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Early Mobilization of Hand Fractures in B.C.
November 2006
| Principal Investigator: | Samuel Sheps (University of British Columbia ) |
| Co-investigators: | Ken Bassett (University of British Columbia ) |
For more information about this study please contact Lynne Feehan.
Issue
Hand fractures are the most common work-related fracture injury, and some of these fractures may benefit from a treatment called early controlled mobilization (ECM). This project assessed the evidence for this treatment's effectiveness, and conducted epidemiological research on work and non-work related hand fractures in B.C., using the B.C. Linked Health Database (BCLHD).
Key findings
- There is not enough scientific evidence to draw conclusions about how ECM affects hand fracture healing and functional status.
- There are approximately 14,500 hand fractures in B.C. each year and about 1 in 7 of those is work-related.
- Most (67%) of the work-related hand fractures that could potentially have been treated with ECM were not. If future research establishes that ECM improves outcomes, this may represent a significant opportunity to improve hand fracture treatment and return-to-work.
Objectives
- To systematically review the scientific literature to asses whether there is evidence that ECM results in better fracture healing and functional outcomes compared with post-fracture immobilization, for people with hand or finger fractures not involving a joint.
- To examine epidemiological data from the BCLHD to determine:
- Who is most at risk for hand fractures
- Who provides initial care for hand fractures and in what clinical setting
- How many work-related hand fractures there are in B.C.
- How work-related hand fractures are managed medically
- What the claims duration and costs are for work-related hand fractures in B.C.
Method
Systematic Review
A search of medical databases was conducted to identify potentially relevant studies. To be included, a study had to be a prospective controlled, quasi-randomized or randomized controlled clinical trial, comparing treatment outcomes for ECM and immobilization. Two independent reviewers (one content expert and one methodology expert) reviewed abstracts of potentially relevant studies to identify which ones met the inclusion criteria. The quality and findings of the studies were assessed.
Epidemiological Studies
In the first epidemiological study, the researchers examined data from the BCLHD on hand fractures treated in B.C. between 1996 and 2001. Statistical analysis was conducted to examine the incidence and demographics of hand fractures, and the initial health care utilization trends for people treated for a hand fracture in B.C.
In the second epidemiological study, the researchers examined a stratified random sample of records from the BCLHD for people who were identified as likely having sustained a work-related fracture in B.C. in 2001. Statistical analyses were conducted to examine the incidence, claim rates, demographics, clinical characteristics, medical management and claims costs and duration for the sample of work-related hand fractures.Results
Systematic Review
- About 1000 references for potentially relevant studies were identified, and 344 abstracts were formally reviewed.
- Only six of the studies were found to be relevant and examined in depth, and they were all rated as quasi-randomized and of poor quality. They also differed in the kinds of outcomes examined, so the data from the studies could not be combined.
- The studies showed benefits in terms of mobility and earlier return-to-work for participants treated with ECM, and did not detect harmful effects of the treatment. However the review found that the evidence from these studies was not strong enough to draw definite conclusions about the impact of ECM.
Epidemiological Studies
- Over the five year time period of this study (1996 to 2001), there was an average of 14,500 hand fractures per year identified in B.C. Males were at twice the risk for a hand fracture, with most of this risk sustained between the age of 15 and 40 – their most active and productive working years.
- About 1 out of every 7 of the 14,654 hand fractures in B.C. in 2001 was identified as work-related.
- Work-related hand fractures were more likely to require surgery, suggesting that these fractures tend to be more clinically complex than hand fractures in the general population.
- ECM was not used for most (67%) of the work-related fractures that could potentially have been treated with early controlled motion.
- Health care and time loss costs for work related hand fractures in B.C. were estimated at over $6 million in 2001. About 40% of these costs were covered by the public health care system and privately funded illness and disability benefits.
Conclusions
There is not enough scientific evidence to establish the impact of ECM on hand fracture healing and functional status. However, some studies suggest that there may be benefits in terms of mobility and earlier return-to-work, while no studies found evidence of harmful effects from the treatment. The researchers conclude that ECM can continue to be considered as a clinical option in these fractures.
The large proportion (67%) of work-related hand fractures not receiving ECM may represent an opportunity for improving outcomes and cost effectiveness if it can be established that ECM has a positive impact on treatment and return-to-work.
The researchers also conclude that many work-related hand fractures are treated outside the workers compensation system and that up to 40% of the costs are absorbed by the public health system and private illness/disability plans.Future directions
Further clinical research is needed to examine whether ECM results in better treatment outcomes, faster return-to-work, and potential cost savings. The researchers recommend increasing professional training in B.C. regarding the role of ECM and specialized hand therapy services following a hand fracture.
To address the large proportion of work-related hand fractures that are treated outside the workers compensation system, the researchers also recommend raising public, health care provider and employer awareness of reporting requirements for these injuries.Publications and presentations
Published Refereed Papers
Feehan LM, Oxland T, Tang C. Early controlled passive motion improves early fracture alignment and structural properties in a closed extra-articular metacarpal fracture in a rabbit model. J Hand Surg 2007: 32A(2):200-208 [NOTE: This is a related publication, not specifically arising from this grant]
Feehan LM, Sheps S. Incidence and demographics of hand fractures in British Columbia , Canada : A population based study. J Hand Surg 2006; 31A(7): 1068-1074.
Feehan LM, Basset K. Is there evidence for early motion following an extra-articular hand fracture? J Hand Ther 2004; 17(2): 300-308.
Feehan LM. Early controlled mobilization of potentially unstable extra-articular hand fractures. J Hand Therapy 2003; 16(2): 161-170.
Published Abstracts and Conference Presentations
Feehan LM, Basset K. Is there evidence for early mobilization following an extra-articular hand fracture? http://www.crd.york.ac.uk/crdweb/ (Peer Reviewed, DARE Structured Abstract).
Feehan LM. Early controlled mobilization of potentially unstable extra-articular hand fractures. Year Book of Hand Surgery, 2004:22. (RA Berger MD, PhD - Reviewed Abstract).
Feehan LM, Sheps S. Hand fractures in B.C.: Incidence, demographics and acute health care utilization trends. IFSHT 2004: 6 th Congress of the International Federation of Societies for Hand Therapy. June 28, 2004. Edinburgh , Scotland. (Conference Proceedings Abstract - Scientific Paper).
Feehan LM, Sheps S. Is there evidence for early motion following an extra-articular hand fracture? ASHT 26 th Annual Meeting, October 11, 2003. (Conference Proceedings Abstract- Scientific Paper).