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ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 4  |  Page : 98-102

A retrospective study on the clinical profile of patients with open hand injury presenting to the emergency department of a tertiary care center in South India


Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission09-Sep-2019
Date of Decision03-Oct-2019
Date of Acceptance17-Oct-2019
Date of Web Publication12-Dec-2019

Correspondence Address:
Dr. Darpanarayan Hazra
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_38_19

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  Abstract 

Background: The human hand is a vital part of our day-to-day activities. Most of the time, our body movements do not cause problems, but it is not surprising that symptoms develop from everyday wear and tear, overuse, or an injury. To reduce this risk, even the smallest hand injuries require proper medical care. Materials and Methods: We conducted a retrospective observational study of all trauma patients with open hand injuries presenting to our emergency department (ED). Details of the incident, injuries, management, and outcome were noted. Results: During the study period of 8 months, we received a total number of 4414 trauma patients to our ED, among which 291 (7%) had hand or upper extremity injuries. Most of these patients had crush injury (33.7%) or cut injuries (27.4%) that are mostly work related. Most of the injuries happened in the active age groups ranging from 0 to 30 years of age where cut injury and crush injury (13%) were the most common, Road traffic accidnets account for (26.3%), whereas cracker burst injuries were the cause in (8.9%). The index finger (17%) is the most commonly injured finger, followed by the thumb (16%). Fractures and amputations of the fingers and hands were seen in (24.7%) and (22.1%), respectively. Other injuries included lacerations (15.3%) and tendon injury (14.2%). Most patients (93%) were taken up for emergency procedures such as wound wash, debridement, suturing, or nailing of the fractures in the ED. Approximately half (48%) of the total patients were admitted in ward and had to undergo major surgical intervention. The rest were either discharged (45%) stable or discharged against medical advice (7%) after the primary care. Conclusions: This study showed the pattern of hand injuries in the children, the young, and the elderly. Public awareness and education, along with needed legislative enforcement for the betterment and well-being of the mass, is needed to prevent the catastrophe since these injuries are prevalent in the productive age groups.

Keywords: Emergency department, open hand injury, profile of trauma, trauma


How to cite this article:
Kharrngi BC, Hazra D, Joseph JV, Abhilash KP. A retrospective study on the clinical profile of patients with open hand injury presenting to the emergency department of a tertiary care center in South India. Curr Med Issues 2019;17:98-102

How to cite this URL:
Kharrngi BC, Hazra D, Joseph JV, Abhilash KP. A retrospective study on the clinical profile of patients with open hand injury presenting to the emergency department of a tertiary care center in South India. Curr Med Issues [serial online] 2019 [cited 2020 Sep 26];17:98-102. Available from: http://www.cmijournal.org/text.asp?2019/17/4/98/272801




  Introduction Top


The human hand has unique anatomical features that can be controlled to a higher degree. The dexterity of the human hand cannot be explained solely on anatomical factors. The neural machinery underlying hand movements is a major contributing factor, placing the hands “closer” to the brain. They are the instruments of performance and protection, the main source of differentiated tactile sensations and a precise working organ enabling gestures. The right and left hands are each controlled by the opposite hemisphere of the brain. Usually, one hand is preferred for fine and complex motion, leading us to speak of someone as being either right- or left-handed.[1],[2],[3] At one time or another, everyone has had a minor injury to a finger, hand, or wrist that caused pain or swelling. Most of the time, our body movements do not cause problems, but it is not surprising that symptoms develop from everyday wear and tear, overuse, or an injury.[4],[5],[6] Finger, hand, or wrist injuries most commonly occur during sports or recreational activities, work-related tasks, and work or projects around the home, especially if using machinery such as lawn mowers, snowblowers, or hand tools, accidental falls, and fistfights.[5],[6] Therefore, an injury to the hand and its underlying structures carries the potential for serious handicap and can have an adverse effect on the normal daily activities depending on the type and region of injury. To reduce this risk, even the smallest hand injuries require proper medical care.[1],[7],[8]

This retrospective study was done to determine the prevalence of patients with open hand injury and the different types of mechanism of injury, the sites of injury to the hand involved, and whether procedures were done in the emergency department (ED) leading to the different outcomes in the patient's life, functions, and disability of the hand who suffered the injury.


  Materials and Methods Top


Study design

The study was a retrospective cohort study conducted in the ED of Christian Medical College (CMC) Hospital, Vellore.

Setting

The study was conducted in the ED which is a 50-bed department and tends to about 300 patients per day including trauma and nontrauma patients.

Participants

The study recruited all patients with open injury to the hand, presented to the ED of CMC, Vellore, during the study period. We reviewed a total of 190 patients over a period of 8 months (August 2016–March 2017).

Inclusion criteria

Patients with open hand injury.

Exclusion criteria

  1. Charts with incomplete data
  2. Upper limb injuries other than hand injury (distal to the wrist).


Variables

The charts were reviewed, and the relevant details of history, clinical findings, laboratory investigations, and X-rays findings were documented in the study form. The management in terms of conservative and surgical was noted like immediate managements or procedures performed in the ED. The outcomes of the patients from the ED with regard to the admission, discharged, discharged against medical advice, or deaths were also documented.

Outcome variable

Outcome of open hand injuries presenting to ED.

Bias

This is a retrospective study, and therefore, we could not control exposure or outcome assessment and instead relied on others for accurate record-keeping.

Study size

Based on the pilot study information, the prevalence of open hand injury among trauma patients in May 2015 was 14%. With a 5% precision and 95% confidence, the required sample size of the study would be 183. We reviewed a total of 190 patients over a period of 8 months.

Laboratory test

All patients had routine blood investigations and relevant radiological tests based on the initial primary and secondary surveys.

Statistical analysis

All categorical variables were expressed as frequencies and percentages. The data were entered in EpiData software and were analyzed using the Statistical Package for the Social Sciences (IBM Corp. Released 2015. IBM SPSS, Version 23.0, Armonk, NY, USA). Data were summarized using mean along with standard deviation for continuous variables, and frequencies along with percentages were calculated.

Ethical considerations

This study was approved by the Institutional Review Board prior to the commencement of the study; approval from the Institutional Review Board Ethical Committee was obtained (IRB Min no: 10621 dated April 3, 2017). Patient confidentiality was maintained using unique identifiers and password-protected data entry software with restricted users.


  Results Top


A total of 4414 trauma patients presented to the ED of CMC Hospital, Vellore, during the study period. Among them, 291 (7%) had hand injury or upper extremity injuries. These patients' charts were screened, and 190 (65%) patients were included in the study [Figure 1]. The patients were classified into four age groups. Among these patients, (19.5%) were from the pediatric age groups as young as 1 month to 15 years of age, (42%) of the patients were 16-30 years old, and (35%) from the age of 31–60 years. The mean age of presentation was 28.3 years. Male predominance was observed with 164 (86%). Most of the patients sustained crush injury (33.7%) or cut injuries (27.4%), which are mostly work-related injury. Road traffic accidents (RTAs) accounted for (26.3%), whereas injury due to cracker burst was (8.9%). Thermal or burn, electrical, and other injuries were (1.1%), (1.1%), and (1.6%), respectively [Figure 2]. Of all the patients, (64.74%) of the patients had already received some treatment or were referred or were discharged from some other hospitals, whereas (33.16%) patients presented directly to the ED. Less than 10% of the patients with open hand injuries had a history of alcohol intake associated with the injury. Most of the hand injuries occurred in daily laborers (44%), such as farmers, sugarcane juice maker, and mason. The factory or machine worker who deals with machine and tools comprised (22%). There were (14%) preschoolchildren who suffered hand injuries such as door crushed injuries, sharp cuts, or thermal burns. It was noted that these students usually developed crushed injury to the fingers by a bench or while playing in the school and accounted for (9%) of total open hand injury. Other occupations such as homemaker or office worker sustained very less hand injuries [Figure 3]. Most open hand injuries (48%) happened during the working hours of the day (0800–1559 h), and (39%) occurred during the evening (1600–2159 h). The rest of the hand injuries (13%) happened at night hours (2200 h–0759). In the working hours (0800–1559 h), most of the injuries happened in the workplace and noted in (20%) of the patients. The most common cause of hand injuries in the evening hours (1600–2159 h) was due to RTAs (16%) [Figure 4]. The fingers were very common to open hand injury. The index finger (17%) was the most common site, followed by the thumb (16%), the middle finger (12%), and then the little finger (7%). Injuries to the palm (13%) in crushed injury and cracker burst injury were also quite significant. Among the injuries, fractures (24.7%) and amputations (22.1%) were quite common to the fingers or hands. Tendon injury was noted in (14.2%), and a laceration injury was seen in (15.3%) [Table 1]. Majority of the study population had a fracture i.e. (60%) patients, while (38%) of the patients had no fractures. Among the patients who had fractures (60%), the distal phalanx (33%) was among the most commonly involved bone followed by the proximal phalanx (28%) and metacarpals (24%). Carpals and middle phalanx were (5%) and (10%), respectively [Figure 5]. Most patients (93%) were taken up for emergency procedures such as wound wash, debridement, suturing, or nailing of the fractures in the ED. There were 48% of the total patients admitted into the ward and had to undergo major surgical intervention. The rest were either discharged (45%) stable or discharged against medical advice (7%) after primary care.
Figure 1: Strobe diagram

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Figure 2: Modes of injury with age groups

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Figure 3: Occupation of patient

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Figure 4: Time and place of incidence

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Table 1: Types of injury

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Figure 5: Site of hand injury

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  Discussion Top


Any injury has the potential to cause prolonged disability or death. Depending on the severity of injury, quick management and transport to an appropriate medical facility or a trauma center may be necessary to prevent loss of life or limb. Trauma to the hand is quite common in the society.[1],[2],[3] In some particular cases, the entire finger or hand may be subjected to amputation. The majority of traumatic injuries are work-related. Today, skilled hand surgeons can sometimes reattach the finger or thumb using microsurgery if the patients present to the ED on time following the injury where the injured parts are viable.[9],[10],[11]

In this retrospective study on open hand injuries, we found that the total number of open hand injuries in the period of 8 months was 190 among the 4414 trauma patients. The prevalence of open hand injuries among all trauma patients presenting to the ED was 4.3%.

In our society, males are the workforce and the breadwinner of the family. Hand injuries are commonly seen during the working hours of the day.[12],[13] These patients who sustained open hand injury are predominantly males as compared to females in the ratio of 6.3:1, which is similar to a study conducted by Gupta et al. in Ludhiana city of Punjab in 2013 (male:female ratio: 6.2:1).[14]

Most of the patients in the younger age group sustained crushed injuries, especially to the fingers on the door and the benches in school or while playing at home. Another type of injuries is also found commonly during festivities where crackers are used and which is very prone to open hand injury. Therefore, awareness campaign and pamphlet distribution can be organized during such seasons. Among the types of open hand injuries, fractures and amputation of the fingers or hands were the common ones. The most common bone involved in fracture is the distal phalanx, with the index finger being the most common.

Most of the patients who sustained open hand injuries were taken to a local medical center or primary care center where they received first aid. Fifty percent of the injured patients presented to the ED within 1–3 h of the incident owing to the fact that CMC has a dedicated department of Hand and Leprosy Re-constructive surgery (HLRS) and being the referral center, which covers a large area in and around Vellore.

Wound wash is performed in most patients after initial workup by the ED registrars. Emergency procedures such as suturing or surgical amputation of the fingers or wire fixation of the bones in the ED were done by the referred doctors (HLRS). More than half of the patients were discharged and some were asked to follow-up in the outpatient department, as wound wash and other emergency procedures are adequate enough for their injuries and do not need admission in the hospital. Those who were admitted in the ward were taken up for emergency operations in the theater or needed further evaluation and management. A few patients (7%) were discharged against medical advice or discharged at request to go to other hospitals or medical centers due to personal constraints.

Stringent steps and regulations must be taking care of by the owners, governments, or employee union, etc., to avoid such health hazards in their settings, and also in the event of injuries, they have insurance or re-imbursements for their medical/treatment bills.[9],[12],[15]

Details of the mechanism of injury and an understanding of the injury patterns associated with particular mechanisms will help guide the examination and choice of radiologic studies. Patients with open fractures should be given a loading dose of a broad-spectrum antibiotic within 6 h after open trauma to reduce the risk infection. Patients with open injury should be referred to a hand or orthopedic surgeon immediately.


  Conclusions Top


As we all know that accidents cannot be avoided but can be prevented. Thus, at the end of this study, we hoped that we could have a better understanding of patients with hand injury and organize awareness programs to different parts of the society where such injury is commonly involved. An intensive and proactive research on open hand injury with public awareness and education along with needed legislative enforcement for the betterment and well-being of the mass is needed to prevent the catastrophe since these injuries are prevalent in the productive age groups.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Ihekire O, Salawu SA, Opadele T. International surgery: Causes of hand injuries in a developing country. Can J Surg 2010;53:161-6.  Back to cited text no. 1
    
2.
Ghosh S, Sinha RK, Datta S, Chaudhuri A, Dey C, Singh A, et al. Astudy of hand injury and emergency management in a developing country. Int J Crit Illn Inj Sci 2013;3:229-34.  Back to cited text no. 2
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Horns J, Jung R, Carrier DR.In vitro strain in human metacarpal bones during striking: Testing the pugilism hypothesis of hominin hand evolution. J Exp Biol 2015;218:3215-21.  Back to cited text no. 4
    
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Cheung K, Hatchell A, Thoma A. Approach to traumatic hand injuries for primary care physicians. Can Fam Physician 2013;59:614-8.  Back to cited text no. 5
    
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Kilian M. Clenched fist injury complicated by septic arthritis and osteomyelitis treated with negative pressure wound therapy: One case report. Chin J Traumatol 2016;19:176-8.  Back to cited text no. 6
    
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Ootes D, Lambers KT, Ring DC. The epidemiology of upper extremity injuries presenting to the emergency department in the United States. Hand (N Y) 2012;7:18-22.  Back to cited text no. 7
    
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Szabo RM, Spiegel JD. Infected fractures of the hand and wrist. Hand Clin 1988;4:477-89.  Back to cited text no. 8
    
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Government of India. Accidental Deaths and Suicides in India. National Crime Records Bureau. New Delhi: Ministry of Home Affairs; 2013.  Back to cited text no. 9
    
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Hsiao M, Malhotra A, Thakur JS, Sheth JK, Nathens AB, Dhingra N, et al. Road traffic injury mortality and its mechanisms in India: Nationally representative mortality survey of 1.1 million homes. BMJ Open 2013;3:e002621.  Back to cited text no. 10
    
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Roy N, Murlidhar V, Chowdhury R, Patil SB, Supe PA, Vaishnav PD, et al. Where there are no emergency medical services-prehospital care for the injured in Mumbai, India. Prehosp Disaster Med 2010;25:145-51.  Back to cited text no. 11
    
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Jeong BY, Lee S, Lee JD. Workplace accidents and work-related illnesses of household waste collectors. Saf Health Work 2016;7:138-42.  Back to cited text no. 12
    
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Tannvik TD, Bakke HK, Wisborg T. A systematic literature review on first aid provided by laypeople to trauma victims. Acta Anaesthesiol Scand 2012;56:1222-7.  Back to cited text no. 13
    
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Gupta A, Gupta AK, Uppal SK, Mittal RK, Garg R, Aggarwal N. Demographic profile of hand injuries in an industrial town of North India: A review of 436 patients. Indian J Surg 2013;75:454-61.  Back to cited text no. 14
    
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Ertl L, Christ F. Significant improvement of the quality of bystander first aid using an expert system with a mobile multimedia device. Resuscitation 2007;74:286-95.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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