Pediatric Traumatic Amputations and Hospital Resource Utilization in the United States, 2003

Pediatric Digit Replantation Following Traumatic Amputation: Nationwide Analysis of Patient Selection, Outcomes, and Cost

Background: Indications for replantation following traumatic digit amputations are more liberal in the pediatric population than in adults, but delineation of patient selection within pediatrics and their outcomes have yet to be elucidated. This study uses a national pediatric database to evaluate patient characteristics and injury patterns involved in replantation and their outcomes. Methods: The Healthcare Cost and Utilization Project Kid's Inpatient Database was queried for traumatic amputations of the thumb and finger from 2000 to 2012. Participants were separated into those who underwent replantation and those who underwent amputation. Patients undergoing replantation were further divided into those requiring revision amputation and/or microvascular revision. Patient age, sex, insurance, digit(s) affected, charges, length of stay, and complications were extracted for each patient. Results: Traumatic digit amputations occurred in 3090 patients, with 1950 (63.1%) undergoing revision amputation and 1140 (36.9%) undergoing replantation. Younger patients, those with thumb injuries, females, and those covered under private insurance were significantly more likely to undergo replantation. Cost, length of stay, and in-hospital complications were significantly greater in replantation patients than in those who had undergone amputation. Following replantation, 237 patients (20.8%) underwent revision amputation and 209 (18.3%) underwent vascular revision, after which 58 required revision amputation. Risk of revision following replantation involved older patients, males, and procedures done recently. Conclusions: Pediatric patients who underwent replantation were significantly younger, female, had thumb injuries, and were covered by private insurance. Our findings demonstrate that in addition to injury factors, demographics play a significant role in the decision for finger replantation and its outcomes.

Trends in Pediatric Traumatic Upper Extremity Amputations

Background: Traumatic upper extremity amputation in a child can be a life-altering injury, yet little is known about the epidemiology or health care costs of these injuries. In this study, using the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID), we assess these trends to learn about the risk factors and health care costs of these injuries. Methods: Using the HCUP KID from 1997 to 2012, patients aged 20 years old or younger with upper extremity traumatic amputations were identified. National estimates of incidence, demographics, costs, hospital factors, patient factors, and mechanisms of injury were assessed. Results: Between 1997 and 2012, 6130 cases of traumatic upper extremity amputation occurred in children. This resulted in a $166 million cost to the health care system. Males are 3.4 times more likely to be affected by amputation than females. The most common age group to suffer amputation is in older children, aged 15 to 19 years old. The frequency of amputation has declined 41% from 1997 to 2012. The overwhelming majority of amputations (92.54%) involved digits. Conclusions: Pediatric traumatic amputations of the upper extremity are a significant contribution to health care spending. Interventions and educational campaigns can be targeted based on national trends to prevent these costly injuries.

Incidence, Distribution, and Cost of Lawn-Mower Injuries in the United States, 2006-2013

OBJECTIVES

Characterization of the epidemiology and cost of lawn-mower injuries is potentially useful to inform injury prevention and health policy efforts. We examined the incidence, distribution, types and severity, and emergency department (ED) and hospitalization charges of lawn-mower injuries among all age groups across the United States.

METHODS

This retrospective, cross-sectional study used nationally representative, population-based (all-payer) data from the US Nationwide Emergency Department Sample for lawn-mower-related ED visits and hospitalizations from January 1, 2006, through December 31, 2013. Lawn-mower injuries were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification code E920 (accidents caused by a powered lawn mower). We analyzed data on demographic characteristics, age, geographic distribution, type of injury, injury severity, and hospital charges.

RESULTS

We calculated a weighted estimate of 51 151 lawn-mower injuries during the 8-year study period. The most common types of injuries were lacerations (n = 23 907, 46.7%), fractures (n = 11 433, 22.4%), and amputations (n = 11 013, 21.5%). The most common injury locations were wrist or hand (n = 33 477, 65.4%) and foot or toe (n = 10 122, 19.8%). Mean ED charges were $2482 per patient, and mean inpatient charges were $36 987 per patient. The most common procedures performed were wound irrigation or debridement (n = 1436, 29.9%) and amputation (n = 1230, 25.6%).

CONCLUSIONS

Lawn-mower injuries occurred at a constant rate during the study period. Changes to nationwide industry safety standards are needed to reduce the frequency and severity of these preventable injuries.

Lawnmowers Versus Children: The Devastation Continues

BACKGROUND

Accidents with lawnmowers can cause mutilating injuries to children. Safety guidelines regarding the use of lawnmowers were promoted by professional organizations beginning in 2001. The Pennsylvania Trauma Systems Foundation maintains a database including all admissions to accredited Levels 1 to 4 trauma centers in the state. The annual rates of admission for children in our state and the severity of injuries subsequent to introduction of safety guidelines have not been reported, to our knowledge. Ride-on lawnmowers have been associated with more severe injuries in children.

QUESTIONS/PURPOSES

We asked: (1) What was the incidence of hospital admissions for children with lawnmower-related injuries during 2002 to 2013 and did the incidence vary by age? (2) What was the severity of injuries and did the severity vary by age? (3) How often did these injuries result in amputation? (4) What types of lawnmowers were involved?

METHODS

This was a retrospective study using a statewide trauma registry. We queried the Pennsylvania Trauma Outcome Study database for children 0 to 17 years old admitted to trauma centers in Pennsylvania between January 2002 and January 2014 with injuries resulting from lawnmower-related accidents. All accredited Levels 1 to 4 trauma centers in the state are required to submit their data to the Pennsylvania Trauma Systems Foundation which maintains the Pennsylvania Trauma Outcome Study database. Demographic information, Injury Severity Scores, International Classification of Diseases procedure codes, and injury location codes were recorded. Type of lawnmower was determined from the narratives and was identified in 60% (119/199) of patients. Traumatic and surgical amputations performed during the index hospitalization were included in the analysis. Information on later surgeries was not available. Subjects were stratified by age: 0 to 6, 7 to 12, and 13 to 17 years old.

RESULTS

The incidence of lawnmower injuries in Pennsylvania was a median five of 100,000 children (range, 4-12/100,000) during the study period. The median age was 6 years (range, 1-17 years). The median Injury Severity Score was 4 (range, 1-75). Children 0 to 6 years old had higher median Injury Severity Scores (median, 8; range, 1-75) compared with those 13-17 years old (median, 4; range, 1-20; difference of the medians, 4; p < 0.001). A total of 53% of the patients (106/199) underwent at least one amputation. There were 83 amputations in or of the foot, 18 in the leg, 14 in the hand, and three in the arm. Ride-on lawnmowers accounted for 92% (110/119) of mowers identified by type.

CONCLUSIONS

The incidence of serious injuries to children owing to lawnmower-related trauma did not change during the 12-year study period. If children younger than 6 years had not been near the lawnmower and those younger than 12 years had not been operating one, at least 69% of the accidents might have been prevented. We recommend annual publicity campaigns during spring to remind the public of the dangers of lawnmowers to children.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Pediatric Traumatic Amputations in the United States: A 5-Year Review

BACKGROUND

Pediatric traumatic amputations are devastating injuries capable of causing permanent physical and psychological sequelae. Few epidemiologic reports exist for guidance of prevention strategies. The objective of this study is to review the recent trends in pediatric traumatic amputations using a national databank.

METHODS

A review of all pediatric (age, 0 to 17 y) amputee patients was performed using the National Trauma Data Bank from 2007 to 2011. Data including demographics, location of amputation, and mechanism of injury were analyzed.

RESULTS

In the analysis 2238 patients were identified. The majority of amputations occurred in the youngest (0 to 5 y) and oldest (15 to 17 y) age groups with a 3:1 male to female ratio. The most common amputation locations were finger (54%) and toe (20%). A caught between mechanism (16.3%) was most common overall followed by machinery, powered lawn mowers, motor vehicle collisions, firearms, and off-road vehicles. Males were statistically more likely to have an amputation and lawnmower injuries were statistically associated with lower extremity amputations in children 5 years old and below. Motor vehicle injuries were the most common cause of adolescent amputations. Firearm-related amputations occurred predominantly in adolescents, whereas off-road vehicle amputations occurred in all ages.

CONCLUSIONS

Common trends in pediatric amputations are relatively unchanged over the last decade. Young children sustain more finger amputations from a caught between objects mechanism, whereas adolescents sustain serious amputations from higher energy mechanisms such as firearms-related and motor vehicle-related injuries. Lawnmower-related amputations continue to most significantly affect younger children despite increased public awareness. Improved prevention strategies targeting age and mechanism-related trends are necessary to prevent these costly and debilitating injuries.

LEVEL OF EVIDENCE

Level IV.

Referral Patterns of Emergent Pediatric Hand Injury Transfers to a Tertiary Care Center

Several studies have identified the inappropriate use of emergent interfacility transfer as an opportunity to improve health care use. The authors sought to identify common characteristics among children who were transferred from a community hospital to a pediatric tertiary care center for definitive treatment of hand/wrist injuries. All patients undergoing emergent transfer to a pediatric Level I trauma center and academic tertiary referral center for evaluation and management of injuries to the hand/wrist during the 2-year study period were retrospectively identified. Demographic and transfer data were abstracted from the medical record. Referring hospitals were subcategorized by the presence or absence of hand surgical emergency department coverage and the capability to admit/operate on children. Overall, 169 patients were identified who transferred to the authors' institution for hand injuries. There were no differences in the day or time of transfer. Of those transferred, 59 (35%) were admitted for definitive care, of whom 51 (86%) required a surgical intervention within 24 hours. Of the remaining 110 (65%) patients discharged from the emergency department, 27 (25%) underwent elective surgical intervention within 2 weeks. There were a greater number of transfers from institutions without the ability to admit children, regardless of hand surgical emergency department coverage status. Understanding pediatric referral patterns may improve use of emergency department facilities because most patients who were transferred were discharged the same day. Educational outreach and improved interfacility communication may result in enhanced resource use for evaluation and management of pediatric hand injuries.

Traumatic amputations in children and adolescents: A demographic study from a tertiary care center in Northern India

PURPOSE

To determine the demographic pattern, level, mechanism of traumatic amputation in children and adolescent age group and to compare findings with other studies.

METHODS

Patients aged less than 18 years with traumatic amputation attending Department of Physical Medicine and Rehabilitation, King George's Medical University, Lucknow, India between July 2013 and January 2016 were enrolled and their demographic characteristics were analyzed.

RESULTS

Fifty-three patients were included aged less than 18 years when injured. Mean age of the population studied was 9.89 ± 4.13 with male to females ratio of 3:2. Majority (69.81%) of traumatic amputations involved lower limb. Most common level was unilateral transtibial (35.85%), followed by transfemoral (16.98%). In upper limb, most common type was transradial. RTA followed by train accidents was most common mechanism of traumatic amputation. 8 patients needed revision surgery. 52.8% patients of acquired amputations complained of phantom sensation and 37.74% phantom pain.

CONCLUSIONS

This study aims to visualize the current scenario and the data generated could be possibly helpful in planning policies and programs at institutional as well as at higher levels for prevention, treatment and distribution of resource to the young amputee population, to ensure their better health care and also opportunities in life.

Cross-cultural variation in preference for replantation or revision amputation: Societal and surgeon views

Treatment decisions after an injury like finger amputation are made based on injury and patient factors. However, decisions can also be influenced by provider and patient preferences. We compared hand surgeon and societal preferences and attitudes regarding finger amputation treatment in Japan and the US. We performed a cross-sectional survey with subjects derived from large tertiary care academic institutions in the US and Japan. We secured 100% participation of American hand surgeon members of the Finger Replantation and Amputation Multicenter Study and presenting hand surgeons at the 32nd Annual meeting of the Central Japanese Society for Surgery of the Hand. Societal preferences were gathered from volunteers at the 2 universities in the US and Japan. There were no significant differences in estimations of function, sensation, or appearance after replantation; American and Japanese societal participants preferred replantation compared to surgeons, although this was more pronounced in Japan. The Japanese society displayed more negative attitudes toward finger amputees than did Japanese surgeons. American respondents anticipated more public stigmatisation of amputees than did American surgeons. Societal preference for replantation was not caused by inflated expectations of outcomes after replantation. Japanese societal preference was likely driven by negative views of finger amputees. American society noted no decrease in physical health after amputation, but did note a quality of life decrease attributed to public stigmatisation. Japanese society and surgeons had a stronger preference for replantation than American society and surgeons, possibly attributed to cultural differences.

A nationwide review of the treatment patterns of traumatic thumb amputations

Traumatic thumb amputations are a common problem with significant associated cost to patients, hospitals, and society.The purpose of this study was to review practice patterns for traumatic thumb amputations using the National Trauma Data Bank. By using a large nationwide database, we hoped to better understand the epidemiology and predictors of attempts and successful replantation.The design was a retrospective review of the National Trauma Data Bank between the years 2007 and 2010, investigating patients with traumatic thumb amputations. Analyses of these patients based on replantation attempt, mechanism of injury, and demographics were performed. Comparisons were made between hospitals based on teaching status and on patient volume for replant attempt and success rates.There were 3341 traumatic thumb amputations with 550 (16.5%) attempts at replantation and an overall success rate of 84.9%. Nonteaching hospitals treated 1238 (37.1%) patients, and attempted 123 (9.9%) replantations with a success rate of 80.5%. Teaching hospitals treated 2103 (63.0%) patients, and attempted 427 (20.3%) replantations with a success rate of 86.2%. Being in a teaching hospital increased the odds of attempted replantation by a factor of 3.1 (P < 0.001) when compared to a nonteaching hospital. Treatment at a high-volume center increased the rate of attempted replantation by a factor of 3.4 (P < 0.001), as compared to low-volume hospitals.Practice patterns show that teaching and high-volume hospitals attempt to replant a higher percentage of amputated thumbs. Success rates are similar across practice settings.

Table saw injuries: epidemiology and a proposal for preventive measures

BACKGROUND

Table saws are ubiquitous devices in professional, home, and school woodshops that have the potential to cause severe injuries. Many of these injuries results in finger and thumb tendon, nerve, and vascular damage or amputation. Long-term outcomes of these injuries can include functional and sensory deficits. Table saw manufacturers are required to equip saws with blade guards to prevent blade contact; nevertheless, treatment of table saw injuries is a common occurrence in U.S. emergency departments.

METHODS

The authors performed a literature search using PubMed and the Cumulative Index to Nursing and Allied Health Literature to compile epidemiology data relevant to table saw injuries. The authors also reviewed the U.S. Consumer Product Safety Commission's briefing package on table saw blade contact injuries.

RESULTS

Over 30,000 table saw injuries occur annually. Fingers and hands are the most frequently injured body parts, and lacerations are the most common injuries. Individuals suffering from occupational injuries tend to be younger than those injured during amateur woodworking. A small but important minority of injuries are to students participating in school shop classes. Medical costs for the treatment of table saw injuries are estimated at more than $2 billion every year.

CONCLUSIONS

SawStop technology stops the saw blade when contact with skin is made, resulting in a small cut rather than a more complicated laceration or amputation. The application of this novel technology in saw designs can prevent serious injuries that deleteriously affect lives at the personal and societal levels.

The epidemiology of amputation injuries in the Austrian helicopter emergency medical service: a retrospective, nationwide cohort study

PURPOSE

Data on the epidemiological characteristics of traumatic amputations in prehospital emergency care, especially in the context of air rescue, are scarce. Therefore, we aimed to describe the epidemiology of total and subtotal amputation injuries encountered by the OEAMTC helicopter emergency medical service (HEMS) in Austria, based on an almost nationwide sample.

METHODS

We retrospectively reviewed all HEMS rescue missions flown for amputation injuries in 2009. Only primary missions were analyzed.

RESULTS

In total, 149 out of 16,100 (0.9 %) primary HEMS rescue missions were for patients suffering from amputation injuries. Among these, HEMS physicians diagnosed 63.3 % (n = 94) total and 36.9 % (n = 55) subtotal amputations, with both groups showing a predominance of male victims (male:female ratios were 8:1 and 6:1, respectively).The highest rate occurred among adults between 45 and 64 years of age (35.6 %, n = 53). The most common causes were working with a circular saw (28.9 %, n = 43) and processing wood (16.8 %, n = 25). The majority of the cases included digital amputation injuries (77.2 %, n = 115) that were mainly related to the index finger (36.2 %, n = 54). One hundred forty patients (94.0 %) showed a total GCS of more than 12. Amputations were most prevalent in rural areas (84.6 %, n = 126) and between Thursday and Saturday (55.0 %, n = 82). The replantation rate after primary air transport was low (28 %).

CONCLUSIONS

In the HEMS, amputation injuries are infrequent and mostly not life-threatening. However, HEMS crews need to maintain their focus on providing sufficient and fast primary care while facilitating rapid transport to a specialized hospital. The knowledge of the epidemiological characteristics of amputation injuries encountered in the HEMS gained in this study may be useful for educational and operational purposes.

Applicability of large databases in outcomes research

Outcomes research serves as a mechanism to assess the quality of care, cost effectiveness of treatment, and other aspects of health care. The use of administrative databases in outcomes research is increasing in all medical specialties, including hand surgery. However, the real value of databases can be maximized with a thorough understanding of their contents, advantages, and limitations. We performed a literature review pertaining to databases in medical, surgical, and epidemiologic research, with special emphasis on orthopedic and hand surgery. This article provides an overview of the available database resources for outcomes research, their potential value to hand surgeons, and suggestions to improve their effective use.

Children treated in United States emergency departments for door-related injuries, 1999-2008

This is the first study to provide national estimates of pediatric door-related injuries in the United States. Data from the National Electronic Injury Surveillance System were analyzed for patients ≤17 years who were treated in US emergency departments for a door-related injury from 1999 through 2008. An estimated 1 392 451 US children ≤17 years received emergency treatment for door-related injuries, which averages approximately 1 injury every 4 minutes in the United States. Both the frequency and rate of injury increased significantly. Boys accounted for 55.4% of injuries, and 41.6% of children were ≤4 years. The most common mechanism of injury was a "pinch in the door" (54.8%) or an "impact to the door" (42.0%). Patients admitted to the hospital were most frequently treated for amputations (32.0%) or lacerations (25.2%). The frequency of injuries associated with glass doors increased significantly with increasing age, in contrast to injuries from other types of doors.

Traumatic amputations in children and adolescents: demographics from a regional limb-fitting centre in the United Kingdom

There is no published literature detailing the demographics of paediatric amputations in the United Kingdom. We performed this review of children and adolescents referred to a regional limb-fitting centre from the 1930s to the current decade who suffered amputation as a result of trauma, and compared our data with similar cohorts from other units. Of the 93 patients included, only 11 were injured in the last 20 years. Road traffic accidents accounted for 63% of traumatic amputations. Of all amputations, 81% were in the lower limb and 19% in the upper limb. Our figures are similar to those from a United Kingdom national statistical database of amputees which showed on average four traumatic amputee referrals to each regional limb-fitting centre in the United Kingdom per ten-year period. Compared with the United States, the incidence of paediatric traumatic amputations in the United Kingdom is low.