手部外傷是勞工職業傷害的一大族群，所引起的傷害不僅是外形上的缺損，同時也嚴重影響手部功能復原情形，而導致重返工作的困難。由於這些職業意外傷害的受害者，通常都是正值生產力旺盛的青年，因此意外的結果不只造成國家及社會經濟競爭力的損失，亦會造成家庭經濟來源的重擔。勞工在受傷後，往往會遇到重返工作之窘境，影響手傷勞工的工作能力與復工之因素，是相關醫療人員及手傷個案高度關切的議題。手部外傷評估不僅是傷害嚴重程度的指標，亦可以是預測手傷後重返工作的相關因子。
手傷勞工復工情形，可由勞工受傷後重返工作的時間長短、復工後薪資的高低變化，以及工作內容的轉換與否加以探討。本研究將使用臨床評估手部外傷的手部傷害嚴重程度評估系統(Hand Injury Severity Scoring System)、以及使用美國醫學學會 (American Medical Association, AMA)制定之評估手部外傷的評量指南AMA Guides所得之手部傷殘指數(Hand Impairment Ratio)，以深入探討不同評估方法預估手傷勞工復工情形之相關性與適用性。
研究共招募了102位職業手外傷的個案，在受傷至少6個月後且經治療和復健後臨床症狀穩定，個案接受問卷調查、手傷嚴重程度評分系統(Hand Injury Severity Scoring System)，及手部傷殘指數(Hand Impairment Ratio)的評估以紀錄個案手傷後的手部功能情形和復工狀況。研究結果顯示不同的手部傷殘評估(HIR、HISS_SCORE、HISS_GRADE)之間存在一定的正相關，HIR於勞工受傷前後是否復工組間比較有顯著差異(P=0.026)，TRTW於受傷前後是否復工組間則有差異傾向(P=0.063)，未來可進一步探討兩種不同評估方法於手傷勞工手部功能的適用性及復工情形的預測性。

SUMMARY

Hand injury is a major occupational injury of labor groups, which causes not only the defect of appearance, but also seriously affects the hand function, which leads to difficulties in returning to work. Return to work (RTW) is an important issue of hand-injured workers, and the factors related to RTW and hand function are highly concerned. 102 patients with occupational hand injury were recruited in this study to
answer the RTW questionnaire and received the hand evaluation HISS and HIR to explore the relevance and applicability of different assessment tools for estimating RTW of hand injured workers. RTW outcomes assessed whether the subjects successfully returned to work, either from a job change or salary reduction, and the length of the time it took for them to return to work (TRTW).We performed a retrospective study in RTW outcomes after occupational hand trauma by measuring the subjects’ hand impairments and found some correlations between the measured variables. HIR showed the significant correlation with RTW outcomes.

Key words: Occupational injury, hand trauma, Return to work (RTW)

INTRODUCTION

Hand injury is a major occupational injury of labor groups, which causes not only the defect of appearance, but also seriously affects the hand function, which leads to difficulties in returning to work. Because the workers with occupational injuries usually are main productive labor, so unexpected results not only cause loss of socio-economic competitiveness, and would also lead to the burden of family economic sources. Return to work (RTW) is an important issue of hand-injured workers, and the factors related to RTW and hand function are highly concerned. Hand injury evaluation is an index of injury severity, and a relevant factor to predict RTW after hand injury.

The outcomes of hand injured workers’ RTW can be discussed by length of time to RTW, salary change level and whether job contents change or not after hand injury. Clinical hand injury severity assessment system (Hand injury severity scoring system, HISS), and hand disability index (Hand Impairment Ratio) which is evaluated according to American Medical Association (American Medical Association, AMA) are used to explore the relevance and applicability of different assessment tools for estimating RTW of hand injured workers .

MATERIALS AND METHODS

The study recruited 102 patients who suffered occupational hand trauma and who were admitted for surgery from 2003 to 2006 at a tertiary referral hospital center in southern Taiwan. The patients were at least 6 months post-injury and clinically stable following treatment and rehabilitation. Patients that had a history of other severe hand injury and difficulty with communication were excluded from the study. The study proposal was evaluated by the IRB of National Cheng Kung University Hospital. Hand injury severity scoring system (HISS) ,Hand Impairment Ratio (HIR) and questionnaire were evaluated and recorded accordingly.

RTW outcomes assessed whether the subjects successfully returned to work, either from a job change or salary reduction, and the length of the time it took for them to return to work (TRTW). Descriptive statistics were used to illustrate the demographic background and hand impairment measures of the subjects with different RTW outcomes. Chi-square analysis was used for nominal variables and t-tests and ANOVA for continuous variables were used to compare different RTW groups.

RESULTS AND DISCUSSION

The demographic statistics and RTW information in Table 1 reveal a total of 65 subjects returned to their previous jobs without any job modification, while 14 subjects returned to work with job change. 23 subjects in this study did not return to work after their hand injury.

The average TRTW of all subjects was 76.81 days (SD: 115.8 days). The means of the TRTW in different demographic groups are shown in Table 1. There was no statistically significant difference between the relative groups in gender, education level, and dominance of the injured hand. However, there was a statistically significant difference in TRTW between the RTW groups with and without salary reduction (p<0.05), but no difference between the RTW groups with and without job change.

Among the three RTW level groups, the analyses found no significant differences in age, gender, education level, and dominance of the injured hand. In the 79 subjects who returned to work, 51 subjects did not have a salary reduction, but 15 subjects did receive a salary reduction after the injury. No significant difference was observed in age, gender, education level, and dominance of injured hand between these two groups. However, the chi-square analysis showed a significant difference in salary reduction between the two RTW groups with and without job change (P = .01). The RTW group without job change tended to have no salary reduction.

The distribution of the hand impairment measures in different RTW groups is shown in Table 2. The one-way ANOVA indicated that HIR of the RTW group without job change was significantly different from the RTW group with job change (P=0.026). In addition, a tendency of significant difference was also found in TRTW between the RTW groups with and without job change (P=0.063).

HIR was found to have significantly moderate and positive correlation with TRTW, when HISS_S and HISS_G have low correlation with TRTW. All the hand impairment measures were mutually examined by Pearson’s correlation analysis and the coefficients are shown in Table 4. HIR, HISS_S, and HISS_G were found to have significantly moderate and positive correlations with each other.

CONCLUSION

Literature indicated that the actual outcome of RTW can be very complicated and influenced by demographic variables such as age and gender. However, the subjects between various RTW groups in this study were found to have no significant differences in age, gender, education level, or dominance of injured hand. The reasons could be the limited and skewed distribution in samples and other undetected factors such as family economic status, employer’s support, job opportunity, personal volition and confidence, etc., which need further investigation. This study presented the subtle correlation of RTW outcomes and hand impairment measures. The findings can point to some practical focuses in occupational rehabilitation for the workers with hand trauma.

This study presented a subtle correlation between RTW outcomes and the hand impairment measures among the workers with hand trauma. However, the subjects obtained were sampled from convenience and skewed to those who already were RTW, which limited the sample size and the extent of interpretation. Data retrieved from the subjects were only able to explain the RTW outcome in regards to with/without job change or salary reduction and TRTW. Nevertheless, the RTW levels and salary reduction could be affected by other social-economic factors beyond our detection.

Bernacki EJ, Guidera JA, Schaeffer JA, Tsai S. A facilitated early return to work program at a Large Urban Medical Center. J Occup Environ Med. 42:1172–1177. 2000.

Bruyns CN, Jaquet JB, Schreuders TA, Kalmijn S, Kuypers PD, Hovius SE. Predictors for return to work in patients with median and ulnar nerve injuries. J Hand Surg. 28:28-34, 2003.

Campbell DA, Kay SP. The Hand Injury Severity Scoring System. J Hand Surg. 21:295-298, 1996.

Chamberlain MA, Moser VF, Ekholm KS, O'Connor RJ, Herceg M, Ekholm J. Vocational rehabilitation: an educational review. Journal of Rehabilitation Medicine. 41(11):856-869, 2009.

Chen Y-H, Lin H-T, Lin Y-T, et al. Self-perceived health and return to work following work-related hand injury. Occupational Medicine.;62(4):295-297, 2012.

Lee Y-Y, Chang J-H, Shieh S-J, Lee Y-C, Kuo L-C, Lee YL. Association between the initial anatomical severity and opportunity of return to work in occupational hand injured patients. The Journal of trauma. 2010.

Mink Van Der Molan AB, Matloub HS, Dzwierzynski W, Sanger JR. The hand injury severity scoring system and workers' compensation cases in Wisconsin, USA. J Hand Surg. 24:184-186, 1999.

Mink Van Der Molan AB, Ettema AM, Hovius SE. Outcome of hand trauma: the hand injury severity scoring system (HISS) and subsequent impairment and disability. J Hand Surg. 28:295-299, 2003.

Matsuzaki H, Narisawa H, Miwa H, Toishi S. Predicting functional recovery and return to work after mutilating hand injuries: usefulness of Campbell's Hand Injury Severity Score. J Hand Surg. 34:880-885, 2009.

Saxena P, Cutler L, Feldberg L. Assessment of the severity of hand injuries using "hand injury severity score", and its correlation with the functional outcome. Injury. 35:511-516, 2004.

Smedley J, Dick F, Sadhra SS. Oxford handbook of occupational health: Oxford University Press; 2007.

Stergiou-Kita M, Dawson D, Rappolt S. Inter-Professional Clinical Practice Guideline for Vocational Evaluation Following Traumatic Brain Injury: A Systematic and Evidence-Based Approach. Journal of Occupational Rehabilitation. 1-16, 2011.

Talmage JB, Melhorn JM. A physician's guide to return to work: American Medical Association; 2005.

Urso-Baiarda F, Lyons RA, Laing JH, Brophy S, Wareham K, Camp D. A prospective evaluation of the Modified Hand Injury Severity Score in predicting return to work. Int J Surg. 6:45-50, 2008.

Wong JY. Time off work in hand injury patients. J Hand Surg. 2008;33:718-725.