BASIC PRINCIPLES
THE COST OF HAND INJURIES
The cost of hand injuries in financial and human terms is tremendous. In the year 2000, >50 million Americans experienced a medically treated injury, resulting in lifetime costs of $406 billion (Corso et al. 2006). Injuries to the hand and wrist account for approximately 20% of visits to the emergency department (Angermann & Lohmann 1993, Larsen et al. 2004). The most commonly injured body part in occupational accidents in the United States is the upper extremity, according to a report of the Center for Disease Control and Prevention. Hand injuries account for one-third of all injuries at work, one-third of chronic injuries, one-fourth of lost working time, and one-fifth of permanent disability (Marty et al. 1983). In a recent study from The Netherlands, hand and wrist injuries annually accounted for $740 million (in US dollars) and ranked first in the order of most expensive injury types, before knee and lower limb fractures ($562 million), hip fractures ($532 million), and skull–brain injury ($355 million) (de Putter et al. 2012). Although hand injuries occur in all age groups, they are most prevalent in young people, thus affecting the active and earning part of the population most severely. The consequences of a hand injury for an individual include pain and suffering immediately, possible loss of function, and earning capacity for the rest of one's life and reduced potential to live one's life to its full potential. The burden for society is therefore in the form of a drain on financial resources, along with a loss of contributions from its most active and capable segment.
The cost of an injury is both direct and indirect. The cost of medical treatment is the direct cost, and this depends on the severity of injury, the methods of treatment and complications caused by the injury, and any medical intervention. This is only a fraction of the overall cost and does not take into account the financial impact on the patient and his family or the costs to the employer, community, and the cumulative impact on the national economy. In the Raimbeau's report from France, only 20% of the cost was for treatment and the remainder was the indirect cost of the hand injuries (Raimbeau 2003). It is estimated that a mean of 31 days of work are lost per upper extremity injury, resulting in three to four million working days lost each year in the United States. In France, 18% of the total days lost by work accidents and 18% of the cost of work accidents were due to hand injury. Both the direct and indirect costs of a hand injury rise with increasing injury complexity. The burden of hand injuries may be assumed to be greater in low- and middle-income countries because of economic factors, lack of infrastructure for the care of hand injuries, and the devastating impact of hand injury on the earning potential of an individual and his family. This burden can be reduced by effective preventive measures, recognition of the importance of hand surgery by the medical leadership of a country, proper primary treatment of hand injuries by specialist hand surgeons, and functional rehabilitation of the injured patient. The resources spent toward this objective are most cost effective. Using the summary measure of ‘healthy life years’ (HeaLYs), the hand is the anatomical region that yields the most gain of HeaLYs (Salinas et al. 2002).
EVOLUTION OF HAND SURGERY
Hand surgery as a specialty evolved during World War II and the treatment and care of hand injuries has progressed considerably since then. The principles of early debridement, leaving the wound open, ‘second look,’ and delayed closure, born of necessity in the combat environment, have evolved into an emphasis on primary healing by radical debridement and early coverage and composite reconstruction wherever it can be accomplished safely in civilian practice (see Chapters 6 and 13). The advent of microsurgery in the latter part of the last century had a major impact on the way hand injuries are being treated now. Replantation of the amputated parts became feasible and reconstruction by free tissue transfer made salvage of severely injured hands possible. Reconstruction of these injuries was inconceivable before the microsurgical era (see Chapters 17 and 18). Flap surgery has been completely revolutionized from the days of random pattern flaps by better understanding of cutaneous blood supply and application of microsurgical techniques. Now a myriad of flaps is available to match the reconstructive needs of an individual wound and various combinations of tissues can be transferred as composite reconstruction with minimal donor site morbidity (see Chapter 13). Results of tendon repair have improved by emphasizing primary repair when feasible, better suture materials and techniques that allow early motion, along with the evolution of postoperative tendon protocols based on a better understanding of biological principles (see Chapters 10 and 11). Modern techniques of nerve repair under magnification and emphasis on tension-free nerve repair using nerve grafts when required, as well as placement of the repaired nerve in a well-vascularized, scar-free bed have helped to improve results immeasurably from the days when the principle objective of nerve suture was simply the physical union of the cut ends at almost any cost (see Chapter 12). Nerve transfer procedures developed in last two decades, and the availability of many sensory cutaneous flaps has addressed the majority of reconstructive issues. These developments have minimized the need for secondary reconstructive procedures such as tendon transfers.
Experience has shown that the care of complex hand injuries is better accomplished in specialized hand surgery centers where patients can be treated from initial resuscitation to functional rehabilitation without ‘fragmentation’ of treatment. Continuity of medical care is an important principle (Raja Sabapathy 2006). Initial care determines, to a large extent, the ultimate outcome of a hand injury. Proper primary treatment in a specialized unit reduces the rate of complications, minimizes need for secondary procedures such as toe transfers, and improves the outcome.
PREVENTING HAND INJURIES
The adoption of safety measures is the best strategy to prevent hand injuries and minimize their tremendous impact. Looking at just one sector of the construction industry in the United States, the figures show that road constructors pay $48 million more for hand injuries each year than the $8.3 million it would cost them to equip all of their hazard-exposed workers with protective gloves. In the United States, 2the Occupational Safety and Health Administration (OSHA) is the key agency responsible for enforcing safety regulations and keeping the work place safe. Low- and middle-income countries often do not have a comparable regulatory prevention network such as OSHA, and thereby lack any stringent adherence to safety guidelines. As a result, hand injuries are relatively more common and their consequences are more serious. Globalization, rapid industrialization, and the push for economic development in some of these societies have outpaced safety measures in industry and farming and have magnified the impact of the hand injuries (Schaub & Chung 2006). The National Hand Societies have an important role in increasing awareness in the public and persuading their governments to implement effective safety measures. Farm workers are particularly vulnerable in these countries as most farming equipment lacks safety guards, and the farming sector is deprived of any state-sponsored social security or workplace compensation schemes.
The principles of treating hand injuries are universally applicable in diverse medical environments as will be apparent from the array of authors and presentation of their experience in the following chapters. A plea for understanding and application of these principles is the raison d'être for this treatise. Optimal care is the best strategy to reduce the cost and suffering resulting from hand injuries.
ABOUT THIS BOOK
The book is divided into four sections. The first section (Chapters 1–7) covers the nature of the problems in complex hand injuries and the principles involved in diagnosis, treatment, and rehabilitation. It also deals with the necessary contributions for comprehensive treatment of complex hand injuries from radiology, anesthesiology and hand therapy departments. Proper imaging of the hand is essential for the accurate diagnosis and treatment of hand injuries. Computed tomography (CT) scanning and magnetic resonance imaging (MRI), in addition to traditional radiographs, have added tremendously to our ability to evaluate complex hand injuries (see Chapter 4). The development of modern techniques for regional anesthesia has greatly influenced choice of anesthesia in recent years. These techniques are presented in Chapter 5. An essential role is played by the hand therapist in preventing complications of hand injuries and maximizing the potential for functional recovery. A close collaboration between the hand surgeon and therapist is therefore of the utmost importance in achieving the best possible outcome in hand injuries (see Chapter 7).
The second section (Chapters 8–13) deals with individual tissue system injuries such as skeletal, tendon, nerve, and skin injuries. Emphasis is on comprehensive primary repair and early rehabilitation wherever permitted by the conditions of the wound, available facilities and skills, and support services.
The third section (Chapters 14 and 15) covers the injuries resulting from some special mechanisms such as thermal and chemical injuries and injuries under special circumstances, such as war injuries. Combat injuries have their peculiar issues due to the weapons used and circumstances of the war. In recent conflicts, although survival has improved, the rate and severity of injuries to the extremities have both increased. The principles of comprehensive primary repair that are suitable for civilian injuries may not be applicable in wartime circumstances and definitive repair may need to be delayed (see Chapter 15).
The last section (Chapters 16–19) deals with the use and impact of special techniques such as microsurgery and external fixation in dealing with complex hand injuries. No other technical development has influenced the treatment of complex hand injuries in the manner microsurgery has, regarding our ability to save the amputated parts and reconstruction by tissue replacement (see Chapters 17 and 18). Despite the best primary treatment, secondary procedures may be needed to achieve full potential of functional recovery (see Chapter 16). These procedures are performed either to complete the deferred primary repair or to improve the outcome of primary procedures.
No attempt is made to produce an encyclopedic compilation nor it is a book of techniques. The essential philosophy in this book is an emphasis on understanding the principles that can be applied universally despite the great variability in the presentation of injuries and the facilities available to treat them.
REFERENCES
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- de Putter CE, Selles RW, Polinder S, et al. Economic impact of hand and wrist injuries: health-care costs and productivity costs in a population-based study. J Bone Joint Surg Am 2012; 94: e56.
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- Raja Sabapathy S. Management of complex tissue injuries and replantation across the world. Injury 2006; 37: 1057–1060.
- Salinas AM, Villarreal E, Nuñez GM, et al. Health interventions for the metal working industry: which is the most cost-effective? A study from a developing country. Occup Med (Lond) 2002; 52: 129–135.
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