Hand Therapy >
Volume 14, Number 1 >
Pp. 10-21
Health Care and Epidemiology, University of British Columbia, Vancouver, BC, Canada
Correspondence: Dr Lynne Feehan, Centre for Hip Health and Mobility, Faculty of Medicine, University of British Columbia, 311-2647 Willow Street, Vancouver, BC V5Z 3P1, Canada. Email: Lynne.feehan{at}hiphealth.ca
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Methods. A BC-linked health data-set one-year retrospective review of all reported work-place hand fracture injuries in BC in 2001 with additional evaluation of individual health care and claims data from randomly selected individuals with a compensation claim in 2001.
Results. There were 14,654 hand fractures, of which 14% (2085) were work related; an annual incidence rate of 11/10,000 workers. Males accounted for 88% (1488/2085) of the fractures and the mean age was 39 (SD: ±12). Only 60% (290/482) of randomly selected people filed a compensation claim. Of these claims, 90% (260) had a validated hand fracture injury, 72% (218) were non-articular and 13% (38) had complex associated tissue injuries. About 69% (180) had no or simple closed reduction, 82% (213) had no additional fixation, 63% (163) were immobilized for at least 21 days and 9% (24) developed a secondary complication that required surgery. Average days off work was 46 (range 0–290) and average claims cost was $5500 CDN (range $145–$56,900).
Conclusions. Hand fractures are a common workplace injury in BC, with a significant proportion of workers not claiming compensation. These injuries generally presented clinically as simple fractures that were managed conservatively with few complications. Despite this, there was still a significant socioeconomic burden primarily due to lost work-place productivity due to time loss from work. These findings likely reflect similar trends for work-related hand fractures throughout Canada and other countries with similar health care and workers' compensation systems.
Key Words: Claim rates • claim costs and duration • clinical presentation • complications • demographics • fracture • hand • incidence • management • population-based • work-related
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The rates reported for work-related fracture injuries vary considerably in the literature ranging from 4% to 6% of work-related injuries in three studies in the USA5,7,8 to 18% of all work-related injuries in Norway.9 Three USA studies also report rates for work-related hand fractures relative to all work-related fracture injuries, with work-related hand fractures accounting for 18% in one study,8 and 36% and 41% of all work-related fracture injuries in the other two.5,7 Chung and Spilson,10 estimated that 9% of an estimated 1.5 million hand and forearm fractures treated in emergency departments in the USA in 1998 occurred in the workplace. Whereas, Stanton et al.11 report that 15% of 655 people treated in a single accident and emergency department in the UK in 2004 for a metacarpal and phalangeal fracture had a work-related injury. Only one study, Islam et al.5 reported an annual incidence rate for work-related hand fractures; in this study there were 23 work-related hand fracture injuries for every 10,000 workers in West Virginia. There are a number of reasons for the differences in these work-related hand fracture injury rates including differences in the demographics, socioeconomic status and industrial base within the populations studied. In addition, differing definitions for a work-related injury, as well as differences in reporting, compensation policies and data capturing may also account for some of the variation.7
To our knowledge, no previous study has conducted a population-based study evaluating all work-related hand fracture injuries occurring in a large diverse population working in a broad range of occupations and industries with variable risks for sustaining a hand fracture. Thus, the objectives of this study were two-fold: (i) to describe population-based incidence, demographics and compensation claim rates for all work-related hand fractures identified from the BC-linked health data-sets (BCLHD)12 during 2001; and (ii) to describe the mechanism of injury, clinical presentation, medical management and secondary surgical complications, as well as the claims duration and costs from a stratified random sample of all work-related hand fracture injuries treated in BC in 2001.
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This study utilized extracted data records from the BCLHD Medical Service Plan (MSP), Hospital Separation (HS), MSP Registration (Registry) and WorkSafeBC data-sets.6,12 All records for treatment of hand fractures within each of these data-sets were identified using the International Classification of Disease, Version 9 (ICD-9) codes for Metacarpal (815), Phalangeal (816) or Multiple (817) hand fractures.14 From the records of all individuals treated for a hand fracture in 2001, all ‘work-related’ hand fracture injuries were identified by:
All people who received medical treatment for a self-reported or medically identified work-related hand fracture in 2001 were identified and then those which could also be linked to at least one WorkSafeBC compensation claim in 2001. This was followed by a further stratified (by geographic region) random sample of all reported work-related hand fracture injuries, followed again by the identification of those individuals in the random sample with at least one WorkSafeBC compensation claim in 2001.
The individual claim numbers for each of these claims were then used to access and review each person's WorkSafeBC electronic claim file to validate the presence of an actual or suspected hand fracture injury. Finally, for all individuals with an actual hand fracture injury the mechanism of injury, fracture characteristics, medical management and secondary surgical complication data were extracted from the e-file and linked for further analyses with each individual's claims duration and cost data extracted from the BCLHD – WorkSafeBC claim and injury data records.
Two reviewers (one certified hand therapist and one qualified plastic surgeon) independently reviewed and extracted the hand fracture data from the WorkSafeBC e-file. Data extraction was validated in a separate random sample of 25 e-files independently reviewed by both reviewers in order to identify potential areas of clinical disagreement. Any questions regarding the potential accuracy of any extracted data for this study was reviewed by both reviewers, with any disagreement resolved by consensus or coded as unknown if there was no agreement.
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Only 1415 of the 2085 (68%) individuals with a work-related hand fracture could be linked to any compensation claim in 2001. Whereas 49% (1016/ 2085) could be specifically linked to a claim accepted for a hand fracture [ICD(9) Code (815-817)] with two people linked to two distinct hand fracture injury claims in 2001. Of the 399 people linked to a non-hand fracture compensation claim in 2001, 82% (327) were linked to an upper extremity injury claim, with the five most common injury categories being contusion, laceration, fracture (non-hand) or amputation within the upper extremity. There was no difference in either the age or gender distribution for those with or without a compensation claim in 2001.
Hand fracture validation
Of the 325, individuals with at least one compensation claim 290 (89%) were found to have an actual (n = 260) or suspected (n = 30) hand fracture injury after e-file review. Therefore, only 290 of the original 482 (60%) randomly selected people who received treatment in the public health-care system in BC for a work-related hand fracture injury in BC in 2001 could be linked to compensation claim for a validated hand fracture injury in the same year.
Demographics
The 260 individuals with a validated hand fracture injury had 301 hand fractures (1.2 fractures/person), of whom, 228 had a single hand fracture, 23 had two hand fractures and nine people had three hand fractures. As expected, the age (mean age: 38 ± 12) and gender (88% male) distribution were representative of the total population of work-related hand fractures in BC in 2001. Males accounted for all multiple fractures. The right side was injured in 53% (n = 138) of the injuries; there were no bilateral hand fracture injuries.
Mechanism of injury
A crushing injury (hand or finger caught between or under heavy objects) accounted for 67% (174/260) of the hand fracture injuries, with a hitting injury (hand of finger hit or is hit by a hard object) accounting for 17% (44/260) of the injuries. A fall, saw or roller injury accounted for a further 15% (39/260) of the hand fracture injuries, whereas the remaining 2% (4/260) were caused by other mechanisms.
Fracture characteristics
Of 301 fractures, 218 (72%) were non-articular fractures. Figure 2 shows an additional breakdown for the distribution of the articular and non-articular fractures by bone, joint and hand injured. The fracture pattern was not described in the radiology report for 95 (32%) of the fractures. Of the remaining 206 (68%) with a known fracture pattern, 92 had a comminuted, 45 had an oblique, 32 had an avulsion, 28 had a transverse and nine had a spiral fracture pattern. The fracture site within the bone was not described in 54 (18%) of the 301 fractures. Of the 247 (82%) where the location of the fracture was known, 98 occurred in the head or neck, 68 occurred in the base, 42 occurred in the shaft and 39 occurred in multiple regions of the bone.
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1 day) admissions. The remaining 78% (198/260) received definitive treatment for the fracture in an outpatient setting; including treatment in an emergency department, an ambulatory care clinic or a physician's office.
Fracture reduction and fixation
Fracture reduction and fixation management was examined for the most complex hand fracture injury occurring within the individual. Of the 259 with full documentation, 13 (5%) had a primary fingertip revision amputation. An additional 181 (70%) had no reduction or a simple closed reduction. Whereas 22 (8%) had a more complex closed reduction and 43 (17%) had an open reduction. A total of 213 (82%) had no additional fracture fixation, 41 (16%) had some form of pin fixation, whereas five (2%) had a plate and/or screw fixation of the fracture. Of the 43 open reductions, 19 (44%) also had additional tissue(s) surgically repaired (Table 2).
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Secondary complications
Table 3 summarizes that 24 of the 243 people (10%) with complete medical information had a complication that required at least one hospital admission for a fracture-related complication, with a total of 53 hospital admissions. Table 4 summarizes the complication rates, odds and odds ratio relative to several clinical variables reported to influence health outcomes including: the hand bone fractured, the number of fractures, the presence of an associated tissue injury, the presence of an initial surgical intervention, the type of reduction, the type of fixation and the duration of immobilization.16–29
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The incidence rate in BC of 11/10,000 is half of the 23/10,000 worker annual incidence rate for hand fractures in West Virginia reported by Islam et al.5 These differences are likely due to different methods for defining the numerator and the denominator in the incidence ratio in the two studies. In our study, all self-reported or medically identified work-related hand fractures were ascertained from the 14,654 hand fractures treated in BC in 2001(the numerator) from a broad-based population at risk for sustaining a hand fracture including almost 1.9 million working residents identified from the 2001 BC Population Census data (the denominator). In contrast, the Islam et al.5 study identified only people with a work-related hand fracture compensation claim in a state-administered worker's compensation system (the numerator) drawn from a population base of high-risk workers working in industries registered with the Bureau of Labour Statistics in West Virginia (the denominator). Therefore, the incidence rate for work-related hand fractures in our study is more likely to be representative of a true population-based rate for work-related hand fracture injuries, as our study identified any work-related hand fracture injury treated in any medical setting by any medical professional occurring in a large socioeconomically diverse population, working in a broad range of occupations and industries with variable risks for sustaining a hand fracture.
In contrast to the general population in BC, where males account for 67% of all hand fractures,6 working males in BC accounted for 88% of all the work-related hand fractures, which can be attributed in part to the fact that there were more males than females working in BC in 2001. However, when examined in terms of relative risk, working males were at a 2.14 greater relative risk for sustaining hand fracture than working females, which is slightly higher than the 2.08 relative risk for a hand fracture for males in the general population in BC,6 suggesting that males are working in higher-risk work environments than are females. Of note, the reported hand fracture incidence rates in the general population in BC showed marked differences for people of 15–25 years old (67/10,000) compared with those of 25–75 (29/10,000),6 whereas in this study there was no difference in the age-stratified incidence rate for work-related hand fractures among those 15–25 years of age (10/10,000) compared with working people of 25–75 years of age (11/10,000). This is an interesting finding as it suggests that the markedly increased risk for hand fractures during adolescence and young adult years (15–25-year-olds) in the general population is likely not due to an occupational risk but rather to other factors such as periods of bone fragility associated with rapid growth during adolescence,6,30,31 as well as, higher participation in non-occupational high-risk recreational, leisure or sporting activities throughout adolescence and young adulthood.6,10,11,32–35
In our study, 40% of the stratified random sample of all people treated for a self-reported or medically identified hand fracture in 2001 could not be linked to a validated hand fracture claim in 2001. This was a notably large proportion of people not filing for a compensation claim. Not claiming for the injury means that the direct health care and wage loss costs for these work-related hand fracture injuries would have been inappropriately covered by the publicly funded health-care system in BC and by other privately funded employment sickness and/or short-term disability benefits. This finding is important as it suggests that up to 40%, or up to 2.5 million of the estimated 6.2 million dollar costs associated with direct health care and wage loss compensation for work-related hand fractures in 2001 in BC were not covered appropriately by the employer-funded and provincially legislated WorkSafeBC payment system. Increased public, health-care worker and employer awareness regarding the obligation to report and claim for work-related hand fracture injuries in BC would not only transfer these costs to the WorkSafeBC system, but equally importantly it would enhance the accuracy of ‘true’ work-related hand fracture claim rates, which in turn could lead to more effective workplace safety and prevention initiatives focused on reducing rates for work-related hand fracture injuries.36
Our data did not allow us to examine the specific reasons of why someone may have chosen not to file for a compensation claim for a work-related hand fracture in BC in 2001. However, this finding is consistent with other studies reporting compensation filing rates for work-related injuries.37–40 In particular, it is very similar to a study by Shannon and Lowe,39 who conducted a telephone survey of 2500 people across Canada in 2001 and found that 40% of the 255 people with an eligible work-related injury did not file for injury compensation. In addition, we found no differences in age or gender with regard to claim-filing rates for a work-related hand fracture injury, suggesting that other personal, socioeconomic and/or workplace factors associated with people not claiming compensation for a workplace injury or disease reported in other studies37–41 may also be contributing factors for why a person in BC may choose not to file for a compensation claim following a hand fracture.
In our study, the vast majority (84%) of the hand fracture injury claims were from a crushing or hitting type injury, resulting most commonly in a single (88%), non-articular (72%) fracture with no other significantly associated regional tissue injury (87%). So not surprisingly, the majority (76%) were treated definitively in an outpatient setting within 48 hours of the injury with the majority again (75%) treated with or without a closed reduction and no additional fixation, followed most commonly (67%) by a period of immobilization of at least three weeks with only small percentage (10%) likely to have a secondary complication. These findings clearly indicate that the majority of work-related hand fractures in BC are likely to present as simple clinical injuries that can be managed conservatively with limited complications.42 However, despite this, the socioeconomic impact of work-related hand fractures is still profound with an estimated 52,000 lost work days for work-related hand fractures in BC in 2001.43–47
In contrast to a 10% general population admission rate reported for treatment for a hand fracture in BC,48 and a 15% hospital admission rate for hand fractures treated in the UK,11 24% of the work-related hand fracture injury claims in our study had a hospital admission. This finding suggests that although the majority of work-related hand fracture injuries are clinically non-complex injuries, they are still more likely to present as a more severe clinical injury requiring a hospital admission for definitive care than are hand fracture injuries sustained outside of the workplace.
The secondary complication rate of 10% for a work-related hand fracture complication is comparable with Ip et al.,49 who reported a secondary surgical intervention rate of 12% (n = 108) in a series of 924 hand fractures treated by the orthopaedics department in an acute care hospital in Hong Kong from 1984 to 1994. The study of Ip et al.49 provides a comprehensive overview of the fracture characteristics and fracture reduction and fixation methods for the hand fractures treated in their series. However, they did not specifically present a breakdown for either the initial fracture characteristics or the fracture reduction and/or fixation management choices for the subset of 12% in their series requiring an additional surgical intervention; so we are unable to draw comparisons to our study with regard to possible associations with these clinical factors and complications following a hand fracture.
There are several clinical studies that describe potential clinical risk factors thought to be associated with complications following a hand fracture,16–29 however, none are randomized prospective clinical trials so it is difficult to attribute a direct relationship with these reported clinical risk factors and the actual postfracture complication rate. However, while this study was also not a prospective study, data from our population-based random sample did show that people with multiple fractures, a phalangeal fracture or an associated regional tissue injury, as well as people treated with a surgical intervention, an open reduction, pin and plate/screw fixation, and immobilization of greater than 21 days had a markedly higher odds ratio for developing a fracture complication requiring a secondary surgical intervention, than did people presenting with a single, non-phalangeal, non-complex hand fracture injury treated with no or a closed reduction and no fixation and early motion. Further studies are warranted to identify which of these factors related to hand fracture clinical presentation and management are most likely to be associated with secondary fracture complications, as our study indicates that there was a three-fold increase in claims duration and costs in fractures with a secondary complication.
There are a number of potential limitations associated with conducting a retrospective review of hand fracture data in the BCLHD administrative health services data-set and these have been described previously.5 In addition, it should be noted that although it is a requirement in BC to report and bill WorkSafeBC for any medical treatment for a work-related injury in the MSP and HS data-sets, these data should be viewed with some caution as they are not monitored for accuracy.12 Secondly, it is important to note that one possible explanation for the poor claims rate in this study is that a certain proportion of the people receiving treatment for a reported work-related hand fracture during 2001, may have sustained the injury prior to 1 January 2001 thus would not have been linked to a hand fracture claim in our study. However, we believe this is likely a small proportion of individuals given that almost all of our random sample sought and received care within 48 hours of their injury.
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