Presentation and Outcome of Hand Trauma in a Plastic Surgical Unit Muhammad Saaiq et al

Original Article

Presentation and Outcome of Hand Muhammad Saaiq*

Hameed-Ud-Din**
Muhammad Ibrahim Khan***
Trauma in a Plastic Surgical Unit Saud Majid Chaudhery****

* Postgraduate Resident,
Objective: To determine the frequency of various causes of hand trauma and the **Assistant Professor And Head,
pattern of outcome in terms of traumatic amputation of fingers / hand, duration of *** Senior Registrar
hospital stay, complications/ morbidity and mortality. ****Postgraduate Resident
Study Design: Case series study. Department of Plastic Surgery,
Pakistan Institute of Medical Sciences
Place and duration: This study was carried out in the Department of Plastic and (PIMS), Islamabad.
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. Address for Correspondence:
Muhammad Saaiq,
Conclusion: Hand trauma predominantly affects young males who have occupational Postgraduate Resident,
exposure to different machines. It is associated with a high rate of traumatic amputation of Department of Plastic Surgery,
hand and digits. Most of the cases result from avoidable occupational hazards. PIMS, Islamabad.
Key Words: Hand trauma. Hand injuries. Hand fractures. E-mail: msaaiq@yahoo.uk.com

or all the components of hand and wrist. The

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
1-3
10% of all emergency department presentations.
Hand trauma refers to trauma that involves any
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
1, 2, 4
hand.
The outcome of hand trauma depends not only
on the severity of injury but also on the adequacy of
1-3
timely instituted treatment. In the developed countries
effective hand injury preventive measures have greatly
reduced the incidence as well as severity of these
5, 6
disabling injuries.
The present study was undertaken to determine
the frequency of various causes of hand trauma and the

Ann. Pak. Inst. Med. Sci. 2009; 5(3): 131-135 131

Presentation and Outcome of Hand Trauma in a Plastic Surgical Unit
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
Ann. Pak. Inst. Med. Sci. 2009; 5(3): 131-135
Muhammad Saaiq et al
mean age was 28 ± 11.35 years. Majority of the patients
(69.56 %) were in their 2nd and 3rd decades of life.
(Figure I)
60
52
50
41
40
No. of
30
PATIENTS 25
20
13
10 7
0
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.
132
Presentation and Outcome of Hand Trauma in a Plastic Surgical Unit Muhammad Saaiq et al

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

Ann. Pak. Inst. Med. Sci. 2009; 5(3): 131-135 133

Presentation and Outcome of Hand Trauma in a Plastic Surgical Unit
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
22-24
literature.
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
7, 25, 26
been reported by other studies. 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
5-7
other published studies.
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
Ann. Pak. Inst. Med. Sci. 2009; 5(3): 131-135
Muhammad Saaiq et al
from avoidable occupational hazards.
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