title: Hand trauma: A prospective observational study reporting diagnostic concordance in emergency hand trauma which supports centralised service improvements.
abstract: BACKGROUND
  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).
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Plastic Surgery Department, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK. Electronic address: DrBMiranda@googlemail.com.
authors.forename: B H
authors.initials: BH
authors.lastname: Miranda
authors.affiliation: Plastic Surgery Department, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.
authors.forename: Z P
authors.initials: ZP
authors.lastname: Spilsbury
authors.affiliation: Clinical Trials Research Centre, University of Liverpool, Liverpool, Merseyside, L69 3BX, UK.
authors.forename: A
authors.initials: A
authors.lastname: Rosala-Hallas
authors.affiliation: Plastic Surgery Department, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.
authors.forename: S
authors.initials: S
authors.lastname: Cerovac
mesh_terms: D003710:Demography; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006230:Hand Injuries / Q000145:classification / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery; D006801:Humans; D008297:Male; D010346:Patient Care Management / Q000458:organization & administration*; D010808:Physical Examination / Q000379:methods; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D013223:Statistics as Topic; D013514:Surgical Procedures, Operative / Q000379:methods / Q000706:statistics & numerical data; D006113:United Kingdom / Q000453:epidemiology
keywords: Diagnosis; Hand trauma; Management; Service provision; Trauma centre