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ORIGINAL ARTICLE
Year : 2017  |  Volume : 17  |  Issue : 2  |  Page : 82-86

Functional outcome related to occupation after orthopedic trauma of upper and lower extremity


Department of Orthopaedics, Burdwan Medical College, Burdwan, West Bengal, India

Date of Web Publication6-Jun-2017

Correspondence Address:
Abhilash Sarkar
5A, Sushil Sen Road, Kolkata - 700 025, West Bengal
India
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DOI: 10.4103/1319-6308.207579

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  Abstract 

Context: In today's healthcare scenario, increased emphasis is being placed on patient centred care and patient satisfaction. Despite its importance, little work has been done to analyse functional outcome related to occupation after trauma.
Aims: To evaluate return to work-after one year of major orthopaedic trauma, how patient's satisfaction regarding functional outcome co-relates with other outcome measures.
Settings and Design: Institution based prospective study.
Materials and Methods: Prospective study of cases admitted randomly through the emergency department at our hospital. The cases were managed as per standard protocols and evaluated at 6 months and 1 year with respect to their ability to resume their previous job.
Statistical Analysis Used: Randomised study on patients who met the eligibility criteria.
Results: After 6 months, most patients (74%) could not return to work or required job modifications. At 1 year follow up, almost 41% could return to their previous job although another 40% required job modifications. 75 cases at 6 months and another 59 cases at 1 year were lost.
Conclusion: The findings of this study indicate that a number of demographic, occupational, psychosocial, economical, institutional factors are significant predictors of return to work after minor to moderate non-life threatening orthopaedic trauma.

Keywords: Occupation, pain, return to work, socioeconomic, trauma


How to cite this article:
Ghosh A, Dasgupta S, Naiya S, De C, Sarkar A. Functional outcome related to occupation after orthopedic trauma of upper and lower extremity. Saudi J Sports Med 2017;17:82-6

How to cite this URL:
Ghosh A, Dasgupta S, Naiya S, De C, Sarkar A. Functional outcome related to occupation after orthopedic trauma of upper and lower extremity. Saudi J Sports Med [serial online] 2017 [cited 2017 Aug 20];17:82-6. Available from: http://www.sjosm.org/text.asp?2017/17/2/82/207579


  Introduction Top


In today's health care, increased emphasis is being placed on patient-centered care, and patient satisfaction is being considered as a valuable outcome measure.

Despite its potential importance, to our knowledge, little work has been done to analyze the determinants of patient satisfaction after management of trauma.

Our goal was to analyze how the patient's satisfaction with the outcome correlates with other more traditional measures of outcome such as clinical parameters, functional results, physical and psychological impairment, and pain. In addition, we aimed to investigate the sociodemographic characteristics of the patient.

Over many years, research has been directed toward understanding the determinants of return to work (RTW) following injury.[1],[2] RTW is an identified outcome of occupational rehabilitation and is considered a marker of effectiveness of the compensatory systems.

Much of the focus of research to date has been on RTW following cumulative trauma associated with neck and back injuries.[3] There have been only a few studies that have considered determinants of RTW following a range of minor or moderate acute nonlife-threatening orthopedic trauma.

Aims and objective

  1. To evaluate RTW after 1 year of major orthopedic trauma of upper and lower extremity. Here, major trauma means nonlife-threatening injuries of upper and lower limb which keeps the patient out of work for some days
  2. How the patient's satisfaction regarding functional outcome correlates with other outcome measures (clinical, physical impairment, psychological impairment, pain, range of movement, and muscle strength) and other major complications
  3. As there is no universally acceptable scale to measure occupational outcome, we carried our study depending on our patient's feedback.



  Materials and Methods Top


Study population

Cases admitted through the emergency department in our hospital. Within 6 h, following trauma and meeting the inclusion criteria.

Inclusion criteria

  1. Selected open fracture Gustilo type 1 and 2
  2. Closed fracture of extremity
  3. Age 16–55 years.


Exclusion criteria

  1. Age younger than 16 years or more than 55 years
  2. Primary orthopedic treatment done elsewhere
  3. Fractures associated with burn injuries
  4. Documented psychiatric disorder
  5. Associated medical complication.


Study duration

The duration was 12 months.

Sample design

Randomized study on patients who met the eligibility criteria.

Study design

The study design was an institution-based prospective study.

Parameter to be studied

Return to preinjury work: here, we divided our follow-up patients into three groups according to patient's satisfaction about his present work status.

  1. Group 1: No return to the previous occupation
  2. Group 2: Modified work in the previous occupation
  3. Group 3: Returned to the previous occupation.


Follow-up

After discharge from hospital, at 2 weeks, 1 month, 3 months, 6 months, and 1 year. According to work status after 6 months and 1 year, we divided the patients into three groups according to patient's opinion. Follow-up time point was chosen depending on the stages of disability (acute, subacute, and chronic) following injury.

Management protocol

The trial was conducted in a medical college in a rural setup. Out of 250 patients who had been initially enrolled, 175 patients followed up after 6 months, 116 patients were located and interviewed 1 year after. Despite numerous letters, other patients could not be traced. We have used AO, Gustilo–Anderson, and other accepted systems for classification of fracture.

We have selected the cases admitted in our emergency department within 6 h following trauma, randomly. We have followed the standard management protocol we follow at our hospital. For our study, we have taken lower limb fracture and upper limb fracture of dominant extremity.

During admission, we taught the patient pre- and post-operative modalities of physiotherapy. During discharge, we taught the patient the exercise protocol. After 1 year, we interviewed the patients and graded them.

Follow-up data collection

We have asked the patients for follow-up at our outpatient department. Out of 250 patients, 175 (70%) came for the 6-month follow-up and only 116 patients (46.4%) came after1 year [Table 1],[Table 2],[Table 3],[Table 4],[Table 5], [Chart 1].
Table 1: Distribution of cases based on fracture site at 6 months and 1 year follow-up including the number of cases that were lost at 1 year follow-up

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Table 2: Gender distribution at 6months and 1year follow up

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Table 3: Age Distribution at 6 months and 1 year Follow-up

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Table 4: Return to Pre-injury Occupation at 6 month and 1 year follow-up

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Table 5: Distribution of cases based on socio-economic status at 6 months and 1 year follow-up

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Evaluation of results

At 6 months, out of 175 patients, 47 patients returned to the previous occupation, 62 patients had modified their job, and 66 patients were not able to join work. The reasons were due to pain stiffness, weakness of limb, infection, improper fixation of fracture, and financial problems of the patient which led to compromise in management.

After 1 year when RTW was assessed, only 48 (41.38%) patients returned to previous occupation. Nineteen patients (16.38%) never returned to their previous occupation and the rest had to modify their type of work at their previous workplace [Table 6].
Table 6: Occupational status at 6 months and 1 year

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  Discussion Top


The comparison of RTW rates observed in this study and rates observed by others is limited by the timing of outcome measurements, different inclusion criteria, and different definitions of RTW. RTW rates may also be influenced by features of compensation systems as well as factors related to access to treatment and rehabilitation. The RTW rates reported in this study are consistent with findings from other studies that include similar injuries and follow-up periods and highlight the need for further consideration of minor and moderate orthopedic injury cohorts.[4] Many of the predictive factors for RTW found in this study are similar to those found in other trauma populations including those sustaining whiplash and musculoskeletal injuries.[5],[6] Consistent with a number of studies, younger age and higher education levels were associated with higher RTW rates. In common with other studies, gender was not a significant predictor of RTW.

Validated outcome measures such as disabilities of the arm, shoulder, and hand (DASH)-questionnaire are now standardized methods that are being used more commonly in the evaluation of the hand and upper extremity.[7]

Due to this variation between functional assessment by different scoring systems and patient's own satisfaction, we only gave importance to the latter.

Muscle strength testing

Manual muscle testing has been used to determine muscle strength in the rating of impairment according to guides. The measurement of the strength of muscles in the uninjured extremity with the force gauge was used to translate the result of the force gauge testing on the side of the injury into a manual muscle-testing grade.[8],[9] Here, we had relied upon patient's answer – are they satisfied with their muscle power? - yes/no.

Range of motion

According to the method of Kendall and McCreary, subjects who had a joint-motion ratio of at least 81% were considered to have normal strength for that joint motion. Here, we asked the patients if they were satisfied with the movements of affected joint in articular fracture, and joints proximal and distal in case of nonarticular fracture, and if the joint stiffness forced them to modify or to leave their work.

Pain

Whether the affected limb pain-free or was pain restricting their working capacity, or was there a disabling factor preventing them to join their work. Patient's own language was used to understand the nature and severity of pain better.[10]

Among 66 Grade-1 patients at 6 months, 22 lost follow-up, and among 62 Grade-2 patients, 12 were lost.

Among 116 patients after 1 year follow-up, 19 (16.36%) patients had to leave previous occupation. The reasons to leave occupation were - pain in the affected extremity, stiffness of involved or nearby joint, weakness of affected limb, and infection. Among 19 patients, 9 had infection at surgical site and 2 progressed to chronic osteomyelitis. It also caused implant loosening and nearby joint stiffness. In 6 other patients, there was persistent pain and joint stiffness as patient could follow proper exercise protocol due to infection and pain.

A total of six patients suffered from implant-related problem. One patient having fracture of patella was operated with tension band wiring, but due to inadequate fixation, he had to start movement late which resulted in stiffness of knee. One patient with intertrochanteric fracture operated with dynamic hip screw suffered from cutout of lag screw which restricted their work due to pain and stiffness. Two patients with fracture neck femur operated with compression hip screw suffered from pain in hip and limitation of movement due to inadequate fixation in one case and screw cutout in another case. One patient each, with proximal tibia and proximal humerus fractures suffered from implant loosening due to inadequate fixation, causing stiffness of knee and shoulder joint, and pain which limited them to join work. One patient with intercondylar fracture of humerus suffered from stiffness as there was improper fixation and delayed starting of movement. Among these 19, in four patients, we could not provide proper management as the patients were unable to provide implants. One patient with Gustilo type 2 compound fracture of tibia, planned for external fixator application, could not be done. One patient with unstable trochanteric fracture had to be managed with skeletal traction, one patient with Schatzker type 3 proximal tibia fracture was managed by plaster of Paris cast application, and another patient with bimalleolar fracture had to be managed with K-wire. We have also seen that the outcome of articular fractures is less satisfactory than nonarticular fractures.

Forty-nine (42.24%) patients had to modify their job as they were not able to perform their previous job. The reasons were mainly pain, stiffness of joint, and limb-length discrepancy.

Parameters that influenced RTW are:

  • Pain
  • Range of movement
  • Muscle strength
  • Major complication
  • Infection, implant failure
  • Preinjury job type
  • Sociodemographic status
  • Insurance status
  • Institutional problem.


The factors which having no role in RTW:

  • Age
  • Gender
  • Education
  • Race.


Insurance/financial status

Although most of the patients in our study had no insurance coverage, the impact cannot be studied here properly. Some patients were not able to arrange for proper implants.

For example, we had to manage one Schatzker type 3 proximal tibial fracture, conservatively, though operative management was planned.

Institutional problem

Lack of provision of different types of implant freely, delay in surgery due to unavailability of operation theater dates. Two patients with femoral neck fractures were operated after 14 and 18 days, respectively, which affected their outcome adversely.

Psychological outcomes

Depression and anxiety were common in patients who were not able to resume work, and in most cases, they were the only earning member in the family. Depression and anxiety were also present in Group 2 patients, as they earned less due to their job modifications resulting in economic loss to their families.

In our study, most of the patients were self-employed. When they were asked why they were eager to RTW, most of them answered for financial security.

Rehabilitation

In the current study, 116 participants received some form of rehabilitation following discharge from the hospital at which they first presented, 73 participants received rehabilitation in the community, and the remainder received it initially as a hospital subsequently in the community. While physiotherapy was the most common form of rehabilitation received, missing data limit the interpretation of this form of rehabilitation. Those participants who did not need rehabilitation returned to work earlier than participants requiring rehabilitation, suggesting that the need of rehabilitation may be used as a proxy for measuring injury severity. However, rehabilitation could not be evaluated in terms of whether it was a determinant of RTW and thus was not included in the analysis. This finding warrants further study.

Strength and limitations of the study

  • Strength: It is a prospective longitudinal study
  • Limitation: Small sample size, low follow-up rate (46.40%) which restricts a number of facts that can be assessed, thereby affecting the power of the study and its ability to evaluate effects. We have taken heterogeneous type of injuries which means conclusion regarding a single type of injury is limited. At our institution, we were not able to provide optimum care to patients due to limitations such as proper implant, early operation date, and postdischarge rehabilitation.



  Conclusion Top


The findings of this study indicate that a number of demographic, occupational, psychosocial, economical, and institutional factors are significant predictors of RTW after trauma in a sample that had sustained minor to moderate nonlife-threatening orthopedic trauma.

This result needs to be confirmed in larger studies and with more homogeneous type of injury population.

The findings highlighted the need to further assess the functional outcome following minor to moderate nonlife-threatening injury and provide additional evidence that RTW cannot be easily explained within a biomedical model that focuses only on factors related to physical injury.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
MacKenzie EJ, Shapiro S, Smith RT, Siegel JH, Moody M, Pitt A. Factors influencing return to work following hospitalization for traumatic injury. Am J Public Health 1987;77:329-34.  Back to cited text no. 1
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2.
Zatzick D, Jurkovich GJ, Rivara FP, Wang J, Fan MY, Joesch J, et al. A national US study of posttraumatic stress disorder, depression, and work and functional outcomes after hospitalization for traumatic injury. Ann Surg 2008;248:429-37.  Back to cited text no. 2
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3.
Athanasou JA. Return to work following whiplash and back injury: A review and evaluation. Med Leg J 2005;73(Pt 1):29-33.  Back to cited text no. 3
    
4.
Hou WH, Tsauo JY, Lin CH, Liang HW, Du CL. Worker's compensation and return-to-work following orthopaedic injury to extremities. J Rehabil Med 2008;40:440-5.  Back to cited text no. 4
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5.
Scholten-Peeters GG, Verhagen AP, Bekkering GE, van der Windt DA, Barnsley L, Oostendorp RA, et al. Prognostic factors of whiplash-associated disorders: A systematic review of prospective cohort studies. Pain 2003;104:303-22.  Back to cited text no. 5
    
6.
Iles RA, Davidson M, Taylor NF. Psychosocial predictors of failure to return to work in non-chronic non-specific low back pain: A systematic review. Occup Environ Med 2008;65:507-17.  Back to cited text no. 6
    
7.
Gummesson C, Atroshi I, Ekdahl C. The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: Longitudinal construct validity and measuring self-rated health change after surgery. BMC Musculoskelet Disord 2003;4:11.  Back to cited text no. 7
    
8.
Bohannon RW. Test-retest reliability of hand-held dynamometry during a single session of strength assessment. Phys Ther 1986;66:206-9.  Back to cited text no. 8
    
9.
Bohannon RW, Andrews AW. Interrater reliability of hand-held dynamometry. Phys Ther 1987;67:931-3.  Back to cited text no. 9
    
10.
Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: A comparison of six methods. Pain 1986;27:117-26.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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