Hand Injury among Patients Visiting Emergency Department in a Tertiary Care Centre: A Descriptive Cross-sectional Study

ABSTRACT Introduction: The hand is a complex organ responsible for activities of daily living, making it susceptible to injuries and accidents. Hand injuries can result in significant functional impairment and it occurs in a younger productive age group. Therefore, it is important to understand the prevalence and patterns of hand injuries. The aim of the study was to find out the prevalence of hand injuries among patients visiting the emergency department of a tertiary care centre. Methods: A descriptive cross-sectional study was in the Emergency Department of a dedicated trauma center from 1 June 2022 to 31 August 2022. Ethical approval was obtained from the Institutional Review Board (Reference number: 148412078179). Demographic profile, pattern, and mechanism of hand Injuries of all 96 consecutive patients were assessed after taking informed consent. Convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 4679 patients visiting the emergency department of the trauma center, hand injuries were seen in 96 (2.05%) (1.64-2.46, 95% Confidence Interval). Conclusions: The prevalence of hand injuries was found to be lower than other similar studies done in similar settings.


INTRODUCTION
The hand is a complex organ with intricate anatomy, essential for employment, communication, expression, and activities of daily living making it susceptible to injuries and accidents. Hand Injuries account for 6.6 to 28.6% of injuries. 1 In Nepal, hand injuries accounted for 4.19% of emergency visits in the 20 to 29 year age group, representing injuries to the most productive population. 2 It is reported that 58.5% of hand injuries had residual functional impairment. 1 It can lead to prolonged time off work. 3 With increasing investment in manufacturing and the mechanization of agriculture, it is essential to understand the prevalence and patterns of hand injuries in Nepal, particularly in the context of a dedicated public trauma hospital in Nepal. The study will form a baseline for further studies.
The aim of the study was to find out the prevalence of hand injuries among patients visiting the emergency department of a tertiary care centre.

METHODS
The descriptive cross-sectional study was carried ampong patients presenting to the Emergency Department of the National The minimum required sample size was 2401. However, the final sample size taken was 4679.
The demographics of the patient like name, age, gender, weight, occupation, hospital number, address, time, and mode of injury along with the place of injury, hand dominance, and time duration of injury at presentation were recorded by filling the Pro-forma. The hand injury was evaluated. The description of the wound and whether the dominant hand was involved were noted. The hand was assessed for injuries to the skin and soft tissue, muscles and tendons, nerves and vessels, and bones and joints and entered into the proforma. Operative and radiographic findings were noted and the hand injury severity was classified using the Hand severity score. 4 Hand injuries were classified based on different occupation of the patients as per the International Standard Classification of Occupations. 5 Data collected were entered and analyzed using IBM SPSS Statistics version 25. Point estimate and 95% Confidence Interval were calculated.

RESULTS
Among 4679 patients visiting the emergency department of the trauma center, hand injuries were seen in 96 (2.05%) (1.64-2.46, 95% CI). The mean age was 29.77±13.83 years with a range from 1 to 72 years. Most of the patients were male, i.e., 76 (79.17%) compared to females who were 20 (20.83%) in number. Right-hand dominance was seen in 87 (90.62%) of the patients while the left was seen in 6 (6.25%). Three infants and children (ages 12, 24, and 24 months) did not show hand dominance. The dominant hand was involved in 48 (50%) of the cases.

DISCUSSION
The prevalence of hand injury in this study was 2.05% which is less to the other retrospective study done in Nepal where the rate of hand injury was 4.19% of the emergency registrations. 2 The study from Poland estimated hand injuries to occur 5.74 per 10,000 population. A systematic review of global trends in hand and wrist trauma estimates an increasing trend in hand injury by 25% particularly in low-middle and middle sociodemographic countries. 6 Free Full Text Articles are Available at www.jnma.com.np It is particularly relevant as the mean age group in this study population was 29.8, which is an active working age group. The mean age group in our study is similar to the findings from the previous study from Nepal where the mean age was 28.79 for males and 30.43 for females. 7 The ages of 20 to 30 had the highest rate of hand injuries. 2 This is in contrast to the findings from the study done in Poland where the mean age was 37 years. The study population is again older in comparison to the study conducted in Nepal, where the mean age was 23.5. The findings of hand injury in this productive population have important repercussions. Without access to proper surgical management and long-term rehabilitation, the potential for long-term pain and loss of productivity is great.
The most common occupation to suffer hand injuries in this study were craft and trade-related workers which included mechanics, carpenters, aluminum frame workers, grill makers, and textile and garment workers. Elementary occupations like manual laborers, factory workers, and stone masons were the next most commonly injured population. Most injuries occurred in the workplace during a work-related activity. However, in the previous study from Nepal road traffic accidents were the most common cause of hand injuries. 2 Machinery injury which includes an electrical circular saw for metal and wood cutting was the most common cause of injury which is similar to the previous studies in Nepal. 7 Road traffic accidents were also an important cause of hand injuries similar to previous studies but it is interesting to note that a considerable number of people injured their hands while cleaning the motorbike chain with the engine running. 8 While burn injuries to the hand and their sequelae played a major part in the surgical workload in a previous study from Nepal, burn injuries to the hand were not seen in this series. 9 Hand injuries can have a varied presentation ranging from lacerations in the skin to amputations, causing significant functional impairment. Most of the cases in this series presented tendon injuries and phalangeal fractures. Worryingly, digital amputations were also very common in this series. While most of the patients had minor injuries as per the Hand Injury Severity score, about 14% had major to severe hand injuries. 4 This is concerning because there was a significant correlation between the severity of hand injury and persistent disability from the polish study, where an average of 58.5% of the patients had functional hand impairment. They also demonstrated a correlation between loss of hand function and return to the preinjury profession. 1 In a Dutch study, it was seen that the median time to return to work was 10.5 weeks with 9% taking longer than a year to return to work. 10 Several patients had crush injuries and amputations in this series, it is worrying because it was seen in a previous study by Wong that severe crush had the highest time off work. 3 As most of our cases belonged to crafts, trade-related and elementary professions, this can place a significant financial burden and may result in a loss of livelihood.
While most of the cases involved manual labor, only 25% of the hand injuries were funded by the employer. Most studies find that indirect costs contribute to the majority of healthcare costs. Most of the economic impact of hand injury stems from the loss of productivity. 1 Although this is a single-center hospital-based study in a dedicated trauma center in Nepal, it is of short duration and it may not reflect the actual burden of the disease. Long-term follow-up looking into the outcome of hand injuries would be necessary to assess the impact of hand injuries.

CONCLUSIONS
The prevalence of hand injuries was found to be lower than other similar studies done in similar settings. Workplace injury was the most common cause of hand injury. Hand Injuries occurred in a young and productive population with machinery being an important causative factor. It is essential to explore safety measures at the workplace as most of the hand injuries occurred during work-related activity in a productive age group.