Hand trauma: A prospective observational study reporting diagnostic concordance in emergency hand trauma which supports centralised service improvements

Abstract

Hand injuries are common, contributing up to 30% of accident and emergency (A&E) attendances. The aim of this study was to prospectively analyse the pathological demographics of hand injuries in a level 1 trauma centre with a Hand Trauma Unit and direct A&E links, and compare clinical and intra-operative findings. The null hypothesis was that there would be no differences between clinical and intra-operative findings (100% diagnostic concordance). Data were prospectively collected for referrals during 2012. Referral diagnosis, additional pathologies found on clinical assessment and intra-operative findings were documented on a live database accessible from both the Hand Unit and associated operating theatres. Odds ratios were calculated using SAS. Injuries (1526) were identified in 1308 patients included in the study. Diagnostic concordance between Hand Unit clinical examination and intra-operative findings was 92.5%±2.85% (mean±SEM); this was lower for flexor tendon injuries (56.3%) because a greater number of additional pathologies were found intra-operatively (2.25±0.10). This 'trend' was noted across multiple referral pathologies including phalangeal fractures (1.28±0.02; 82.9%), lacerations (1.33±0.04; 79.1%), extensor tendon injuries (1.30±0.05; 87.8%) and dislocations (1.18±0.05; 87.8%). Odds ratio analysis indicated a relationship between primary referral diagnoses that were more or less likely to be associated with additional injuries (p<0.05); referral diagnoses of flexor tendon injuries and lacerations were most likely to be associated with additional injuries. As hand injuries are a common presentation to A&E departments, greater emphasis should be placed on training clinicians in the management of hand trauma. Our findings, coupled with the presented relevant literature reports, lead us to advocate that A&E departments should move towards a system wherein links to specialist hand trauma services are in place; we hereby present useful data for hospitals implementing such services.