An Epidemiological Survey of Hand Burn Injuries Admitted to a Large Burn Center in the New York City Metropolitan Area

Abstract

Background:

Hand form and function play a vital role in daily living, and even minor trauma can significantly impair quality of life. There is a current paucity of data regarding hand burn patient and injury characteristics, particularly in urban areas in the United States. As the field of hand surgery expands, a demographic understanding of patients with severe injury potentially requiring surgical management is imperative. The aim of this study was to define the epidemiological characteristics of burn injuries involving the hand that were admitted to a large New York City burn center.

Methods:

A retrospective review of the Electronic Health Record was conducted to identify all patients admitted to our burn center with burn injury involving the hand from August 2020 to December 2023. Patient demographics, injury etiology and characteristics, and hospital course details were recorded and analyzed.

Results:

We identified 96 admitted patients with 140 hand burn injuries, with a patient median age of 38 years. Female patients presented to the hospital significantly later after initial injury than male patients and were more likely to suffer from flame-related injury. The median length of stay for initial admission was 17.5 days, with longer length of stay associated with hypertension comorbidity. Patients experiencing homelessness demonstrated higher rates of psychiatric disorder, substance use, and current smoking. Length of follow-up was positively correlated with estimated household income. Compared to the general city population, the patient cohort was made up of a lower percentage of ‘White alone’ and ‘Asian alone’ race categories and higher percentage of persons experiencing homelessness.

Conclusions:

We report the clinical and social characteristics of burn patients with hand involvement admitted to a large urban burn center. Hand burn injuries have distinct risk factors and morbidity implications, and consideration for higher-risk groups is imperative for optimal prevention, acute management, and long-term support.

Introduction:

Hands play a fundamental role in daily functionality. Their multitude of uses and constant environmental exposure render them highly vulnerable to burn injury; despite covering only 3% of total body surface area (TBSA), hands are one of the most frequently injured sites of burn traumas, implicated in up to 80% of all burns.^1–3 Hand burn trauma can occur either in isolation or as part of more extensive injury. As burn care continues to advance and more patients survive severe burns,⁴ increasing focus has developed on hand burn incidence and acute management.⁵ While hand burns themselves do not usually contribute to mortality rate, hand function is a strong predictive factor for the quality of life of burn survivors.⁶ Any degree of hand trauma can pose a profound impact on the patient’s physical, emotional, and psychological well-being, and can lead to long-term psychiatric burdens of depression, anxiety, or post-traumatic stress disorder.⁷ Further, functional limitations and inability to return to work can place patients under severe financial stress compounded upon immediate and longer-term costs of care.⁸ In fact, hand function has been shown as a strong predictor of quality of life and employment status in the post-burn period.^9,10

Prior hand burn epidemiology research reveals that patients are generally working-age adults, male, and victims of non-occupational accidents.^2,5,11 Hand burn etiologies in adults are more commonly due to flame, scald, and electric mechanisms.⁵ While much is known regarding general burn incidence and morbidity risk factors – greater patient age,¹² burn TBSA,¹² medical comorbidities,¹² socioeconomic status,¹³ and racial and ethnic disparities^14,15 – a similar understanding of hand burn injuries is less frequently reported, particularly in the United States. This relative knowledge gap is concerning given the clinical importance placed on hand burns: the American Burn Association formally recommends referral to a burn center for any deep partial or full thickness burns that involve the hands, similarly to other high-risk areas including the face and genitals.¹⁶

Understanding local patient demographics and risk factors is fundamental for optimal management of burn victims with hand involvement: their treatment team often spans burn and trauma surgeons, plastic and reconstructive surgeons, hand surgeons, wound care teams, physical therapists, and occupational therapists. The purpose of this study was to conduct an epidemiological survey of burn injuries including the hand that were admitted to a large American Burn Association-verified burn center in the New York area. The New York metropolitan area is one of the most culturally and ethnically diverse epicenters of the world. New York City (NYC) is home to one of the largest burn centers in the United States, treating hundreds of patients annually. While researchers have previously characterized various burn injury populations in and around NYC,^17–21 as well as global hand burn epidemiology,^2,11,22–25 there is a current paucity of data regarding hand burn patient and injury characteristics in the US. Herein, a retrospective chart review was performed to report patient characteristics, injury characteristics, and hospital course, to investigate disparities within this population, and explore potential strategies for improved hand burn prevention and treatment course.

Methods:

Data Collection:

This retrospective chart review was reviewed and approved by the Institutional Review Board. Patients who were admitted to the burn service for hand burn either as the primary trauma or as a component of a larger body area injury were collected from August 2020 to December 2023. This medical center is a large, urban, academic hospital, both an American College of Surgeons-verified level I trauma center and an American College of Surgeons/American Burn Association-verified burn center. Cases were identified using the International Classification of Diseases 10th (ICD-10) coding system, admission notes, and burn diagrams indicating total body surface area (TBSA) of burn injury of each body part. No cases that met inclusion criteria were excluded. A standard retrospective chart review was performed to collect data from the electronic medical record (EMR). Data recorded included patient demographic characteristics as well as medical, surgical, and social history. Burn injury etiology and characteristics were recorded, as well as hospital course details. As a proxy for socioeconomic status, the median household income per patient ZIP code was obtained from publicly available information from the April 1, 2020 Decennial Census (US Census Bureau).²⁶ Patient demographics were compared with New York City general population and demographics also available from the 2020 Decennial Census.²⁶ Rate of sheltered homelessness was calculated from the Department of Homeless Services Daily Report for April 1, 2020 (NYC Open Data),²⁷ while rate of unsheltered homelessness was calculated from the Homeless Outreach Population Estimate 2020 Results (NYC Department of Social Services),²⁸ a methodologically rigorous, nationwide effort to estimate unsheltered homelessness.

Data Analysis

All data analysis was conducted in Prism 10 (GraphPad, La Jolla, CA). Collected data were coded categorically or numerically, as appropriate. The Shapiro-Wilk test was used to test the normality of the distribution of quantitative variables. A descriptive analysis of qualitative variables was performed, reported as absolute and relative frequencies. Descriptive analysis of quantitative variables was calculated by means with standard deviation for normally distributed data, and medians with interquartile range for non-normally distributed data. Comparisons between qualitative independent variables with binary outcomes were made using Fisher exact tests. Comparisons between quantitative independent variables were made using the Student t-test for independent samples for normally distributed variables and the Mann-Whitney U test for non-normally distributed variables for comparison between two groups, and an ordinary one way analysis of variance (ANOVA) with multiple comparisons for multiple groups. Linear regression modeling was used to compare quantitative dependent and independent variables. An α value of 0.05 was used throughout the analysis; any P value less than 0.05 was considered statistically significant. No correction for multiple comparisons were deemed necessary as all analyses were planned and all comparisons reported.

Results:

Ninety-six patients admitted to the institution’s burn center for burn injury with hand area involvement during the study period were identified (Table 1). Patients were more commonly adult and male. Median age was 38.0 years (range, 2 months to 81 years). Most patients were identified as ‘Other Race’, followed by ‘White’ and ‘Black or African American ‘ in the EMR. Thirty-seven patients (39%) were identified as Hispanic or Latino ethnicity. Median household income of patient ZIP codes was $75,877 [$56,778, $105,331]. The majority of patients were domiciled in a house or apartment. Almost all patients experiencing homelessness at the time of injury were male. Most patients had at least one medical comorbidity diagnosed at the time of injury: the most common being hypertension requiring medication, obesity, and current smoker. Patients experiencing homelessness demonstrated significantly higher rates of psychiatric disorder (63% vs 10%, p = 0.001), substance use (63% vs 3%, p < 0.001), and current smoking (63% vs 11%, p = 0.002), with alcohol abuse trending higher (25% vs 3%, p= 0.053). No significant demographic differences were found between genders.

Table 1:

Patient Demographics.

	Total Population	Male	Female
Characteristic, n (%)	n = 96	n = 62	n = 34	P Value
Age, years, median [IQR]	38.0 [27.0, 57.4]	36.5 [27.0, 55.3]	40.0 [24.5, 62.5]	0.503
Sex
Male	62 (65%)	62 (100%)	-	NA
Female	34 (35%)	-	34 (100%)
Race Category				0.849
White	28 (29%)	19 (31%)	9 (26%)
Black or African American	20 (21%)	12 (19%)	8 (24%)
Asian	5 (5%)	4 (6%)	1 (3%)
Other Race	31 (32%)	18 (29%)	13 (38%)
Multiple Race	6 (6%)	4 (6%)	2 (6%)
Not known	6 (6%)	5 (8%)	1 (3%)
Ethnicity				0.483
Hispanic or Latino	37 (39%)	21 (34%)	16 (47%)
Not Hispanic or Latino	55 (57%)	38 (61%)	17 (50%)
Not Known	4 (4%)	3 (5%)	1 (3%)
Zipcode Median Household Income				0.733
$1 Under $50,000	14 (15%)	10 (16%)	4 (12%)
$50,000 Under $75,000	34 (35%)	22 (35%)	12 (35%)
$75,000 Under $100,000	23 (24%)	16 (26%)	7 (21%)
$100,000 Under $200,000	25 (26%)	14 (23%)	11 (32%)
Living Situation				0.235
House/Apartment	88 (92%)	55 (89%)	33 (97%)
Sheltered Homeless	3 (3%)	2 (3%)	1 (3%)
Unsheltered Homeless	5 (5%)	5 (8%)	0 (0%)
Comorbidities
Any Comorbidity	73 (76%)	48 (77%)	25 (74%)	0.803
Hypertension Requiring Medication	20 (21%)	12 (19%)	8 (24%)	0.793
Obesity	17 (18%)	9 (15%)	8 (24%)	0.279
Current Smoker	15 (16%)	13 (21%)	2 (6%)	0.076
Hyperlipidemia	13 (14%)	5 (8%)	8 (24%)	0.058
Psychiatric Condition	14 (15%)	9 (15%)	5 (15%)	1.000
Diabetes Mellitus	12 (13%)	7 (11%)	5 (15%)	0.749
Substance Abuse Disorder	8 (8%)	6 (10%)	2 (6%)	0.708
Alcohol Use Disorder	5 (5%)	5 (8%)	0 (0%)	0.158
Other*	12 (13%)	9 (15%)	4 (12%)	-
Handedness				1.000
Right	76 (79%)	49 (79%)	27 (79%)
Left	4 (4%)	3 (5%)	1 (3%)
Unknown	16 (17%)	10 (16%)	6 (18%)

^*Includes comorbidities where n<5: HIV, coronary artery disease, arthritis, congestive heart failure, stroke, cardiac arrest.

Hand burn injuries were most commonly bilateral: a total of 140 hands injured, more commonly on the dorsal surface rather than palmar or both surfaces (Table 2). Median total burn surface area (TBSA) on the hand area was 1.00, where an entire hand is represented by 2.5. The most common burn etiology among these patients were flame and scald injury, and the majority of burns were accidental, non-employment related. Female patients were more likely to suffer from flame-related injury against all other categories compared to male patients (p = 0.043). No significant difference in hand or total TBSA was found between patient gender, race or ethnicity.

Table 2:

Injury Characteristics.

	Total Population	Male	Female
Characteristic, n (%)	n = 96	n = 62	n = 34	P Value
Injury Site				0.889
Right Hand	27 (28%)	17 (27%)	10 (29%)
Left Hand	23 (24%)	14 (23%)	9 (26%)
Both Hands	45 (47%)	30 (48%)	15 (44%)
Total Hands Injured (n)	140	91	49
Burn Side of Hand Injured, per hand				0.734
Palmar	20 (14%)	14 (23%)	6 (18%)
Dorsal	62 (44%)	42 (68%)	20 (59%)
Both	51 (36%)	30 (48%)	21 (62%)
Not Recorded	7 (5%)	5 (8%)	2 (6%)
Characteristics of Hand Burn, median [IQR]*
Hand TBSA (n=86)	1.00 [0.50, 1.50]	1.00 [0.50, 1.50]	0.50 [0.50, 2.00]	0.558
2nd Degree Hand TBSA (n=71)	0.75 [0.40, 1.50]	0.88 [0.50, 1.44]	0.75 [0.25, 1.50]	0.960
3rd Degree Hand TBSA (n=28)	0.63 [0.25, 1.00]	1.00 [0.25, 1.00]	0.50 [0.15, 0.75]	0.145
Characteristics of Total Burn, median [IQR]*
Total TBSA (n=96)	5.00 [1.69, 11.25]	5.00 [1.79, 10.33]	4.00 [1.46, 13.31]	0.685
2nd Degree TBSA (n=88)	3.00 [1.31, 9.19]	3.00 [1.25, 9.00]	3.00 [1.45, 10.13]	0.759
3rd Degree TBSA (n=44)	1.88 [0.75, 7.00]	2.63 [0.75, 7.19]	1.50 [0.31, 6.25]	0.502
Etiology Category				0.298
Flame	32 (33%)	16 (26%)	16 (47%)
Scald	27 (28%)	18 (29%)	9 (26%)
Flash	13 (14%)	11 (18%)	2 (6%)
Contact	12 (13%)	7 (11%)	5 (15%)
Electrical	6 (6%)	5 (8%)	1 (3%)
Chemical/Corrosion	4 (4%)	3 (5%)	1 (3%)
Cold Injury	2 (2%)	2 (3%)	0 (0%)
Inhalation Injury	10 (10%)	4 (6%)	6 (18%)	0.159
Injury Circumstance
Accidental Injury: Non-Employment Related	71 (74%)	43 (69%)	28 (82%)	0.836
Accidental Injury: Employment Related	18 (19%)	13 (21%)	5 (15%)
Suspected Self-inflicted	3 (3%)	2 (3%)	1 (3%)
Suspected Assault/Abuse	1 (1%)	1 (2%)	0 (0%)

^*Only patients with documented values for hand and total TBSA are reported.

The demographic information listed in Table 1 was used as independent variables to stratify patients based on injury characteristics (Table 3). Patients with hypertension had a significantly longer length of stay for initial admission (p = 0.040). Higher household income level was correlated with longer follow-up (coefficient of regression = 45.31, 95% CI 3.37–87.25, p = 0.035).

Table 3:

Injury Risk Factors Association with Hospital Course.

Characteristic, P Value*	Length of stay of initial admission	Length Injury to last Follow Up
Comorbidity
Hypertension	0.040	0.781
Diabetes Mellitus	0.868	0.860
Obesity	0.636	0.731
Current Smoker	0.615	0.054
Any Comorbidity	0.115	0.645
Race**	0.956	0.470
Ethnicity**	0.835	0.755
Living Situation**	0.863	0.057
Household Income	0.134	0.035

^*Household Income was analyzed via univariate linear regression. All other variables were analyzed with Whitney Mann tests.

^**To ensure adequate sample size for comparison, race included White, Black or African American, Other Race. Ethnicity includes Hispanic or Latino, Not Hispanic or Latino. Living Situation includes House/Apartment and Homeless (Sheltered or Unsheltered).

Time from injury to initial admission was significantly longer in female patients compared to male patients (p = 0.020) (Table 4). Median length of initial admission was 17.5 days, with most patients discharged home. Discharge disposition differed significantly between male and female patients, with male patients more likely to be discharged to another home or custodial living situation, to have left against medical advice or discontinued care, or to have expired, while female patients were more likely to be discharged home under care of home health service. Almost all patients received follow up care at the burn center, with only three patients (3%) following up with a plastic surgeon. Few patients were readmitted for further management. Median injury to last follow-up time was 153.5 days, defined by the last office visit, video visit, or procedure with a provider involved in burn injury care.

Table 4:

Hospital Course.

	Total Population	Male	Female
Characteristic, n (%)	n = 96	n = 62	n = 34	P Value
Injury to Initial Admission, days, median [IQR]	0.00 [0.00, 1.00]	0.00 [0.00, 1.00]	1.00 [0.00, 3.00]	0.020
Initial Admission
Length of Stay, days, median [IQR]	17.5 [11.0, 36.0]	18.0 [11.0, 32.3]	17.0 [10.0, 41.0]	0.742
Length of Stay per TBSA, median [IQR]	3.60 [1.84, 7.58]	3.44 [1.78, 7.42]	3.86 [1.96, 10.28]	0.435
Discharge Disposition				0.012
Home or Self-Care (Routine Discharge)	59 (61%)	40 (65%)	19 (56%)
Transferred to Other Facility, SNF, etc.)	15 (16%)	10 (16%)	5 (15%)
Home Under Care of Home Health Service	9 (9%)	1 (2%)	8 (24%)
Other Home or Custodial Living Situation	3 (3%)	3 (5%)	0 (0%)
Left Against Medical Advice	6 (6%)	5 (8%)	1 (3%)
Deceased/Expired	2 (2%)	2 (3%)	0 (0%)
Not Recorded	2 (2%)	1 (2%)	1 (3%)
Follow Up Care				0.247
Burn Center	86 (90%)	57 (92%)	29 (85%)
Plastic Surgery	3 (3%)	2 (3%)	1 (3%)
Hand Occupational Therapy Clinic	1 (1%)	0 (0%)	1 (3%)
Out of Country	1 (1%)	0 (0%)	1 (3%)
Not Needed	2 (2%)	2 (3%)	0 (0%)
Not Recorded	3 (3%)	1 (2%)	2 (6%)
Patients Readmitted	20 (21%)	15 (24%)	5 (15%)	0.308
Length of Readmission, days, median [IQR]	6.00 [1.00, 11.00]	6.00 [1.00, 11.00]	5.00 [1.00, 19.50]	0.920
Injury to Last Follow Up, days, median [IQR]	153.5 [56.0, 331.75]	111.0 [50.5, 339.0]	192.5 [86.3, 331.8]	0.408

Discussion:

We present a clinical and social characterization of burn patients with hand involvement admitted to a large NYC burn center. All burn injuries are consulted by the burn service at our institution, and admission is provider discretion. Hand involvement was isolated from our center’s total burn population for the hand’s potential for disproportionately severe functional and financial disability per burn area. Burn patients with hand involvement demonstrate significantly worse inpatient outcomes and a greater financial burden to the healthcare system than non-hand involvement burn injuries.²⁹ Given the area’s ubiquitous visibility and utility, the sequelae of hand burns include significant disadvantages in social reintegration and increased incidence of depression compared to non-hand burns, and diminished self-reported overall functionality.^30–33 Hand burn involvement is moreover associated with higher rates of post-injury job switching³¹ and significantly longer time to return-to-work than burn injuries without hand involvement, especially if surgically grafted, and can result in lifelong disability with risk of poverty from lost work capacity.^8,34,35

According to the American Burn Association,³⁶ 66% of admissions to US burn centers were male, and as other studies from high-income countries have previously shown,^18,37,38 our burn injury population had a higher percentage of male persons (65%) than the general NYC population (48.5%). This discrepancy may be caused in part by greater male employment in high burn risk occupations (e.g., firefighting, handling industrial chemicals), or a higher likelihood of engaging in risk-taking behaviors. Within our patient cohort, there was no statistically significant difference between extent of burn injury as measured by TBSA, or in the exposure of underlying structure at the burn site.

Further gender disparities were evident in the treatment course. Female patients took significantly longer to present for initial admission after injury (p = 0.020). Given that injury characteristics were largely similar between genders, this finding suggests an underlying barrier in care access that preferentially impacts female patients. Such barriers include a delay in deciding to seek care, potentially compounded by increased domestic responsibility that generally falls upon female family members,³⁹ or a more limited access to transportation. Prior research reports that women wait longer than men in seeking medical care for acute cardiac disease;^40,41 however, this finding has not previously been reported in the US burn literature. We found male and female patients had similar lengths of stay, but significant differences in discharge disposition (p = 0.012). More male patients were discharged home under self-care, left Against Medical Advice (AMA), and deceased, while more female patients were discharged home with home health services. Male patients have previously been found to make up the majority of AMA discharges,^42,43 which we find consistent within our cohort.

When considering racial demographics, the NYC general population was made up of a higher percentage of ‘White alone’ (37.5%) and ‘Asian alone’ (14.5%) races than our observed patient population (29% and 5%, respectively). The Census reported 23.1% of the NYC population as ‘Black or African American alone’, similar to our cohort (21%).²⁷ We observed a higher percentage of patients with Hispanic or Latino ethnicity (39%) compared to 29% of the general population.²⁶ National burn repository data has demonstrated a disproportionate number of Black patients experiencing burn injuries compared to the general population,¹⁴ and Black adult and pediatric burn victims are at higher risk of suffering from inhalation injury and intentional burns.^44–46 Other studies that group ethnic minorities as “other” or “non-white” found a higher rate of comorbidity in these patients, and found those pediatric patients more likely to suffer burn injuries and at an earlier age than their “white” counterparts.^47–49 Importantly, race and ethnicity information from the EMR may not be collected in a standardized manner, thus limiting the insight provided.

The 2022 general population of people experiencing both sheltered and unsheltered homelessness in NYC was calculated from publicly available sources to be 0.54%²⁷ and 0.04%⁵⁰ respectively in April 2020, which was taken as a reference point to be comparable with US Census²⁶ population data used. In our hand burn patient cohort, we found roughly a 10-fold greater percentage of patients experiencing sheltered homelessness (3%) and a 100-fold greater percentage for unsheltered homelessness (5%). A prior demographic study of an urban burn unit in Chicago – another large, urban center – from 1999–2004 found 4.5% of admitted patients were experiencing homelessness.⁵¹ This population is known to be at higher risk for both increased severity of burn injury and adverse outcomes post-injury, given the shared association with higher risk for substance abuse, mental illness, comorbidities, barriers to care, as well as a higher risk of assault.^51–54 In corroboration of this effect, we found within our small cohort of patients experiencing homelessness significantly higher rates of psychiatric disorder (p = 0.001), substance use (p < 0.001), and current smoking (p = 0.002) compared to domiciled patients. The homeless population requires special consideration, both in acutely managing complex comorbidities as well as in coordinating a challenging discharge with adequate follow-up.

The estimated median 2020 household income of our cohort ($75,877) was comparable with the median NYC household income from 2018–2022 of $76,607.⁵⁵ Income was positively correlated with length of follow-up, which suggests patients in higher socioeconomic classes are more likely to - and able to - continue care beyond the acute phase. However, these income levels are estimates and may not reflect true socioeconomic status, particularly for patients experiencing homelessness.

Comorbid conditions pose a well-recorded negative influence in patient courses, inclusive of burn injuries.⁵⁶ We found a diagnosis of hypertension requiring pharmacotherapy was associated with longer length of stay (p = 0.040). Our cohort further revealed a high psychiatric illness burden which included schizoaffective disorder, personality disorders, dementia, and anxiety, and encompassed all cases of suspected self-inflicted injury and suspected assault.

Approaching interventions in reducing incidence and morbidity of burn injury involving the hand should be multifactorial. Efforts commence with injury prevention: educational efforts should involve easily comprehensible safety information focusing on common etiologies (e.g., household- and occupation-related). Measures such as the introduction of smoke detectors and controlled hot water are known to decrease overall burn incidence rates and severity and can offer a similar benefit for hand injury.⁵⁷ Outreach programs that offer burn prevention education tailored to schools, senior communities, and healthcare and social service professionals should include specific discussion of hand burn considerations. The urgency of seeking immediate care post-injury should be emphasized, especially for female patients. Regarding management, treatment guidelines continue to evolve as the knowledge of hand burn interventions and outcomes increases. Recent advances in hand burn care include innovative hand compression methods^58,59 and virtual reality-guided rehabilitation,^60,61 which show promising results. Commitment to long-term follow up care and rehabilitation instructions should be highlighted as essential in recovering native hand function. Urban settings, such as the one in this study, often benefit from greater availability and quality of burn care and patient education efforts compared to more rural areas; however, access barriers persist.

High risk patient populations, including those experiencing homelessness and with psychiatric and substance-abuse co-morbidities, simultaneously present with higher rates of hand burns greater challenge for outreach and care retention.⁶² Educational interventions targeting shelters, early involvement of social work upon patient presentation, and enhanced support regarding follow up care (e.g., referral to case management, more frequent touch points, transportation services to and from appointments) can aid this patient population to a limited extent. Importantly, the surgeons and broader team caring for such challenging patients should recognize their heightened risk profiles and consider how to improve acute and long-term support within their individual institutions.

This study contains several limitations. In focusing on hand-specific injury, our study population includes isolated hand burns as well as larger burns that involve the hand; thus, nuances between these two subpopulations are lost. Our results are limited in their generalizability to all burn injury patients; however, given the unique risk factors and functional disability sequelae of hand burns, this distinction allows for scrutiny of an important sub-group within burn trauma. As with any retrospective analysis, our results rely on accuracy and completeness of the EMR. Though few patient charts recorded race and ethnicity as ‘Not Known’, this group nevertheless impacts the validity of analyses stratified by these variables. Patients may have received undocumented, external care before admission or after discharge. Injury TBSA is often visually estimated upon arrival to the emergency room, thus measurements are liable to inter-provider variability. The hand burn patient cohort from this large, urban burn center may not be generalizable to other populations. Though our center is one of the largest in the US, the relatively small sample size limits our statistical power. Finally, the analysis time period overlaps with the COVID-19 pandemic, and its multifaceted impact on both provision of and recognized delay in non-emergent medical care⁶³ may have affected the metrics collected. Prior analysis revealed this pandemic impacted acute and rehabilitation burn services as hospital resources were diverted away from non-COVID provision of care.⁶⁴ The pandemic’s disruption of patient access to care (which disproportionally impacts lower socioeconomic classes through reliance upon public transportation) compounded with the non-fatal nature of most hand burn injuries suggests that hand burn injury patients may have seen a greater COVID-19 impact over the general burn population, particularly in hard-hit epicenters like NYC.

In this retrospective epidemiological analysis, we reveal important disparities in care amongst urban hand burn high-risk subpopulations – female gender, racial and ethnic minorities, unhoused status, and medical comorbidities – an understanding of which is crucial to guide prevention efforts, acute management, and long-term follow-up in this patient population.