Upper Extremity Wood Saw Injuries: Experience at a Single Level 1 Trauma Center

Abstract

Background:

Saw injuries are common, with more 75 000 occurring each year in the United States alone. While these injuries occur frequently, management strategies are not universally agreed upon, and data regarding outcomes and complications are lacking. We propose to provide a comprehensive picture of upper extremity saw injury patterns, management strategies, complications, and outcomes.

Methods:

Patients presenting to a single level 1 trauma center between 2012 and2019 with upper extremity laceration, crush, or amputation were identified. In all, 10 721 patients were reviewed, and those without wood saw injuries were excluded. Patient demographic information, injury details, management strategy, and outcomes were collected.

Results:

In all, 283 upper extremity wood saw injuries were analyzed. Injuries most commonly affected the fingers (92.2%), and the frequencies of simple lacerations and complicated injuries were nearly identical. The table saw was the most commonly implicated saw (48%) with more than half of the injuries being complicated, the most common being bone injury. Most patients were treated nonsurgically (81.3%), with the majority undergoing wound care in the emergency department followed by home antibiotics (68.2%). Subsequent complications were exceedingly rare (4.2%), with wound infection occurring in 5 patients. Amputations occurred in 19.4% of patients, leading to permanent functional impairment.

Conclusions:

Wood saw injuries are common, generating functional and financial burden. While injuries range in severity, management can typically be conducted within the emergency department with local wound care and outpatient oral antibiotics. Injury complications and long-term issues are rare. Ongoing efforts to promote saw safety are required to minimize the burden of these injuries.

Introduction

Electric and manual wood saws are commonly used tools across the United States. Although they possess significant utility for construction and other woodworking tasks, they are also a frequent cause of injury. The National Electronic Injury Surveillance System provided by the US Consumer Product Safety Commission estimated that greater than 75 000 injuries occur annually from saw use, with other estimates projecting more than 30 000 occur from the use of table saws alone.^1,2 With this high frequency, some studies have been conducted to collect basic data regarding epidemiology and the extent of saw injuries to inform decisions regarding the implementation of safety measures.^{2 -6} Even with safety measures in place, there is poor evidence for adequate protection and consumer satisfaction.^3,7,8 The resultant saw injuries not only have a lasting impact on function and quality of life but also represent both a personal and systemic financial burden as a result of medical expenses and lost wages.

While saw injuries represent a common mechanism of injury, posing substantial functional and financial burden, robust data regarding epidemiology, treatment, and outcome following wood saw injuries are limited. Drawing from a large patient population presenting to a single level 1 trauma center over several years, the purpose of this project was to present a comprehensive overview of wood saw injury patterns, management, outcomes, and complications. We hypothesized that wood saw injuries would more commonly cause complicated injuries at the level of the fingers.

Materials and Methods

A retrospective analysis of patients presenting to a single level 1 trauma facility between 2012 and 2019 with upper extremity laceration, crush, or amputation injury was conducted. Institutional review board approval was obtained to perform this study. In all, 10 721 patients were identified using a broad search of diagnosis codes in the electronic medical record for a range of upper extremity pathologies, including laceration, avulsion, contusion, amputation, tendon injury, open wound, puncture, penetrating wound, abrasion, skin tear, degloving, cut, traumatic hematoma, and so on, and screened for those with injuries attributable to wood saws. Wood saws included in the analysis were table saw, circular saw, miter saw, reciprocal saw, band saw, hand saw, and “other” saws—those not specified in the medical chart. Patients who were not injured by a wood saw (10 427), presented from an outside hospital without treatment records (n = 7), or were under 18 years old (n = 4) were excluded. The remaining 283 patients with upper extremity wood saw injuries were included. Electronic medical records and radiographs were reviewed. Demographics, medical comorbidities, and social history were collected. Information regarding the type of saw, injury features, and treatment was collected. Complex injuries were defined as those that resulted in amputation or had tendon, bone, artery, and/or nerve involvement. Complex injuries including the tendon, artery, or nerve injury were diagnosed by physical examination performed by consulting service in the emergency department (ED) or intraoperatively. Early complications including infection, neuroma, and indications for secondary operations were recorded, and employment impact was also assessed.

Results

In all, 283 patients were identified with upper extremity saw injuries. The mean age was 50.1 years (range, 18-91 years), and 97.5% were men. Most were right-hand-dominant and 172 (60.1%) were nondominant injuries. The underlying comorbidities were identified in 64 patients, including 25 with diabetes mellitus, 17 with cardiac disease, 2 with renal disease, 1 with peripheral vascular disease, and 31 with psychiatric illnesses. Recreational substance use at baseline included 117 (41.3%) with tobacco, 126 (44.5%) with alcohol use, and 7.8% disclosing recreational drug use.

Most injuries occurred within the finger (92.2%), followed by the hand (6.3%), wrist (2.5%), and forearm (0.7%), with some injuries occurring at multiple levels (n = 5) (Table 1). The index finger was the most commonly injured (47.5%), followed by the thumb (35.2%), and the majority involved a single finger (71.6%), with only 1 patient having all 5 digits of 1 hand injured (Table 1, Figure 1). Simple soft tissue laceration accounted for half of all injuries. Complex injuries involved the bone (42.8%) and the tendon (26.1%), with amputation in 19.4%. Wrist and forearm injuries were rare.

Table 1.

Injury Patterns Based on Anatomical Location and Types of Injury and Injury Patterns Based on Type of Saw.

Injury patterns	Total	Soft tissue only	Tendon	Bone	Artery	Nerve	Amputation
Finger	261	128	64	118	30	41	55
Thumb	92	41	16	38	6	9	12
Index	124	57	33	45	15	25	20
Long	90	32	20	42	12	15	21
Ring	58	20	15	25	7	7	9
Small	21	5	7	12	6	7	8
Hand	18	11	7	1	3	5	0
Wrist	7	3	3	2	0	2	0
Forearm	2	2	0	0	0	0	0
Injury by saw	Table saw	Circular saw	Miter saw	Reciprocal saw	“Other” saw	Band saw	Hand saw	Total
Total	136	63	14	8	45	10	7	283
Finger	134	55	11	5	40	9	7	261
Soft tissue only	52	17	6	3	38	6	6	128
Tendon	40	20	2	0	0	2	0	64
Bone	75	33	5	1	2	1	1	118
Artery	24	5	1	0	0	0	0	30
Nerve	29	10	1	1	0	0	0	41
Amputation	37	14	4	0	0	0	0	55
Hand	4	4	3	3	3	0	1	18
Soft tissue only	0	3	1	3	3	0	1	11
Tendon	4	1	2	0	0	0	0	7
Bone	1	0	0	0	0	0	0	1
Artery	3	0	0	0	0	0	0	3
Nerve	5	0	0	0	0	0	0	5
Wrist	1	3	0	0	0	1	0	7
Soft tissue only	0	2	0	0	0	1	0	3
Tendon	1	2	0	0	0	0	0	3
Bone	0	2	0	0	0	0	0	2
Artery	0	0	0	0	0	0	0	0
Nerve	2	0	0	0	0	0	0	2
Forearm	0	0	0	0	2	0	0	2
Soft tissue only	0	0	0	0	2	0	0	2

Figure 1.

Characterization of wood saw wounds: (a) number of injured digits in each hand injury and (b) wound type by complexity at each anatomical level of the upper extremity.

Injury pattern and frequency were assessed by type of saw (Table 1). Table saws (48%) and circular saws (22.3%) accounted for most injuries. Of the table saw injuries, 55.9% included the bone and 33.1% included the tendon. Table saws were also the most common cause of amputations (n = 37), accounting for 67.3% of all amputations. No amputations occurred proximal to the digits (Table 2). Only 18.2% of amputations implicated the thumb. Finger amputations most commonly occurred proximal to the distal interphalangeal (DIP) joint (55.5%). Regarding thumb amputations, 6 of10 impacted the interphalangeal joint or proximal phalanx.

Table 2.

Level of Injury for Finger Amputations.

Thumb	Proximal phalanx	Interphalangeal joint	Distal phalanx
	4	2	4
Finger	Proximal phalanx	Proximal interphalangeal joint	Middle phalanx	Distal interphalangeal joint	Distal phalanx
	12	2	11	2	18

Initial management occurred in the ED in 90.1%, whereas 18.7% required surgical treatment, with some following initial ED management. Most underwent irrigation and debridement (90.1%), with 80.3% having laceration repair in the ED. In total, 41.2% received intravenous antibiotics, and 68.2% were given prescription for oral antibiotics at the initial encounter. For those who had primary surgery, the most common procedures included irrigation and debridement (64.2%), tendon repair (56.6%), and revision amputation (41.5%). Of those who underwent operative management, 13 patients (24.5%) required subsequent surgery. Most commonly, these surgeries were for implant removal (30.8%), arthrodesis (23.1%), tenolysis (15.4%), and nail procedures (15.4%), among others. Orthopedics was the most commonly consulted service (32.2%), followed by plastic surgery (30.7%). Collaborative care between different specialties occurred in 11% of cases. Although some patients had multiple surgeries with more than 1 primary team, surgeries were more commonly conducted by the orthopedic surgeons (Table 3).

Table 3.

Wood Saw Injury Management.

Setting	Total patients	Debride	Laceration repair	Revision amputation	Nailbed procedure	IV Abx	Home Abx
ED	255	230	205	25	17	105	174
OR	Total patients	Debride	Revision amputation	Tendon repair	Vascular repair	Nerve repair	Replant	ORIF	Arthrodesis	Soft tissue cover
Primary surgery	53	34	22	30	7	20	4	15	11	3
	Total patients	Debride	Revision amputation	Implant removal	Tenolysis	Arthrodesis	ORIF	Replant	Nail procedure	Neuroma excision
Subsequent surgery	13	1	1	4	2	3	1	1	2	1
Team	Total	Surgery
Ortho	75	27
Plastics	66	24
Emergency medicine	96	0
Express care	15	0
Multiple	31	2

Note. Management setting and associated procedure along with medical specialty responsible for management. Of the patients who underwent primary surgery, 28 were managed operatively without prior ED treatment. “Multiple” teams include patients who were managed by more than 1 service over the course of initial ED bedside management, to follow-up, to operation(s). ED = emergency department; OR = operating room; ORIF = open reduction and internal fixation; IV = intravenous; Abx = antibiotics.

Most patients had definitive management within the ED followed by 1 follow-up visit, most commonly with an orthopedic or plastic surgery hand specialist. In total, 165 patients had at least 1 follow-up visit, while only 24 had ≥6 months of follow-up. Of these patients, 33% reported pain at 6 months and 25% at 12 months. Complications were rare; among those with follow-up, only 5 developed infection (3.0%) requiring antibiotics and local wound care and 2 patients reported neuroma (1.2%). Of the 5 patients who developed infection, 3 (60%) did not receive antibiotics at their initial encounter. Seven patients (4.2%) underwent 3 or more surgeries for indications, including infection, neuroma, and revision amputation. With the numbers available, complications and secondary surgeries were not associated with medical or psychiatric comorbidities.

Of the patients with available employment status (n = 211), 160 patients were employed at the time of injury, and 40.6% missed work (mean, 53.8 days). Eleven patients (6.9%) were unable to return to work. Overall, 22 workers’ compensation claims were filed, of which 77.3% were complex—most commonly complicated by bone involvement (n = 16), followed by tendon involvement (n = 10) and then artery and nerve involvement (n = 7 for each). Thumb injuries accounted for 50% of workers’ compensation claims, 3 of which were due to amputation. Nine of the patients with workers’ compensation claims sustained primary amputations (41%). Complex injuries and primary amputations were more common among workers’ compensation patients (P < .0001 for both).

Discussion

Even with ongoing efforts to promote safety of saws, upper extremity saw injuries remain a common and serious mechanism of injury. Drawing from a large patient cohort at a single level 1 trauma center, our robust data set provides a comprehensive overview of patterns, management, and complications of wood saw injuries. Our study was largely composed of right-handed men near mean age of 50 years. Within this cohort, serious comorbidities were relatively uncommon and did not appear to influence injury or complications. Notably, injury to the nondominant hand was the most common. Similar to previous studies, table saws were the most common mechanism. ⁷ Most of the injuries occurred at the level of the finger, with index finger being most commonly implicated. Consistent with our hypothesis, of injuries to the finger, complex injuries were more common than simple lacerations. This pattern has been demonstrated in other smaller, less detailed reports in the past. ³

Considering the mechanism of injury, the pattern of injury severity was similar across types of saw. For both table saws and circular saws, the 2 most common sources of injury, complex injuries were more common than simple lacerations, and the distribution of the types of injuries was similar. Of note, amputations were most common with table saws. The high frequency of complex injury from saws demonstrates substantial threat saws pose for serious life-changing injury. These findings, coupled with findings from previous studies investigating saw safety, demonstrate the need for ongoing safety promotion across saw types.^3,7,8

While there were a range of injury severities, most patients were managed with bedside irrigation and debridement and laceration repair followed by home antibiotics. For those patients who did require surgical intervention, procedures were most commonly required for the treatment of complex injury, especially tendon repair and revision amputation procedures. Regardless of the management strategy, complication rates were exceedingly rare, with only 3% of patients developing infection.

Emergency medicine physicians accounted for a sizable portion of definitive management and bedside management prior to outpatient hand specialist visits. As such, there is a clear rationale for further education of ED physicians on management of these upper extremity wood saw injuries to ensure proper initial management. This need is further supported by the additional functional and financial burden associated with subsequent injury complications in this patient population. Aside from ED staff management, orthopedic surgery was the most commonly consulted service for both bedside management in the ED and for surgical intervention. Consult service bedside management in the ED by orthopedic and plastic surgery services was completed by residents and fellows. The frequency of plastic surgery consultation demonstrates overlap between the expertise of these 2 teams in the management of upper extremity traumatic injuries. In some cases, these teams worked collaboratively. These findings may serve as basis for framing management training and injury expectations in both fields and support the role of physicians from both specialties in the education of nonspecialist providers on the management of upper extremity wood saw injuries.

Even with the relatively low rate of complications following upper extremity saw injuries, functional and financial burden from these injuries remains. Nearly 20% of patients had finger amputations, an injury that can significantly impact function and quality of life. More than 20% of amputations involved the thumb, and of these, 60% implicated the interphalangeal joint or proximal phalanx, injuries that cause substantial functional impact. Similarly, amputation injuries to other fingers more commonly occurred proximal to the DIP joint, suggesting injuries causing greater functional deficit were more common. Financial burden of these injuries is also consequential- Medical costs across the United States from saw injuries are estimated to exceed $2.1 billion annually, with a mean personal cost of more than $30 000 for medical expenses and lost wages.^9,10 These economic implications may have extrapolated our patient population as more than 40% missed work, and some were unable to return to work altogether. These data demonstrate the clear financial burden that may result from saw injury, not only from direct medical expenses but also from indirect costs of lost wages.

While this article provides a range of important data points regarding upper extremity saw injuries, it is not without limitations. Complications were very rare, and long-term follow-up was poor. Due to the low rates of infectious and other complications and the heterogeneity of the injuries, we were not able to detect differences in complications based on the administration of oral and/or intravenous antibiotics. Of note, 47% of patients (118) did not have a record of follow-up visit after their initial encounter. Of these patients, 96 were managed definitively in the ED (83) or express care setting (13) without consult for specialist care. As such, lack of follow-up for many of these patients may be attributed to lack of medical indication. With that being said, the exact rate of loss to follow-up versus discharge without follow-up is missing in our data and serves as a meaningful limitation for our reports of outcomes and complications. To address this, complication rates were adjusted to only include patients with at least 1 documented follow-up visit. This strategy may overestimate complication rates. As it does not include patients for whom follow-up was not indicated, it serves to best address this limitation of our data and present our complication/outcomes data most appropriately.

Overall, these data provide a meaningful sample size of patients with common upper extremity wood saw injuries, demonstrating the range of injuries, management, and outcomes. With a clear need for ongoing safety measures in the construction space, these findings may improve understanding regarding the frequency and scope of injuries across types of saws, with very few long-term complications. Future work to investigate indications for using antibiotics appears warranted, as medications may be overprescribed at present. Equipped with the information in this study, physicians may also be better prepared to counsel patients on safe use of saws. Future research into prevention and optimal management of upper extremity saw injuries is warranted.