CFP
HOME HELP CONTACT US FEEDBACK SUBSCRIPTIONS CURRENT ISSUE PAST ISSUES SEARCH
QUICK SEARCH:   [advanced]


     

Can Fam Physician
Vol. 54, No. 7, July 2008, pp.1001 - 1007
Copyright © 2008 by The College of Family Physicians of Canada
This Article
Right arrow Abstract Freely available
Right arrow Résumé
Right arrow Full Text (PDF)
Right arrow Rapid Responses: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when Rapid Responses are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Feehan, L. M.
Right arrow Articles by Sheps, S. S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Feehan, L. M.
Right arrow Articles by Sheps, S. S.
Related Collections
Right arrow Résumés de recherche

Research

Treating hand fractures

Population-based study of acute health care use in British Columbia

Lynne M. Feehan, PhD MSc(PT)
Recently completed her doctorate in Interdisciplinary Studies at the University of British Columbia in Vancouver

Samuel S. Sheps, MD FRCPC MSc
Professor and researcher in the Department of Health Care and Epidemiology at the University of British Columbia

Correspondence to: Dr L.M. Feehan, Division of Orthopaedic Engineering Research, Department of Orthopaedics, VGH Research Pavilion, 500—828 W 10th Ave, Vancouver, BC V4Z 1L8; telephone 604 875-4111, extension 66294; fax 604 875-4851; e-mailFeehan{at}interchange.ubc.ca

Hand fractures are the second most common type of fracture and account for up to 20% of all fractures in adults and children.1,2 In British Columbia (BC), an estimated 14 500 hand fractures occur each year for an annual incidence of 36 fractures per 10 000 people.3 For both male and female patients, hand fractures most commonly occur during early adolescence, just after the period of most rapid bone growth.3–8 Across the lifespan, men are twice as likely as women to sustain hand fractures, and most of these fractures occur between the ages of 15 and 40, during the most active and productive working years.3

Despite the fact that hand injuries are so common, an extensive review of current literature on hand fractures9 and related health care use,10–13 and a search of the Canadian Institute for Health Information’s data sets14 failed to find any previous studies assessing initial management of hand fracture injuries in a large diverse population across a range of medical settings. The purpose of this study was to identify trends in initial acute health care use by all people in BC identified as having received treatment for hand fractures during a 5-year period.3


   METHODS
TOP
 METHODS
RESULTS
 DISCUSSION
 Limitations
 Conclusion
 Footnotes
 Acknowledgment
 References
 
This population-based study involved a retrospective review of 72 481 charts of BC residents previously identified from the British Columbia Linked Health Dataset (BCLHD) as having received treatment for hand fractures between May 1, 1996, and April 30, 2001.3 The BCLHD contains comprehensive linked longitudinal population health and social service data for all BC residents. The data are maintained by the Centre for Health Services and Policy Research at the University of British Columbia in Vancouver and are available for applied health service and population health research projects approved by the Ministry of Health.3,15 This study was approved by the Ministry of Health and received institutional clinical research ethics approval.

Data were retrieved from the BCLHD Medical Service Plan (MSP), hospital separation, and the MSP Registration (Registry) data sets.15 The MSP data set contains records of payments made to medical practitioners for medical services provided.15 The hospital separation data set contains records of every hospital admission.15 The Registry data set includes individual demographic and geographic data for registered BC residents.15 Hand fractures were identified using the International Classification of Diseases, version 9, (ICD-9) codes for metacarpal (815), phalangeal (816), and multiple (817) hand fractures.16 British Columbia population and regional demographic data were retrieved for 1996 to 2001.17 Further details of specific data extraction and syntheses have been described previously in a study examining the population-based incidence of hand fractures in BC and the demographics of patients treated for hand fractures.3 This study examined data to define trends in initial acute health care use for hand fractures, including initial fracture treatment (who treated patients and where were they treated) and hospital use (type of hospital, physician responsible, wait time, length of stay, and geographic variations).


   RESULTS
TOP
 METHODS
 RESULTS
DISCUSSION
 Limitations
 Conclusion
 Footnotes
 Acknowledgment
 References
 
Most patients (70 092, 97%) treated for hand fractures in BC during the 5-year period of this study were initially seen as outpatients (Table 1). About 54% of those received their initial treatment in nonhospital outpatient settings, such as doctors’ offices or outpatient medical clinics. Around 45% were first treated as hospital outpatients in emergency departments, urgent care centres, or ambulatory care clinics (Table 1). Of interest was the finding that 70% received their initial outpatient care from primary care physicians; 20% were initially treated by either plastic, orthopedic, or general surgeons; and 9% were initially managed by emergency medicine specialists (Table 2).


View this table:
[in this window]
[in a new window]

  		Table 1 Location of initial care for hand fractures: N = 72 481.

 

View this table:
[in this window]
[in a new window]

  		Table 2 Number of outpatients initially treated and sometimes admitted by various types of physicians: N = 70 092.

 
About 10% (7482) of patients with hand fractures had associated hospital admissions: 60% (4463) of these were day surgery patients, 40% (2996) were acute admissions, and less than 1% (23) were treated while in rehabilitation or extended care hospitals. Only 3% (2389) were initially treated for hand fractures as a component of direct hospital admission (Table 1). The remaining 7% (5093) had initial outpatient care before admission. About 18% of people receiving initial treatment by specialist surgeons had subsequent hospital admissions, whereas only 5% of people initially treated by primary care physicians had subsequent hospital admissions (Table 2). Specialist surgeons admitted 71% of acute cases; primary care physicians admitted 21%. About 96% of the day surgery patients were admitted by either orthopedic or plastic surgeons, 3% were admitted by general surgeons, and only 1% were admitted by primary care physicians (Table 3).


View this table:
[in this window]
[in a new window]

  		Table 3 Type of admission by physician responsible for admission: N = 7459.

 
The overall provincial annual admission rate for hand fractures was 37 (15 for acute care and 22 for day surgery) per 100 000 people (Table 4). The Northern Health Authority had a much higher relative annual admission rate overall (relative risk [RR] 2.1) than the province did, including both relatively higher rates for day surgeries (RR 2.4) and acute admissions (RR 1.7) (Table 4).


View this table:
[in this window]
[in a new window]

  		Table 4 Hospital admission rates by region and comparisons of relative rates

 
Intervals between initial outpatient care and admission by type of admission are shown in Table 5; 67% of all admissions occurred within 48 hours of initial presentation, and 94% occurred within 30 days. Table 5 also shows the ratio for type of physician (primary care: surgeon:emergency physician:other) providing initial outpatient care within each interval.


View this table:
[in this window]
[in a new window]

  		Table 5 Interval between initial outpatient treatment and first hospital admission and ratios of type of physician providing initial outpatient care within each interval: N = 5093 admissions.

 
Of the 4% (2996) of all hand fracture patients with acute admissions, 59% were admitted and discharged within 1 day, 86% were discharged by the end of the first week, and 91% were discharged within 2 weeks (Table 6). Mean length of stay for the 1589 patients with direct acute admissions was 9.3 days compared with 2.5 days for the 1407 patients with acute admissions following initial outpatient care and less than 1 day for the 3686 people having day surgery (Table 6).


View this table:
[in this window]
[in a new window]

  		Table 6 Length of stay by type of acute admission Mean length of stay was 9.3 days (range 1–871 days) for direct acute admissions, 2.5 days (range 1–165) for acute admissions after initial outpatient treatment, and 6.1 days (range 1–871) for all acute admissions (N = 2996).

 

   DISCUSSION
TOP
 METHODS
 RESULTS
 DISCUSSION
Limitations
 Conclusion
 Footnotes
 Acknowledgment
 References
 
Findings from this study indicate that almost all hand fractures in BC are treated conservatively as nonemergency medical problems by primary care physicians. In part this might be the result of the primary care physician model for acute health care delivery in Canada.18,19 It is evident that patients in BC with uncomplicated hand fractures seek first medical contact in physicians’ offices or other nonhospital settings and do not require care from specialist surgeons. Patients with more clinically severe hand fractures, including multiple trauma injuries, are more likely to receive initial care in emergency departments or to be directly admitted to hospital. Patients with more clinically complex injuries seen in any medical setting are likely to be referred to surgical specialists.20–24

Appropriate and timely referral of patients with complex hand fractures is supported by the fact that 19% of people with hand fractures in BC received initial outpatient treatment from specialist surgeons (98% of day surgery patients and 69% of acute admissions), and 67% of all admissions occurred within 48 hours of being seen by a surgeon. Patients in BC do not have direct access to specialist surgeons,18,19 so it is likely that most patients initially treated by specialist surgeons as well as those admitted to hospital were first seen by primary care physicians and then referred to specialist surgeons for timely definitive management and possible admission to hospital.

Referral to specialist surgeons for management of complex hand fractures also accounts for the difference found in rates of subsequent hospital admissions of patients treated initially by specialist surgeons (18% admission rate) compared with those treated initially by primary care physicians (5% admission rate).10 It can be inferred that initial hand fracture management choices made by physicians in BC are appropriate.25–27 Our study found that only 539 (< 1%) of the 72 481 patients with hand fractures had unsuccessful initial conservative treatment and went on to surgery 7 to 29 days after the injury; only 68 patients who were treated conservatively developed early complications that required surgical intervention between 30 and 100 days (1 to 3 months) after initial presentation; another 231 required surgical intervention for fracture complications after 3 months.25–27 Interestingly, unsuccessful conservative management or early complications were not related to type of physician providing initial care, as more than 25% of these patients were managed initially by specialist surgeons. Our study did not look at whether patients with hand fractures that were initially treated surgically were admitted to hospital, so we cannot comment on rates of secondary surgical complications following initial surgical interventions.11,28–30

Our 10% hospital admission rate is higher than the 2% admission rate found in 2 large Scandinavian population-based studies using emergency department or national injury databases that included both hand and wrist injuries.12,13 This difference can be attributed to the greater clinical complexity of hand fractures compared with the other common types of hand and wrist injuries including sprains, lacerations, and contusions included in the other studies.10,12,13 The incidence rate of 37 hand fracture admissions per 100 000 people in BC is comparable to the reported incidence rates of 21 and 61 hand and wrist fracture admissions respectively, for every 100 000 women and men in Switzerland in 2000.31

We noted considerable regional variation in hospital admission rates in BC, with the more rural, isolated, primary industry-based, and socioeconomically deprived northern region having the highest rate for hand fracture-related admissions.17 This finding is consistent with research showing higher rates of all hospital admissions in northern regions of BC.32 The reasons for this geographic variation in hospital admission rates are not clear, although they likely result from a combination of the varying risk of sustaining hand fractures in different regions of the province and differences in the clinical complexity of the injuries.3 Regional differences might also be the result of differences in practice patterns and access to primary care physicians and specialist surgeons, particularly in isolated rural communities.33


   Limitations
TOP
 METHODS
 RESULTS
 DISCUSSION
 Limitations
Conclusion
 Footnotes
 Acknowledgment
 References
 
Potential limitations associated with a retrospective review of hand fracture data in the BCLHD administrative health services data set have been described previously.3 Specifically, it should be noted that data on location of outpatient treatment should be viewed with caution, as it is not monitored for accuracy.19 Some of the very isolated or socioeconomically deprived regions of BC might be underrepresented in the MSP data set, as a higher proportion of primary physician and emergency health care services in these communities are provided under salaried or sessional payment programs.32,33 Similarly, emergency department data from the 2 Vancouver hospitals might be underrepresented, as they also used alternative payment programs during the later stages of this study.33 Finally, given the scarcity of population-based research on hand fractures in Canada, it is unclear whether our findings can be generalized to other geographic regions in Canada. Similar health care systems, population demographics, and diverse levels of socioeconomic development could indicate, however, that our findings likely reflect trends in initial acute health care use for hand fractures across Canada.


   Conclusion
TOP
 METHODS
 RESULTS
 DISCUSSION
 Limitations
 Conclusion
Footnotes
 Acknowledgment
 References
 
In contrast to other common fracture injuries that are routinely managed by specialist surgeons,31,34 most hand fractures in BC receive initial care and ongoing conservative management from primary care physicians.20–24 Findings from this study emphasize the need for primary care physicians to plan for providing care for this common injury. Further prospective longitudinal cohort studies are needed to define how variables, such as clinical presentation; access to primary, emergency, and specialist surgeon care; and variations in acute health care practice models, affect primary care physicians’ practice decisions regarding acute management of hand fractures and, ultimately, clinical outcomes.35,36 Specifically, focused training and continuing education opportunities on new approaches to management of acute hand fracture injuries will ensure that patients continue to benefit from the appropriate management choices of primary care physicians.27,37



   EDITOR’S KEY POINTS
 
  • This study identified trends in initial acute health care use by people in British Columbia who had received treatment for hand fractures during a 5-year period.
  • Almost all hand fracture injuries in British Columbia were treated conservatively as nonemergency medical problems by primary care physicians.
  • Initial conservative treatment was unsuccessful for less than 1% of patients; these patients required surgery 7 to 29 days after the injury. Only 68 of the 72 481 patients developed early complications that required surgical intervention 1 to 3 months after initial presentation; 231 developed late complications that required surgical intervention 3 or more months after initial presentation.

 



   POINTS DE REPÈRE DU RÉDACTEUR
 
  • Cette étude a permis de connaître le type de traitement initial offert aux résidents de la Colombie- Britannique ayant subi une fracture de la main, sur une période de 5 ans.
  • En Colombie-Britannique, presque toutes les fractures de la main ont été traitées de façon classique, comme des problèmes médicaux non urgents et par des médecins de première ligne.
  • Un échec du traitement classique entraînant une chirurgie dans les 7 à 29 jours après la blessure a été observé dans moins de 1% des cas. Seulement 68 des 72 481 patients ont développé des complications précoces requérant une chirurgie 1 à 3 mois après la fracture; 231 ont développé des complications tardives exigeant une intervention chirurgicale 3 mois ou plus après la première consultation.

 


   Acknowledgment
TOP
 METHODS
 RESULTS
 DISCUSSION
 Limitations
 Conclusion
 Footnotes
 Acknowledgment
References
 
This study was funded in part by a grant from the WorkSafeBC Research Secretariat.


   Footnotes
TOP
 METHODS
 RESULTS
 DISCUSSION
 Limitations
 Conclusion
 Footnotes
Acknowledgment
 References
 
Cet article a fait l’objet d’une révision par des pairs.

Contributors

Dr Feehan was responsible for the original idea behind the paper, design and implementation of the study, analysis and presentation of the findings, and writing and editing the manuscript. Dr Sheps contributed advice on the implementation of the study and assisted with the interpretation of results and editing the manuscript.

Competing interests

None declared

This article has been peer reviewed.


   References
TOP
 METHODS
 RESULTS
 DISCUSSION
 Limitations
 Conclusion
 Footnotes
 Acknowledgment
 References
 

  1. Cooper C, Dennison EM, Leufkens HG, Bishop N, van Staa TP. Epidemiology of childhood fractures in Britain: a study using the general practice research database. J Bone Miner Res 2004;19(12):1976–81.[Medline]
  2. Johansen A, Evans RJ, Stone MD, Richmond PW, Lo SV, Woodhouse KW. Fracture incidence in England and Wales: a study based on the population of Cardiff. Injury 1997;28(9–10):655–60.[Medline]
  3. Feehan LM, Sheps S. Incidence and demographics of hand fractures in British Columbia, Canada: a population based study. J Hand Surg (Am) 2006;31(7):1068–74.[Medline]
  4. Bailey DA, Wedge JH, McCulloch RG, Martin AD, Bernhardson SC. Epidemiology of fractures of the distal end of the radius in children as associated with growth. J Bone Joint Surg Am 1989;71:1225–31.[Abstract/Free Full Text]
  5. Parfitt AM. The two faces of growth: benefits and risks to bone integrity. Osteoporos Int 1994;4:382–98.[Medline]
  6. Rauch F, Neu C, Manz F, Schoenau E. The development of metaphyseal cortex, implications for distal radial fractures during growth. J Bone Miner Res 2001;16(8):1547–55.[Medline]
  7. Jones IE, Williams S, Dow N, Goulding A. How many children remain fracture-free during growth: a longitudinal study of children and adolescents participating in the Dunedin multidisciplinary health and development study. Osteoporos Int 2002;13:990–5.[Medline]
  8. Faulkner RA, Davison KS, Bailey DA, Mirwald RL, Baxter-Jones AD. Size-corrected BMD decreases during peak linear growth: implications for fracture incidence during adolescence. J Bone Miner Res 2006;21(12):1864–70.[Medline]
  9. Feehan LM, Basset K. Is there evidence for early motion following an extra-articular hand fracture? J Hand Ther 2004;17(2):300–8.[Medline]
  10. Hill C, Riaz M, Mozzam A, Brennen MD. A regional audit of hand and wrist injuries. A study of 4873 injuries. J Hand Surg (Br) 1998;23(2):196–200.[Abstract/Free Full Text]
  11. Ip WY, Ng KH, Chow SP. A prospective study of 924 digital fractures of the hand. Injury 1996;27(4):279–85.[Medline]
  12. Angermann P, Lohmann M. Injuries to the hand and wrist. A study of 50,272 injuries. J Hand Surg (Br) 1993;18(5):642–4.[Abstract/Free Full Text]
  13. Larsen CF, Mulder S, Johansen AM, Stam C. The epidemiology of hand injuries in The Netherlands and Denmark. Eur J Epidemiol 2004;19(4):323–7.[Medline]
  14. Canadian Institute for Health Information. Health services databases. Ottawa, ON: Canadian Institute for Health Information; 2008. Available from: http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=services_e. Accessed 2008 May 29.
  15. UBC Centre for Health Services and Policy Research. BCLHD: data services. Vancouver, BC: UBC Centre for Health Services and Policy Research; 2008. Available from: www.chspr.ubc.ca/data. Accessed 2008 May 29.
  16. World Health Organization. International classification of diseases. Geneva, Switz: World Health Organization; 1994. Available from: www.who.int/classifications/icd/. Accessed 2008 April 21.
  17. BC Stats [website]. Victoria, BC: British Columbia Government, BC Stats, Ministry of Labour and Citizens’ Services; 2008. Available from: www.bcstats.gov.bc.ca. Accessed 2008 May 29.
  18. Health Canada. Health care system. Ottawa, ON: Health Canada; 2008. Available from: www.hc-sc.gc.ca. Accessed 2008 Apr 21.
  19. Canadian Health Care [website]. Ottawa, ON: Canadian Healthcare Association; 2007. Available from: http://canadian-healthcare.org. Accessed 2008 May 29.
  20. Hoffman DF, Schaffer TC. Management of common finger injuries. Am Fam Physician 1991;43(5):1594–607.[Medline]
  21. Schaffer TC. Common hand fractures in family practice. Arch Fam Med 1994;3(11):982–7.[Abstract/Free Full Text]
  22. Wang QC, Johnson BA. Fingertip injuries. Am Fam Physician 2001;63(10):1961–6.[Medline]
  23. Eiff MP, Hatch RL, Calmbach WL, editors. Fracture management for primary care. 2 ed. Philadelphia, PA: WB Saunders; 2003.
  24. Leggit JC, Meko JC. Acute finger injuries. Part II: fractures, dislocations and thumb injuries. Am Fam Physician 2006;73(5):827–34.[Medline]
  25. Freeland AE, Lund PJ, Russell RC, Metacarpal and phalangeal fractures. Plastic surgery: indications, operations and outcomes. Vol. 4: hand surgery. Toronto, ON: Mosby; 2000. p. 1845–64.
  26. Purdy BA, Wilson RL, Mackin EJ, Callahan AD, Skirven TM, Schneider LH, Osterman AL, Management of nonarticular fractures of the hand. Rehabilitation of the hand and upper extremity. 5 ed. St Louis, MO: C.V. Mosby; 2002. p. 382–95.
  27. Freeland AE, Orbay JL. Extraarticular hand fractures in adults: a review of new developments. Clin Orthop Relat Res 2006;445:133–45.[Medline]
  28. Fusetti C, Meyer H, Borisch N, Stern R, Santa DD, Papaloizos M. Complications of plate fixation in metacarpal fractures. J Trauma 2002;52(3):535–9.[Medline]
  29. Kurzen P, Fusetti C, Bonaccio M, Nagy L. Complications after plate fixation of phalangeal fractures. J Trauma 2006;60(4):841–3.[Medline]
  30. Ali H, Rafique A, Bhatti M, Ghani S, Sadiq M, Beg SA. Management of fractures of metacarpals and phalanges and associated risk factors for delayed healing. J Pak Med Assoc 2007;57(2):64–7.[Medline]
  31. Lippuner K, Golder M, Greiner R. Epidemiology and direct medical costs of osteoporotic fractures in men and women in Switzerland. Osteoporos Int 2005;16(Suppl_2):S8–17.[Medline]
  32. McGrail KM, Schaub P, Black C. The British Columbia health atlas. 2 ed. Vancouver, BC: UBC Centre for Health Services and Policy Research; 2004. Available from: www.chspr.ubc.ca/healthatlas/2004. Accessed 2008 Apr 14.
  33. Watson DE, Brueger H, Mooney D, Black C. Planning for renewal: mapping primary health care in British Columbia. Vancouver, BC: UBC Centre for Health Services and Policy Research; 2005. Available from: www.chspr.ubc.ca/research/phc/mapping. Accessed 2008 Apr 14.
  34. Gehlbach SH, Avrunin JS, Puleo E. Trends in hospital care for hip fractures. Osteoporos Int 2007;18(5):585–91.[Medline]
  35. Schaub TA, Chung KC. Systems of provision and delivery of hand care and its impact on the community. Injury 2006;37:1066–70.[Medline]
  36. Bernstein ML, Chung KC. Hand fractures and their management: an international view. Injury 2006;37(11):1043–8.[Medline]
  37. Matheny JM, Brinker MR, Elliott MN, Blake R, Rowane MP. Confidence of graduating family practice residents in their management of musculoskeletal conditions. Am J Orthop 2000;29(12):945–52.[Medline]



This article has been cited by other articles:


Home page
 Hand TherHome page
L. M Feehan and S. S Sheps
Work-related hand fracture injuries in British Columbia, Canada: a population-based BC-linked health data-set study
Hand Ther, March 1, 2009; 14(1): 10 - 21.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Résumé
Right arrow Full Text (PDF)
Right arrow Rapid Responses: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when Rapid Responses are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Feehan, L. M.
Right arrow Articles by Sheps, S. S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Feehan, L. M.
Right arrow Articles by Sheps, S. S.
Related Collections
Right arrow Résumés de recherche

HOME HELP CONTACT US FEEDBACK SUBSCRIPTIONS CURRENT ISSUE PAST ISSUES SEARCH