Abstract

Due to disease control measures, the number of elderly people increases in the community making them more actively participating in different kinds of activities. DIY-related hand injuries are common and can be severe and disabling. Recent statistical figures from NHS Digital show that there were more than 5,600 admissions in England for powered hand-tool hand injuries, and more than 2,700 for non-powered hand-tool injuries, between 2020-2021. In the Northeast region, we noticed increasing DIY-related hand injuries among older age groups. 14% of the injuries among the elderly seen at emergency departments are related to the upper limb trauma, while 29% of them related to the hand and wrist. The mode and level of injury are important determining factors for the functional outcome. Distal and clean-cut injuries carry far better prognosis than proximal and crush injuries. Patients who underwent surgical intervention especially replantation or revascularization, may be in need for secondary procedures. This will depend on the extent, mechanism, level of injury, adequacy of soft tissue coverage and post operative rehabilitation. Several factors may help in decision making regarding the need for replantation or revascularization. These factors include ischemia time, mechanism of injury, level of amputation, patients’ age and profession, and other concomitant life-threatening injuries Replantation, revascularization became more successful due to recent advances in microsurgical team. Return of function after replantation is an important factor to determine if the replantation was saucerful or not. Those patients may require secondary procedures.

1. Introduction

We sought to gain an insight into the pattern of DIY-related injuries, surgical management and outcome in the postretirement population.

2. Methods

Patients aging above 65 years who presented to our hand unit between July 2017 and January 2022 with DIY related hand injuries were prospectively included in this study. Pattern of injury, surgical management and outcome were recorded. The clinical outcome was assessed during hand physiotherapy follow up based on the Minimal Clinically Important Difference (MCID) of the quick Disability of Arm, Shoulder, Hand score (Quick DASH). Scores at the beginning and end of rehabilitation were compared.

The Disability of the Arm, Shoulder, and Hand (DASH) questionnaire is an upper-extremity-specific outcome measure. It is commonly used in clinical trials and studies on upper-extremity disorders. The Quick DASH is a shorter version of DASH score and used to evaluate the long-term functional outcomes.

Although both of DASH and Quick DASH score are equally reliable, The Quick DASH score is easier that DASH score for this it is more convenient to the patients. To calculate Quick DASH scores, at least 10 of the 11 items must be completed; scores cannot be calculated if more than one item is missing. Higher scores carry bad prognosis. ³ Figure 1.

The minimal clinically important difference (MCID), also known as the minimal important change used to assess the responsiveness to the Quick DASH score. Any small change in the score carry good prognosis to the patient. ⁵. Figure 2.

3. Result

19 patients were included. Age ranged between 66-94 years (average 72). They have been categorized into 15 patients sustained amputation of one or more digits, 2 had multiple flexor tendon divisions in zone-II, 1 patient presented with thumb degloving and 1 sustained open comminuted metacarpal fracture. Figure 3.

The outcome of these patients is variable. The patients of amputation, 8 out of 15 went for successful replantation/revascularization. For the remaining 7, 4 went for terminalization straight away, 2 went for soft tissue reconstruction by local flap and 1 went for terminalization after failed trial of replantation.

The patient of open comminuted fracture underwent reconstruction by iliac bone graft. On the other hand, the patient who suffered from degloving injury left thumb underwent reconstruction by local flap. Finally, the 2 patients of tendon division, had tendon repair successfully. Figure 4.

MCID Score ranged between 7.8 and 56.8 with no specific character for any of the categories.

Dependency outcome was variable, 16 patients were completely independent after completing their physiotherapy, two were partially dependent and one needed full social care package.

Although there is no significant difference in both of pain severity and cold intolerance in between the different categories, the case of thumb amputation which reconstructed by local flap shows the highest CRPS, Quick DASH score and the only one who was in need for full social care package.

Replantation cases was in need for longer period of rehabilitation in comparison to the cases of tendon repair. Average 10 months for the former and 5 months for the later.

The cases of amputation carried a higher complication rate in comparison to the other 3 categories.

4. Discussion

MCID, Quick DASH score are useful tools for the prognostic outcome for the cases of upper limb trauma.

Based on the degree of damage the rehabilitation outcome can be predicted. The cases of amputation needs longer rehabilitation time in comparison to the other categories of upper limb trauma.

5. Conclusion

Severe hand injuries in older age groups can dramatically change their quality of life. Surgical treatment and compliance with hand physiotherapy follow up can be challenging due to frailty or comorbidities.

We propose a better education system to highlight the risks, reduce the incidence, and improve awareness of these injuries among elderly for better quality of life and to reduce the associated workload and financial burden within the NHS.

Limitation of the study

Small group of patients.

References