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Epidemiology of Finger Amputations in the United States From 1997 to 2016

Open AccessPublished:March 25, 2019DOI:https://doi.org/10.1016/j.jhsg.2019.02.001

      Purpose

      There are minimal long-term epidemiological data focused on finger amputations in the United States (US). We sought to quantify the incidence and trends in finger amputations over a 20-year period, describe mechanisms of injury by age groups, and examine trends in emergency department (ED) disposition.

      Methods

      The National Electronic Injury Surveillance System was queried over a 20-year period (1997–2016) for finger amputations presenting to US EDs. Using US Census data, national incidence rates were estimated. We evaluated specific mechanisms of injury and ranked common mechanisms for each age group. Trends in hospital admission rates were evaluated and predictors of admission were examined using logistical regression.

      Results

      From 1997 to 2016, a weighted estimate of 464,026 patients sustained finger amputations in the US with an estimated yearly incidence of 7.5/100,000 person-years. A bimodal age distribution was seen, with the greatest incidence in children aged less than 5 years and adults over 65 years. Doors were the most common injury mechanism in children (aged less than 5 years), whereas power saws were most common in teens and adults (aged more than 15 years). Over the study period, there was a significant increase in patients admitted to the hospital; however, this increase was not seen among African Americans. Significant predictors of hospital admission included male gender, age less than 18 years, high-energy mechanisms, non–African American race, and very large hospital size, as defined by the National Electronic Injury Surveillance System.

      Conclusions

      The incidence of finger amputations is bimodal; young children (aged less than 5 years) and the elderly (aged greater than 65 years) are at greatest risk. There is a widening disparity between African Americans and non–African Americans in relation to ED disposition. Doors and power saws are the most common mechanisms of injury; however, these affect different age ranges. This study’s results highlight the need for improved age-specific safety guidelines and device safety features.

      Type of study/level of evidence

      Prognostic IV.

      Key words

      Traumatic injuries to the hand and fingers are common reasons for emergency room visits.
      • Conn J.M.
      • Annest J.L.
      • Ryan G.W.
      • Budnitz D.S.
      Non–work-related finger amputations in the United States, 2001–2002.
      • Peterson S.L.
      • Peterson E.L.
      • Wheatley M.J.
      Management of fingertip amputations.
      • Sorock G.S.
      • Lombardi D.A.
      • Courtney T.K.
      • Cotnam J.P.
      • Mittleman M.A.
      Epidemiology of occupational acute traumatic hand injuries: a literature review.
      The incidence has been reported to be as high as 45,000 amputations in the United States (US) annually.
      • Conn J.M.
      • Annest J.L.
      • Ryan G.W.
      • Budnitz D.S.
      Non–work-related finger amputations in the United States, 2001–2002.
      Unfortunately, given the important role of the finger in activities of daily living and a variety of vocations, the impact of an amputation can be devastating.
      • Sears E.D.
      • Shin R.
      • Prosser L.A.
      • Chung K.C.
      Economic analysis of revision amputation and replantation treatment of finger amputation injuries.
      • Boyle D.
      • Parker D.
      • Larson C.
      • Pessoa-Brandão L.
      Nature, incidence, and cause of work-related amputations in Minnesota.
      Previous studies
      • Boyle D.
      • Parker D.
      • Larson C.
      • Pessoa-Brandão L.
      Nature, incidence, and cause of work-related amputations in Minnesota.
      • Proano L.
      • Partridge R.
      Descriptive epidemiology of a cluster of hand injuries from snowblowers.
      • Doraiswamy N.V.
      Childhood finger injuries and safeguards.
      • Justis E.J.
      • Moore S.V.
      • LaVelle D.G.
      Woodworking injuries: an epidemiologic survey of injuries sustained using woodworking machinery and hand tools.
      evaluated work- and non–work related risk factors for finger amputations. A short-term epidemiologic analysis of non–work related finger amputation in the US from 2001 to 2002 found differences in amputation patterns with regard to demographics, mechanisms of injury, and treatment patterns.
      • Conn J.M.
      • Annest J.L.
      • Ryan G.W.
      • Budnitz D.S.
      Non–work-related finger amputations in the United States, 2001–2002.
      The authors found that male patients were 3 times more likely to sustain a finger amputation than were female patients, children aged less than 5 years saw the highest rate of finger amputations (18.8/100,000 population), and the most common mechanism of injury in that group was caused by doors.
      To our knowledge, a long-term epidemiologic analysis focused specifically on finger amputations in the US has not been completed to date. The objectives of the current investigation were to quantify the incidence of finger amputations in the US over 20 years (1996–2017), describe common and specific mechanisms of injury in different age groups, and examine trends over time in emergency department (ED) disposition.

      Materials and Methods

      The National Electronic Injury Surveillance System (NEISS) database is managed by the Consumer Product Safety Commission.
      • Schroeder T.
      • Ault K.
      The NEISS sample (Design and Implementation) 1997 to present.
      National Electronic Injury Surveillance System
      The National Electronic Injury Surveillance System: A Tool for Researchers.
      National Electronic Injury Surveillance System.
      It is composed of a representative probability sample of approximately 100 hospitals of varying sizes throughout the US and its territories. The NEISS hospital coordinators reviews all ED records for the day, selecting those that meet predefined criteria for inclusion in NEISS and transcribing the relevant information into the database. It represents a national sampling of all emergency rooms in US hospitals divided into 5 strata, with 4 strata representing adult EDs segregated by the number of annual visits (small [1–16,830 visits], medium [16,831–28,150 visits], large [28,150–41,130 visits], and very large [41,131 visits or more]) and one stratum for pediatric EDs. Individual EDs are assigned probability weights based on the inverse probability of selection for hospitals in each stratum. These weights are updated every year to adjust to nonresponse, hospital mergers, and changes in the NEISS sampling frame. Weighted NEISS data have been shown to provide accurate national estimates of ED visits for public health and epidemiological research.
      • Ootes D.
      • Lambers K.T.
      • Ring D.C.
      The epidemiology of upper extremity injuries presenting to the emergency department in the United States.
      • Golan E.
      • Kang K.K.
      • Culbertson M.
      • Choueka J.
      The epidemiology of finger dislocations presenting for emergency care within the United States.
      • Shah N.S.
      • Buzas D.
      • Zinberg E.M.
      Epidemiologic dynamics contributing to pediatric wrist fractures in the United States.
      • Lombardo D.J.
      • Jelsema T.
      • Gambone A.
      • et al.
      Extremity fractures associated with ATVs and dirt bikes: a 10-year national epidemiologic study.
      • Harris C.
      • Madonick J.
      • Hartka T.R.
      Lawn mower injuries presenting to the emergency department: 2005 to 2015.
      • Van Tassel D.C.
      • Owens B.D.
      • Wolf J.M.
      Incidence estimates and demographics of scaphoid fracture in the U.S. population.
      • DeFroda S.F.
      • Gil J.A.
      • Owens B.D.
      Epidemiology of lower extremity injuries presenting to the emergency room in the United States: snow skiing vs. snowboarding.
      • Stoneback J.W.
      • Owens B.D.
      • Sykes J.
      • Athwal G.S.
      • Pointer L.
      • Wolf J.M.
      Incidence of elbow dislocations in the United States population.
      • Gil J.A.
      • Elia G.
      • Shah K.N.
      • Owens B.D.
      • Got C.
      Epidemiology of fishing related upper extremity injuries presenting to the emergency department in the United States.
      Data available in the NEISS database include patient demographic data, diagnosis, body part injured, involvement of a product or activity, location of injury, and ED disposition. For this study, the NEISS database was queried from January 1, 1997 to December 31, 2016 for all ED visits in which the injured body part and diagnosis were coded as “finger” (NEISS body part code 92) and “amputation” (NEISS diagnosis code 50), respectively. Using NEISS probability sampling weights, national estimates for finger amputations were calculated for each year from 1997 to 2016. Corresponding US Census data were then employed to calculate national incidence rates for finger amputations stratified by age and sex.
      Using the NEISS coding manual as well as the 2018 NEISS Product Code Comparability table,
      US Consumer Product Safety Commission
      2018 NEISS Product Code Comparability Table.
      US Consumer Product Safety Commission
      NEISS 2018 coding manual.
      we recorded all applicable product codes over the 20-year study period. For improved comprehensibility of the data, categories of injury mechanisms were created by combining appropriate NEISS codes (Appendix A). In addition, specific mechanisms including power saws, routers, or jointers; lawn mowers; leaf shredders; snowblowers; food processors; fans; fireworks; and all-terrain vehicles were manually classified as high-energy.
      After stratification of patients by age, specific mechanisms of injury were evaluated; the 5 most common mechanisms were then ranked for each age group. Student t test/analysis of variance and chi-square analysis were used for direct comparisons of means and proportions, respectively. We evaluated trends in hospital admission rates from 1997 to 2016 using linear regression. Independent predictors of admission including age, race, sex, mechanism of injury, and hospital size were examined using logistical regression. Microsoft Excel (version 16.11.1, Microsoft Corp., Redmond, WA, 2017) was used for data collection and visualization. All statistical analyses were performed using SPSS software (version 25, IBM Corp., Armonk, NY, 2017) or Stata software (version 15.0, (StataCorp, College Station, TX, 2017). Statistical significance was defined as P < .05 a priori.

      Results

      Demographics and epidemiology

      From 1997 to 2016, 13,952 patients with complete data presented to EDs reporting to NEISS with finger amputations. This correlated with a national weighted estimate of 464,026 patients. Overall, the estimated yearly incidence of finger amputation was 7.5/100,000 person-years (Table 1). The incidence remained steady over the 20-year study period (R2 = 0.003; P = .799) (Fig. 1). Injuries resulted in a bimodal age distribution with the highest incidence in children aged less than 5 years (15.3/100,000 person-years) and adults aged more than 65 years (9.1/100,000 person-years) (Fig. 2). Males were more likely to sustain finger amputations in all age ranges; however, this difference was greatest among teenagers and adults. In fact, in patients aged more than 15 years, males were at least 4 to 8 times more commonly affected than were females (all P < .001) (Fig. 2). An estimated 78.6% of those in the US presenting with finger amputations were white; 8.9% were black; less than 1% each were Asian, American Indian/Alaskan Native, and Native Hawaiian/Pacific Islander; and 11.4% were coded as other.
      Table 1Number of Cases, National Weighted Estimates, and Yearly Incidence Rate of Finger Amputation, Stratified by Age and Gender
      Age, y/SexnEstimate (20-y)Estimate/yPopulation SizeIncidence/100,00 Person-YearsP Value
      <52,82960,9273,04619,917,00015.3< .001
       Male1,60235,3591,76810,176,00017.4
       Female1,22725,5681,2789,741,00013.1
      5–141,98245,2432,26241,429,0005.5< .001
       Male1,35131,4151,57121,048,0007.5
       Female63113,82869120,381,0003.4
      15–241,10838,9781,94943,124,0004.5< .001
       Male91232,5281,62621,806,0007.5
       Female1966,45032221,318,0001.5
      25–442,923108,4895,42481,674,0006.6< .001
       Male2,43290,0214,50140,440,00011.1
       Female49118,46892341,234,0002.2
      45–643,338132,0156,60181,938,0008.1< .001
       Male2,771109,1855,45939,568,00013.8
       Female56722,8301,14242,370,0002.7
      >651,77278,4203,92143,287,0009.1< .001
       Male1,53167,8413,39219,298,00017.6
       Female24110,58052923,989,0002.2
      All13,952464,02623,201311,116,0007.5< .001
       Male10,599366,34818,317152,335,00012.0
       Female3,35397,6774,884158,781,0003.1
      Figure thumbnail gr1
      Figure 1Finger amputations: national injury estimate by year 1997 to 2016.
      Figure thumbnail gr2
      Figure 2Yearly incidence rate of finger amputations, stratified by age and gender.

      Injury mechanism

      Table 2 lists the 5 most common mechanisms by age group. Doors were the most common mechanism of injury until age 14; however, the relative proportion decreased with age. (Table 2). After age 14, the most common mechanisms for finger amputations were power saws and the proportion of injuries they caused increased with age.
      Table 2Most Common Injury Mechanisms (%), by Age
      Mechanism RankAge, y
      <22–45–1415–2425–4445–64>65
      1Door (69.06)Door (57.55)Door (43.55)Power saw (17.83)Power saw (31.07)Power saw (39.68)Power saw (49.37)
      2Chair (5.04)Bicycle (6.25)Bicycle (11.41)Door (13.75)Knife (10.17)Lawn mower (10.22)Door (9.08)
      3Bicycle (3.13)Chair (4.39)Lawn mower (2.45)Knife (12.77)Door (8.89)Door (7.99)Lawn mower (9.1)
      4Cabinets (2.9)Exercise equipment (2.34)Power saw (2.99)Lawn mower (8.52)Lawn mower (9.77)Snowblower (3.47)Snowblower (3.52)
      5Exercise equipment (1.4)Fence (0.94)Knife (2.75)Food processor (5.43)Food processor (4.56)Knife (4.34)Knife (2.47)
      Other (18.5)Other (28.5)Other (36.9)Other (41.7)Other (35.5)Other (34.3)Other (26.5)
      Some mechanisms were unique to specific age groups. For example, cabinet injuries were mostly seen in infants aged less than 2 years, exercise equipment injuries were most often seen in children aged less than 4 years, and bicycles or bicycle gear–related injuries occurred in children aged 14 years or younger (Table 2). Likewise, food processing equipment was reported among the top 5 mechanisms in those aged 15 to 44 years. Lawn mower injuries were uncommon in children but were a common cause of injury in those aged over 15 years. Snowblowers were among the 5 most common mechanisms of injury only in those aged over 45 years.

      Trends and predictors of hospital admission

      Over the 20-year study period, there was a significant increase in the overall proportion of patients admitted to the hospital (R2 = .409; P = .004). Throughout the study period, patients with finger amputation were significantly more likely to be admitted if presenting to very large EDs compared with all other strata, even after controlling for age, sex, race, and mechanism energy level (adjusted odds ratio [OR] = 2.20; P < .001) (Table 3).
      Table 3Predictors of Hospital Admission
      PredictorsAdmitted (%)Adjusted OR95% CIAdjusted P Value
      Race
       Black8.50.550.43–0.68< .001
       Non-black15.1
      Mechanism energy level
       High-energy24.42.342.03–2.71< .001
       Non–high energy11.4
      Sex
       Female11.30.840.71–0.99.037
       Male18.1
      Age, y
       <1812.91.421.21–1.68< .001
       ≥1817.8
      Hospital size
       Very large hospital strata23.72.201.93–2.50< .001
       Other11.6
      Similarly, when stratified by race, this 20-year trend toward increasing admission rates did not include African Americans (R2 = 0.004; P = .798) (Fig. 3). Over the course of the study period, non–African American patients were more than twice as likely to be admitted as were African American patients, even after controlling for age, sex, mechanism energy level, and hospital size (adjusted OR = 2.20’ 95% confidence interval [CI], 1.93–2.50; P < .001) (Table 3).
      Figure thumbnail gr3
      Figure 3Admission in African Americans with finger amputations compared with all patients, 1997 to 2016.
      Other independent predictors of hospital admission under logistic regression analysis included a high-energy mechanism of injury (adjusted OR = 2.34; 95% CI, 2.03–2.71; P < .001), pediatric patients (adjusted OR = 1.42; 95% CI, 1.21–1.68; P = .01), and male sex (adjusted OR = 1.19; 95% CI, 1.01–1.41; P = .037) (Table 3).

      Discussion

      Over the past 20 years, the national incidence of finger amputations has remained steady (R2 = 0.004; P = .799) (Fig. 1), which suggests little success in injury prevention measures

      Lifsher M. Advocates seek new table-saw safety rules. Los Angeles Times. http://articles.latimes.com/2012/sep/06/business/la-fi-saw-safety-20120906. Accessed May 2, 2018.

      Royal Society for the Prevention of Accidents
      RoSPA: Home Safety Position Statements.
      American Academy of Orthopaedic Surgeons
      AAOS Postition Statement: power lawnmower safety.
      American Academy of Orthopaedic Surgeons
      AAOS Position Statement: power snow blower/thrower safety.
      during this period.
      Although a large number of injury mechanisms were described, and 393 independent NEISS codes were represented, the 5 most common mechanisms were responsible for most amputations in all age groups. In addition to being most at risk, young (aged less than 2 years) and older (aged greater than 65 years) patients had the least variations in injury mechanism; the top 5 mechanisms represented 81.5% and 73.5% of amputations, respectively. The most variations in injury mechanisms were seen in those aged 15 to 24, and only 58.3% of injuries were represented by the top 5 mechanisms.
      These findings complement previous research. In a 2004 study of non–work related finger amputations in the US, Conn et al
      • Conn J.M.
      • Annest J.L.
      • Ryan G.W.
      • Budnitz D.S.
      Non–work-related finger amputations in the United States, 2001–2002.
      found that patients aged less than 5 years presented with finger amputation most commonly owing to door-related accidents; this validated similar results from Doraiswamy’s
      • Doraiswamy N.V.
      Childhood finger injuries and safeguards.
      1999 investigation of pediatric finger injuries. Conn et al also reported that power tool users aged greater than 15 years were most likely to lose parts of one or more fingers, which highlights the finding that middle-aged adults aged 45 to 64 years
      American Academy of Orthopaedic Surgeons
      AAOS Position Statement: power snow blower/thrower safety.
      (regular power tool users) were the most common patient group presenting to hospital EDs with finger amputations. A study of woodworkers revealed that 39% of amputations were caused by table saws and 35% by jointers.
      • Justis E.J.
      • Moore S.V.
      • LaVelle D.G.
      Woodworking injuries: an epidemiologic survey of injuries sustained using woodworking machinery and hand tools.
      Generally, the most common injury mechanisms in children included nonpowered items such as doors, cabinets, exercise equipment, and bicycles. Conversely, with the exception of knives, teenagers and adults were most affected by powered high-energy equipment such as power saws, lawnmowers, food processing equipment, and snowblowers. The difference in energy levels inherent in these mechanisms of injury is likely to result in substantially different patterns in terms of treatment and prognosis.
      The database used did not stratify by occupational injuries compared with injuries in other locales. Such injuries are monitored by the Occupational Safety and Health Administration and may differ in important ways compared with finger amputations sustained among the general population. Once recent study,
      • Nevin R.L.
      • Bernt J.
      • Hodgson M.
      Association of poultry processing industry exposures with reports of occupational finger amputations.
      for example, identified the poultry processing industry as being the largest source of occupational finger amputations.
      An understanding of the most common mechanism of injury for different age groups may be useful in campaigns focused on injury prevention. Public service announcements aiming to caution patients against potential injuries may be effective in reducing the number of injuries.
      • Vosbikian M.M.
      • Harper C.M.
      • Byers A.
      • Gutman A.
      • Novack V.
      • Iorio M.L.
      The impact of safety regulations on the incidence of upper-extremity power saw injuries in the United States.
      Such recommendations may counsel appropriate techniques and promote the routine use of safety equipment; they should also target different age groups according to their most common mechanism of injury. Likewise, upgrades in safety standards for consumer goods and power tools may be effective in preventing finger amputations.

      Lifsher M. Advocates seek new table-saw safety rules. Los Angeles Times. http://articles.latimes.com/2012/sep/06/business/la-fi-saw-safety-20120906. Accessed May 2, 2018.

      Although the American Academy of Orthopaedic Surgeons
      American Academy of Orthopaedic Surgeons
      AAOS Position Statement: power snow blower/thrower safety.
      released position statements on the risk of lawnmowers
      American Academy of Orthopaedic Surgeons
      AAOS Postition Statement: power lawnmower safety.
      and snowblowers, other common mechanisms identified in this study, such as door-, cabinet-, and exercise equipment–related injuries in children, as well as injuries related to food processing equipment in adults, have not been adequately addressed to date. These products, tools, and mechanisms of injury may be prime candidates for future public service announcements and/or improvements in product safety standards.
      Overall admission rates from 1997 to 2016 have been increasing linearly (R2 = 0.4099; P = .004); however, this rise appears to be largely driven by increasing admission among non–African Americans (Fig. 3). Reasons for this observed difference are unclear. Interpretation of this database is inherently limited by our inability to control for confounding factors such as insurance status, as well as our limited access to final treatment decision after admission, but there was evidence in the literature of a racial disparity in the treatment of finger amputations. An analysis of the National Trauma Database by Mahmoudi et al
      • Mahmoudi E.
      • Swiatek P.R.
      • Chung K.C.
      • Ayanian J.Z.
      Racial variation in treatment of traumatic finger/thumb amputation.
      comparing replantation rates of African American patients with those of whites while adjusting for hospital and patient characteristics including insurance status and injury severity found that African American patients were less likely than their white counterparts to undergo replantation. Further investigations are indicated regarding the observed racial disparity in admissions after amputation.
      Our finding of an increase in admission rates over time, particularly in very high-volume hospitals, was unexpected. Recent research
      • Mahmoudi E.
      • Swiatek P.R.
      • Chung K.C.
      • Ayanian J.Z.
      Racial variation in treatment of traumatic finger/thumb amputation.
      • Payatakes A.H.
      • Zagoreos N.P.
      • Fedorcik G.G.
      • Ruch D.S.
      • Levin L.S.
      Current practice of microsurgery by members of the American Society for Surgery of the Hand.
      • Fufa D.
      • Calfee R.
      • Zeng W.
      • Goldfarb C.
      • Wall L.
      Digit replantation: experience of two U.S. academic level-I trauma centers.
      provides evidence of a nationwide decline in replantation rates over the past 20 years. There is evidence that microsurgical techniques are being refined in some centers more than others and that hospitals that are higher volume in terms of digital replants have higher success rates.
      • Brown M.
      • Lu Y.
      • Chung K.C.
      • Mahmoudi E.
      Annual hospital volume and success of digital replantation.
      Thus, hospital consolidation or improved pre-hospital triage may result in patients with more severe injuries presenting to or being transferred to higher-level centers at higher rates. Unfortunately, given the inherent limitations in this database, we cannot determine the reasons for these trends in admission rates. One hypothesis is that increasing the number of patients with insurance coverage over the past 2 decades might have led to a larger proportion of insured patients presenting to EDs seeking care and subsequently being admitted.
      Strengths of this study include the large patient sample, 20-year study period, details about the mechanism or object that caused the injury, and ability to use NEISS probability sampling to obtain accurate estimates of national incidence rates and trends over time. This study also had limitations. Retrospectively analyzed data offer innate interpretation limits. Moreover, the NEISS database had several inherent limitations, including the absence of a number of patient characteristics, specifics regarding injury pattern, method of treatment undertaken, and the inability to determine final subjective and objective and outcomes. Furthermore, the database specifically excludes firearm-related and workplace injuries. Thus, finger amputations related to such mechanisms were not evaluated.
      The current investigation underscores the prevalence of finger amputations as a real clinical problem affecting all age groups. Unfortunately, despite public health measures and technological advances over the past 2 decades, the national incidence of finger amputations has not decreased. These results highlight the urgent need for improved age-specific safety guidelines as well as further improvements in patient education and home and device safety features.

      Appendix

      Appendix AAll NEISS Codes Included in Each Injury Mechanism Group
      DOORPOWER SAWKNIFELAWN MOWERSNOWBLOWERFOOD PROCESSING TOOLCHAIR/STOOLBICYCLE/BICYCLE EQUIPMENTFENCEEXERCISE EQUIPMENTCABINET
      18931411321214481459021540745040187132774056
      1886089532101446145804694053503318561820
      188108941722143914340471405212021851
      18800875170214371406023340261834
      1879087208361436044940251001
      187808640467143104474024
      187708630464142204464023
      185908450443142104124022
      185808440407142004484021
      184808430218141904534020
      18470842141804734019
      18460841140204014018
      18450832140104044017
      1844082504094016
      082404104003
      080704111556
      080104141555
      080104281547
      04451546
      04461541
      04471540
      04481518
      04491501
      04530671
      04720670
      04730658
      0644
      0643
      0602

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