Hand and Wrist Dog-Leash Injuries in the Outpatient Setting: A Review of 443 Cases

Abstract

Background:

Injuries sustained from dog leashes often result in visits to hand surgeons. This study presents an analysis of dog-leash-related upper-extremity injuries at a single orthopedic practice, including treatment options for these injuries, and guidance for prevention.

Methods:

We identified all outpatients who presented to a hand surgeon at a single institution from 2016 to 2021 following an upper-extremity injury related to a dog leash. Charts were reviewed and demographics, injury description and mechanism, and details of treatment were recorded.

Results:

We identified 443 patients that presented for a dog-leash-related injury. The average time from injury to outpatient visit was 23 days. Surgery occurred following injury in 96 patients (21.6%). The most common injury locations were the ring finger, followed by the wrist, third finger, and fifth finger. Interphalangeal joint sprain was the most common injury type followed by phalangeal fracture. The majority of injuries were caused by the extremity catching in the leash while being pulled (337, 75.9%). Among the 96 patients requiring surgery, open reduction and internal fixation was the most commonly performed procedure followed by closed reduction with percutaneous pinning. For patients not requiring surgery (348, 78.4%), splinting or bracing was the most common treatment recommended.

Conclusion:

The majority of dog-leash injuries were caused by the patient’s extremity catching in the leash as it was pulled, resulting in interphalangeal joint injures and phalanx fractures. The most common treatment required for these patients was nonoperative.

Introduction

A recent national pet owner’s survey reported that 69 million US households own at least 1 dog, ¹ and the American dog-walking industry generated revenues approaching $1 billion in 2021. ² Reported benefits of dog-walking include opportunities for physical exercise, social engagement, and emotional health improvement.^3,4 And for many dog owners, walking their dog on-leash is a necessary correlate to dog ownership. Unfortunately, dog-walking also confers risk for injury; this risk has been specifically documented in the elderly population, with an increasing incidence of fractures in elderly patients related to dog walking. ⁵

Available literature on this topic as it relates to specific injuries is sparse; 2 studies have analyzed nationwide trends utilizing an emergency department (ED) database from approximately 100 hospitals, but few studies to our knowledge have reviewed individual patients presenting with dog-leash related injuries.^4,5 As hand surgeons, we are not uncommonly presented with patients whose injuries occurred due to walking a leashed dog. Data specifically related to hand and wrist injuries from dog leashes are similarly limited. The objective of this study was to perform a comprehensive review of the causes and patterns of, and treatments needed for, leash-related hand and wrist injuries seen by the hand surgery division of a single orthopedic practice.

Materials and Methods

Following Institutional Review Board approval, with a waiver of informed consent per institutional protocol, a retrospective database search was conducted to identify all outpatient dog-leash injury visits between January 1, 2016, and October 5, 2021 within the hand and wrist surgery division of a large, multispecialty orthopedic practice with 22 fellowship trained hand and wrist surgeons. All office visit notes with the words “dog” or “leash” were collected via an automated keyword text search, and each resulting patient chart was reviewed to confirm that a leash-related injury occurred.

For each patient with a leash-related injury, we collected data including demographic information of the patient, the anatomic location of their injury, injury type, mechanism of injury as it related to the dog leash, timing of outpatient evaluation, whether surgical or nonsurgical treatment was performed, and timing and nature of surgery (where applicable). Injury type was further categorized into the following groups: phalanx fracture (distal, middle, or proximal), isolated interphalangeal (IP) joint injury including sprain or dislocation without fracture, ligament rupture, including carpal ligaments, thumb/finger metacarpophalangeal (MCP), ulnar collateral ligament (UCL) or radial collateral ligament (RCL), tendon injury, metacarpal (MC) fracture, wrist fracture including distal radius (DRF), distal ulna (DUF), and carpal bone fractures, skin/soft tissue injury including lacerations and contusions, or “other,” indicating an injury that did not fit any preceding category. Patients that presented with injuries proximal to the wrist were excluded. The mechanism of injury was categorized by whether the extremity was caught in the leash, whether the pull of the leash resulted in a fall causing injury, or whether the pull of the leash resulted in a standing impact that caused injury.

Results

Following the database search and review of office notes, we found 443 patients in our practice who presented in the outpatient setting for a dog-leash-related injury during the study period. This cohort includes 377 females (85.1%) and 66 males (14.9%) with an average age of 51.7 (range 10-88). There were 13 (2.9%) pediatric patients (age less than 18). Fifty-four percent of injuries occurred on the left upper extremity (n = 238) whereas 46% occurred on the right upper extremity (n = 202). Three patients sustained injuries to both extremities, and multiple injuries occurred in 23 patients, resulting in 470 total injuries. The patient’s dominant extremity was injured in 47.9% of cases (n = 212), and their nondominant extremity was injured in 52.1% of cases (n = 231). Prior to their outpatient visit, 251 patients (56.7%) initially presented to an urgent care or ED. The average time from injury to outpatient visit was 23 days (range 0-548 days). There were 348 patients (78.4%) who did not require surgery, and 96 patients (21.6%) who underwent operative intervention. The average time from injury to surgery was 18.5 days. Patients in whom surgery was performed presented to a hand surgeon an average of 10 days following injury (range 0-127 days), while patients not requiring surgery presented an average of 27 days following injury (range 0-548 days).

Table 1 provides a full breakdown of injury locations, injury types, mechanisms of injury, and types of surgeries required. The most common injury locations were the ring finger (145), followed by the wrist (80), third finger (75), fifth finger (72), and thumb (35). Proximal phalanx fracture was the most common injury type (75), followed by IP joint sprain (74), middle phalanx fracture (71), and distal phalanx fracture (49). The majority of injuries were caused by the extremity catching in the leash while being pulled (334, 75.4%), followed by falling on the extremity (57, 12.8%). Among the 96 patients requiring surgery, open reduction and internal fixation (ORIF) was the most commonly performed procedure (40), followed by closed reduction with percutaneous pinning (CRPP, 37). The most common injuries treated surgically were phalanx fractures (n = 64, 66.7%), ligament injury (n = 13, 12.5%) and distal radius fracture (n = 12, 12.5%). Of the patients not requiring surgery, splinting or bracing was the most common treatment recommended (n = 226, 64.9%). No patients with isolated IP sprains required surgery, while 31.8% of patients who sustained phalangeal fractures required surgery.

Table 1.

Complete Breakdown of Dog-Leash-Related Injuries and Associated Treatments.

Injury location (N = 470 injuries)	N (%)	Injury description (N = 470 injuries)	N (%)	Patient’s mechanism of injury (N = 443 patients)	N (%)	Treatments provided (N = 443 patients, some receiving multiple treatments)	N (%)	Surgical treatment details (N = 96 patients, 103 procedures)	N (%)
Ring Finger	147 (31.3)	Proximal Phalanx Fracture	75 (16)	Extremity caught in leash	334 (75.4)	Splint/Buddy Tape	226 (51)	ORIF	40 (41.7)
Small Finger	81 (17.2)	IP Joint Sprain	74 (15.7)	Fall	57 (12.9)	Surgery	96 (21.7)	CRPP	37 (38.5)
Wrist	80 (17)	Middle phalanx Fracture	71 (15.1)	Leash-related impact	32 (7.2)	Therapy	37 (8.4)	Ligament repair	13 (13.5)
Long Finger	76 (16.2)	Distal Phalanx Fracture	49 (10.4, 2 open)	Other/unknown	20 (4.5)	Medication	36 (8.2)	Flexor/Extensor Tendon Repair	3 (3.1)
Thumb	35 (7.4)	Wrist Fracture	36 (7.7, 1 Open)			Observation	36 (8.2)	Joint fusion/Arthroplasty	3 (3.1)
Index Finger	30 (6.4)	MCP Joint Sprain	25 (5.3)			Cast	29 (6.5)	I/D	2 (2.1)
Metacarpal/hand	21 (4.5)	Skin/Soft Tissue Injury	25 (5.3)			Other	9 (2)	Other	5 (5.2)
		Wrist Sprain	19 (4)
		Ligament Injury	19 (4)
		Metacarpal Fracture	18 (3.8)
		Tendon Injury	16 (3.4)
		IP joint Dislocation	14 (3)
		Other	29 (6.2)

Note. ORIF = open reduction and internal fixation; CRPP = closed reduction with percutaneous pinning; MCP = metacarpophalangeal; I/D = irrigation and debridement; IP = interphalangeal.

Among surgically treated phalanx fractures, 35 were treated with CRPP (57.4%), 27 were treated with ORIF (42.2%), one was treated with external fixation, and one was treated with hemihamate arthroplasty. One phalanx fracture initially treated with CRPP required conversion to ORIF. All 12 patients with a DRF or DUF underwent surgical treatment with ORIF. There was one ORIF in the setting of a tendon avulsion fracture, and 2 CRPPs occurred in patients with metacarpal fractures. One patient ultimately underwent a thumb basal joint arthroplasty for basal joint arthritis that was exacerbated by the leash injury, and one patient underwent trigger finger release for an aggravation of their trigger finger symptoms from their leash injury.

Discussion

Existing literature on injuries related to dog leashes or dog walking primarily report on ED visits from national databases. In our attempt to further clarify the nature of hand and wrist injuries from dog leashes, in this study we focused on the outpatient presentation of these injuries to the hand and wrist surgery division of a single orthopedic practice. We found 443 patients over a 5-year period with injuries related to a dog leash. Performing individual chart review allowed us to gain a more detailed understanding of the injury types and resulting treatment compared to these broader national database studies. We found that most upper extremity injuries occurred due to the hand/finger being wrapped in the leash. This often resulted in a fracture occurring, and most commonly a fracture of the ring finger. Approximately 1 in 5 patients with a leash-related hand or wrist injury required surgical intervention.

The 2 other published reports of leash-specific injuries we are aware of, from Forrester in 2020 and Pirruccio et al in 2017, broadly documented national trends in these patients as they related to ED visits.^5,6 Forrester found 8189 patients presenting to the ED of approximately 100 US hospitals over an 18 year span, and estimated the incidence of leash injuries to be 63.4 per 1 million people. Among the injuries they documented, 26.8% were fractures, 26% were strains or sprains, and 17.7% were contusions or abrasions. They divided the injury mechanism into “pull” or “trip/tangle,” which roughly correlates with our most frequent mechanisms of injury of “extremity caught in leash” and “fall.” They found that “pull” injuries more commonly resulted in sprains or strains than fractures. In our series, the majority of injuries from an extremity being caught in the leash were fractures rather than soft tissue injuries. Among their “pull” injuries, 68% occurred in the upper extremity, but only 28% of “trip/tangle” injuries occurred in the upper extremity, with the majority occurring in the lower extremity or head/neck. This is concordant with our findings that a lower number of upper extremity leash injuries were due to falling.

Pirruccio et al focused on fractures in the elderly related to walking leashed dogs utilizing the same ED database as the study from Forrester. The most common specific injury they found were hip fractures (17.3%), although the most common overall anatomic region for fracture was the upper extremity (52.1%). Among patients with upper extremity injury, wrist fractures were more common than finger fractures (13.7% vs 8.7%). The minimum age in this cohort was 65, and 28.7% of patients required hospital admission following their ED visit. No patients in our study had been hospitalized prior to evaluation. The nonemergent nature of the injuries we analyzed is evident from the delay in time from injury to outpatient visit and time to surgery.

Very few patients in our cohort were under 18 years of age, although dog-walking may pose a hazard to children as well. A retrospective review of pediatric trauma cases at the Children’s Hospital of Pittsburgh at UPMC found 34 cases of dog-related injuries that were not related to a dog bite. ⁷ These were not all specifically due to a dog leash, but also due to impact with the dog, or falling due to their parent being pulled by the dog and knocking them over. While we would surmise that older adolescents and skeletally mature teenagers would have similar patterns of injury, we cannot determine with certainty whether children, potentially with smaller extremities and different bone/soft tissue structure and compliance would be injured in the same way as the adults in our study. Another unique population at risk for dog-leash-related injuries are military and police dog handlers; a police dog’s lunge may produce 2100 N of force, and upper-extremity overuse injuries in these professions have been reported.^8,9 Based on the results of our study, we are not able to comment specifically on the nature of traumatic injuries in this population.

A similar pattern of upper extremity injuries is present in the surfing population.^10,11 The “surfing leash” connects the surfer to their board to avoid losing the board in the event of a fall. Two retrospective analyses of finger trauma due to surfing, conducted by Pistre and Rezzouk in 2012, and Ruijs et al in 2017, demonstrated that distal phalanx fractures related to a surfing leash comprised the majority of finger injuries suffered by surfers. Similar to our findings, the ring finger was the most common injury location in both surfing studies. The mechanism of finger injury in the surfing population was also very similar what we found with the dog leash, that is with the leash of the surfboard wrapping around one finger after the surfer suffers a fall from their board. A notable difference in this population is the severity of injury—the force of a large wave on the empty surfboard following a fall leads to an immense traction force on the fingers if they are wrapped in the leash, leading to primarily open fractures and a significant number of amputation or degloving injuries. Pistre and Rezzouk found that 35 (42.7%) injuries were complete amputations of the distal phalanx, and 41 (50%) were incomplete amputations. Ruijs et al found that 85% of their cohort’s fractures were open fractures. In comparison, only 3 fractures in our patient series were open.

Although our study data do not provide information related to prevention of these injuries, certain strategies have been suggested to increase the safety of dog-walking. Primarily, the results of our study suggest that a leash should never be wrapped around the hand or fingers, as a sudden pull can lead to the common types of injuries seen in our practice. Maintaining the leash firmly in the palm of the hand is the safest way to avoid injury to the finger and wrist.^12,13 However, this does not necessarily reduce the risk of falls following a sudden lunge by the dog. With larger dogs especially, a shorter leash length reduces the amount of time for the dog to build up speed, reducing the possibility of a strong pull to the owner once the dog reaches the end of the leash. Additionally, longer leashes increase the possibility of the leash wrapping around other objects and creating a tripping hazard for the owner.

Our study has several limitations. First, since a text search for “dog” or “leash” was used to identify patients with leash-related injuries, it is possible that alternative terminology without either of these words (ie, “walking their pet” without mention of leash) could have been used in a patient’s visit note to describe their injury mechanism. This would have resulted in a patient being missed by our search. However, we think it is unlikely that the documented history of an injury caused by a dog or its leash would not include either of these words. Second, there is inherent bias in the nature of the injuries seen by an outpatient hand surgical specialty practice. There are likely less severe injuries such as minor sprains and strains for which patients may not seek care, or may not need subspecialty follow-up care. Similarly, more severe injuries such as degloving injury from the leash or a severe/contaminated open fracture would be likely treated emergently, bypassing the outpatient setting. Approximately one-fifth of the patients in our study ultimately required surgery, although the threshold for making the decision to proceed with surgical intervention may vary between surgeons (and patients), and there also may be a selection bias toward surgical injuries in terms of patients that seek hand surgical consultation. There may be a difference in severity of injury based on size, weight, or breed of the dog involved. Our data do not allow for an assessment of this parameter. Finally, our study is geographically limited to the area covered by our practice and may not represent nationwide trends in the same manner as studies based on nationwide database information.

This retrospective case series reports on the incidence of patients with dog-leash-related injuries that present to a hand and wrist surgeon in the outpatient setting. A majority of these patients presented with phalanx fractures and interphalangeal joint sprains that were treated nonsurgically. As dog-walking continues to be a popular exercise and leisure activity, as well as a necessary part of dog-ownership, hand surgeons should be aware of the types of injuries that can occur and when possible counsel patients accordingly to try to prevent them. Based on our findings, most patients who present to a hand surgeon with a dog-leash injury in the outpatient setting will not require surgical intervention.