7 Hand Amputation 7 (5.07 %)
8 Nerve Injury 5 (3.62 %)
9 Joint Dislocation 4 (2.89 %)
10 Retained Foreign Body 4 (2.89 %)
11 Burn injury 2 (1.44 %)
12 Mallet Finger 1 (0.72 %)
Our industrial and agricultural systems have
recognized limitations that predispose the workers to
hand injuries. Lack of occupational safety protocols, lack
of vocational training and young age at starting industrial
/ agricultural life are among the factors that contribute to
the causation of serious injuries in our set up. Regarding
the risk of such injuries, a variety of factors which be
responsible either directly or indirectly, have been
described in the published literature. Poor work
environmental conditions,
15, 16
poor perception of work
conditions
15
and presence of disease or adverse health
conditions among the workers
17, 18
have been
identified as the general predisposing factors. Sorock
GS
19
described three major risk factors for occupational
hand injuries i.e. deficient use of protective measures,
lack of work experience and worker-related factors
(drowsiness, inattention etc.) Chow CY et al
20
defined
seven significant transient risk factors for acute
occupational hand injuries: using malfunctioning
equipment/materials, using a different work method,
performing an unusual work task, working overtime,
feeling ill, being distracted and rushing. Unlu RE et al
21
identified voluntary poking of hand into operating
machine and unfamiliarity with the work as the leading
causes of crushing type occupational hand injuries.
In our study bone fracture was the most
frequently encountered type of injury. The rate traumatic
amputation of hand and fingers was 5.0% and 12%
respectively. Published studies have reported different
patterns and distribution of injuries. Some studies have
reported laceration type injuries as the most common,
followed by crush injuries, fractures and amputations.
6,
9, 19
Stanbury et al
11
analyzed work-related amputations,
and found that single digit amputations constituted the
leading type (71% of the total amputations) while hand
amputations were around 1.2%.

4. Presentation and Outcome of Hand Trauma in a Plastic Surgical Unit Muhammad Saaiq et al
Ann. Pak. Inst. Med. Sci. 2009; 5(3): 131-135 134
A variety of surgical procedures were
undertaken among our patients as dictated by the
pattern of their injuries. The most common hand specific
interventions included k-wire fixations of various bone
fractures, repair of cut tendons, and abdominal flap
coverage for degloving injuries. Management of
fractures has been described as one of the most
important aspects of hand injury in the published
literature.
22-24
We had our share of complications in the form
of wound infection and hand stiffness in some patients.
Despite adequate debridement, wound care and
antibiotic cover, these patients are prone to wound
infection because of wound contamination occurring at
the time of injury. Some of the patients present late and
have established infection at the time of presentation.
Prevalence of infection in hand trauma wounds has also
been reported by other studies.
7, 25, 26
Adequate
physiotherapy helps to reduce the chance of hand
stiffness and we routinely employ it in collaboration with
our physiotherapy department.
Sixteen of our patients required hospitalization.
Some of these had associated systemic injuries such as
head injury while others needed hand specific
interventional procedures like flap coverage under
general anesthesia. Our findings are in conformity with
other published studies.
5-7
We make the following Recommendations to
address the important public health issue of hand
trauma:
1- Occupational safety protocols should be
developed and aimed at eliminating recognized
workplace hazards. The primary focus of such protocols
should be the industrial, agriculture and other machine
related work environments.
2- The important determinants of injury severity
and outcome such as the injury-mechanism,
circumstances under which the injury ensues,
availability of on-scene medical care, accessibility to
specialist care etc. should all be given due
consideration.
3- An ongoing proactive process of injury-risk
identification, injury anticipation, safety designing,
implementation, and evaluation of risk-reduction
practices should be in place. All these measures would
help to reduce the level of injury and ensure safety of
the workers. Adequate vocational training of the workers
should be ensured in line with these measures.
4- Awareness of public, activation of media and
legislature can prove pivotal in achieving the
aforementioned objectives.
Conclusion
Hand trauma predominantly affects young
males who have occupational exposure to different
machines. It is associated with a high rate of traumatic
amputation of hand and digits. Most of the cases result
from avoidable occupational hazards.
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