Hand Trauma

Brad K. Grunert PhD

In the United States, there are approximately 16 million hand injuries every year (1, 2). Of these injuries, 16,000 result in amputations of digits, hands, or arms (2). In addition, many other hand traumas result in loss of function due to crushes, nerve lacerations and transections, and significant scarring. Hand injuries are often both functionally and psychologically devastating.

Several factors contribute to the psychological sequelae of hand injuries. Hands are the individual’s primary means of interacting with the world. They are critical to both accomplishing tasks and interacting socially. Our hands, unlike our faces, are almost constantly in our line of vision and, thus, have a high degree of salience in one’s day-to-day life. For an individual with a hand injury, it is nearly impossible to avoid viewing the disfigured hand, which is a different experience than, for example, someone with a disfigurement of the body or even the face. Mutilating hand injuries often produce functional and cosmetic deficits that can be overwhelming for the individual experiencing them.

Family members and associates may become guarded, self-conscious, or overly protective of the individual with the injury. The disfigured hand is obvious to most people who come in contact with the affected individual, as the hand is a “public” part of the body rarely concealed. In addition to the clumsiness or altered function created by the injury to the hand, public exposure of the mutilated extremity creates a situation in which the individual is repeatedly called upon to explain how the injury occurred by many individuals who are, at best, only casually known by the injured person. Friends and family often move into a protective role by buffering these interactions that can further contribute to the loss of personal efficacy. The loss of efficacy is magnified by the fact that the individual’s capacity to engage in skilled and habitual tasks is compromised by the functional deficits secondary to the injury. The performance of these activities in public often draws even further attention to the injured extremity, resulting in even greater feelings of stigmatization and social conspicuousness. In the most extreme cases, onlookers may respond with socially inappropriate comments regarding the appearance of the hand, with looks of horror or revulsion, or with staring at the injured extremity. Each of these reactions serves to further alienate and ostracize the injured individual.

This chapter will review the psychological aspects of traumatic hand injuries. The first part will discuss the most frequently occurring psychological reactions to these injuries. As compared to other areas of plastic surgery discussed in this book, the empirical literature in this area is currently less well developed. The second half of the chapter draws heavily from clinical experience and discusses the psychological management and treatment of patients who suffer these often devastating and disruptive injuries.

Psychological and Behavioral Symptom Patterns

The psychological sequelae of hand injuries have been described in the hand surgery literature for over 25 years (3, 4, 5, 6, 7, 8, 9). Many of these factors can be understood in the context of Post Traumatic Stress Disorder (PTSD), which has emerged as the most frequent type of psychopathology associated with hand trauma (10, 11).

PTSD is a well-defined disorder with a distinct pattern of symptoms. First, the individual must have been exposed to an event in which they experienced an injury or circumstance that threatened their bodily integrity or life. The second is that they experience repetitive reliving of the event in a distressing manner (i.e., flashbacks, nightmares). The third is that they avoid reminders of the event in order to prevent triggering of their flashbacks or nightmares. They also experience physiologic arousal including such symptoms as hyperarousal, hypervigilance, and concentration deficits. These symptoms must persist for at least 30 days and must be disruptive to the individuals’ normal daily activities. (PTSD also has been discussed in Chapters 7 and 8). In addition, avoidance of work, appearance-related concerns, sleep disruption, pain, and impairments in social functioning postinjury are other significant psychological responses to hand trauma.

Flashbacks

Flashbacks associated with hand injuries can begin as early as 15 minutes after the injury and are one of the most common psychological responses to hand trauma (12). The occurrence of flashbacks appears to be related to attributions the patient makes regarding the cause of the injury. Individuals attributing their injuries to external causes over which they had little or no control were more likely to experience ongoing flashbacks, as well as avoidance of stimuli associated with the injury, than those believing that the cause of their injury was internal.

Both work-related and nonwork-related hand injury victims have been found to have similar rates of flashback occurrence in the emergency department immediately after their injuries (12). However, at a 6-month follow-up, the work-related patients had a significantly higher percentage of flashbacks than nonwork-related patients. Individuals injured in nonwork settings were much more likely to accept responsibility for being a causal agent of the accident than were the work-injured victims. Hand-injured workers who blamed their coworkers or their equipment for their injury were more likely to resist returning to their previous work than workers who judged themselves to be responsible for their accidents (13). Thus, attribution of cause of injury emerges as a key prognostic indicator for resumption of normal activities following hand injury.

There appear to be three distinct components of flashbacks following hand trauma: (i) replay; (ii) projected; and (iii) appraisal. They appear to be associated with postinjury prognosis.

Replay Flashbacks

The replay flashback consists of the replaying of the entire accident. The person experiencing this often visually re-experiences all of the images from the time of the accident. They may also experience auditory memories (e.g., the sound of their bones shattering), kinesthetic memories (e.g., the feeling of their hand trapped in the machine), and olfactory memories (e.g., the smell of their skin burning). Regardless of the nature of the memory stimuli, they re-experience the accident in a manner very similar to that in which it occurred. Individuals with this type of flashback are the most successful at processing it psychologically. They also returned to work at a much higher rate than did individuals having other types of flashback components (14).

Projected Flashbacks

In this type of flashback, the individual not only replays the flashback but also views a more catastrophic injury as occurring. For instance, the victim may replay an accident in which the finger of the hand was amputated. Rather than the injury flashback ending there, however, the images go on to ones in which the entire arm is pulled into the machine. This type of flashback is more complicated to treat as it involves not only desensitization to the injury that actually occurred, but also cognitive reprocessing of an accident component that never happened. The return to work success rate for these individuals was found to be lower than for those with replay flashbacks alone (14).

Appraisal Flashbacks

In this type of flashback, the individual experiences a snapshot-like recollection of the trauma, without all of the detail of the replay or projected flashback. This almost always consists of an image of the hand as it was first seen after the injury. This type of flashback is generally accompanied by feelings of horror and surreality. This flashback also may involve a projected element, in which the snapshot image of the injury transforms into an even more extensive and traumatic image.

Both the projected and appraisal flashback require much more complex psychological interventions. Imagery techniques used for intervention with these flashbacks are most successful when the patient is able to redevelop the context of the injury (i.e., create a replay-type flashback). Processing the feelings of surreality or dissociation is also necessary. These two types of flashbacks are the most resistant to treatment and have the poorest outcomes associated with them in terms of return to previous employment (14, 15). Specific psychological interventions for dealing with these issues are discussed later in this chapter.

Avoidance

Avoidance symptoms are predictive of return to the activity at which one was injured. At the time of an initial evaluation conducted by a nurse in the emergency room, most injured workers felt that they would be able to return to work (12,15). This was also true for the nonwork-injured patients. At a 6-month follow-up, however, many of the work-injured patients no longer felt able to return to their previous jobs. This was not true for the nonwork-related individuals, the majority of whom reported no significant symptoms of avoidance.

One of the factors that may influence this outcome is the fact that the injured workers received compensation for their injuries. Because the patient is provided with a weekly monetary payment for their injury throughout the recovery time may suggest to the injured individual that someone else is culpable for the injury. Most patients fail to understand that the Workers Compensation system is a “no-fault” insurance (i.e., there is no blame assigned for the cause of the injury), which requires payment even if the injury was intentionally incurred by the worker. Therefore, such payments may create a degree of cognitive dissonance for the worker, which leads them to believe that they had little or no blame for the accident. That is, many feel absolved of blame by the mere fact that they are receiving compensation and, therefore, must have been injured through some form of negligence. This was seen in the pattern of attributions in workers, the majority of whom at 6 months postinjury, were attributing their injuries to external causes such as a lack of safety guards or improper maintenance on the machines on which they were injured. Individuals who suffered nonwork-related injuries displayed a much more stable pattern of attributions as to injury cause and were much more likely to accept personal responsibility for their injury.

Appearance-related Concerns

Regardless of the cause of the injury, concerns about appearance are a major factor in the long-term functioning of the hand-injured patient. Appearance deficits can be divided into two categories: (i) personal or self-appearance and (ii) social appearance. Self-appearance pertains to the individual’s own perceptions of the hand. People are often uncomfortable with the altered appearance of the hand, which can then trigger intrusive thoughts and recollections of the trauma. This negative appraisal of the injured hand can have a variety of effects including shame over the mutilation, camouflaging behaviors, and even significant alterations in sexual desire and performance (11,16). Keeping one’s hand in a pocket, avoiding viewing the hand during physical therapy, or using dressings on the hand long after adequate healing has taken place are frequent indicators of self-appearance concerns. A gradual process of desensitizing the individual to the appearance of the hand often helps to address these concerns and to diminish their impact.

Social-appearance concerns also exist. Often the mutilation accompanying severe hand injuries causes the person to feel socially unacceptable. This can result in a loss of self-confidence and feelings of social inadequacy. It is important to normalize these responses and to encourage the patient to use the hand as normally as possible when in public. This serves two purposes. The first is that the hand injury itself is less conspicuous when the hand is used normally. The second is that even when the mutilation is noticed, the fact that the hand is being used normally (i.e., to gesture during a conversation) conveys to other individuals that the patient has accommodated the injury.

Many hand injury patients are unsure how to respond when someone asks them what happened to their hand. This often causes the injured person to feel uncomfortable, vulnerable, and angry. Assertiveness training can be helpful in re-establishing the personal boundaries of the injured party. Often by simply giving them permission to decline to answer or to tell others that they would prefer not to talk about it can enhance their feelings of control and of their personal boundaries. It is also helpful to normalize the fact that some people will stare at their injured hand and that this is merely a reflection of that person’s curiosity (or rudeness). Often, it is beneficial to have the injured individuals begin their exposure of their hand to public viewing in a controlled manner. For example, they can first show the injury to family members and then progress to having it uncovered while in the clinic and waiting room setting. In this gradual manner, they can become more comfortable with both the personal and social aspects of their hand injury.

Sleep Problems

Sleep problems are frequently present following severe hand injuries. These often begin shortly after the initial injury. Many patients experience a high level of pain and discomfort after the accident. The pain, or diminished effectiveness of pain medication over time, often interrupts their sleep. As patients move into lighter stages of sleep, nightmares of the trauma appear more readily. Individuals are often startled awake from re-experiencing of the accident. Heart palpitations, hyperventilation, and profound hyperhidrosis often accompany the startle reaction to these intrusive thoughts. It is not uncommon for the nightmare to resume once the individual returns to sleep, leading to further sleep disruption.

As this pattern develops, individuals often begin to attempt to avoid sleep as a means of coping. Sleep onset becomes disrupted and the individual’s mood begins to deteriorate as sleep deprivation persists. Individuals frequently describe the time just before they fall asleep as one in which they are more likely to experience flashbacks or recurrent thoughts about the accident. This often occurs because they are not as active and able to distract themselves from thoughts of the trauma as when they are
busy during the day. Patients often opt to begin watching television in bed as they wait to fall asleep in order to keep their mind away from the accident memories, further contributing to poor sleep habits. Many patients benefit from a sleeping aid or anti-depressant to facilitate the resumption of a more normalized sleep pattern. As they progress through the treatment of their intrusive thoughts, the need for these medications generally disappears. We also recommend that these individuals practice a regimen of good sleep hygiene. This includes going to bed at a regular time each night, no napping during the day, using the bed only to sleep in rather than for watching television or reading, and getting out of bed if they fail to fall asleep within 20 minutes and then returning to bed in another half hour.

Pain Problems

Pain is another major concern for most hand-injured patients. As noted above, pain initially following the injury can be very disruptive to sleep. It also produces a generalized sense of irritability and discomfort when poorly controlled. One of the more challenging clinical distinctions to make is determining when the patients’ pain is of a type that will respond to pain medication and when is it more “psychological” in origin suggesting that anti-depressant medication or nonpharmacologic methods may serve as more effective treatments. A combination of both medication and active coping strategies are most effective at providing pain control. This is particularly true with phantom pain occurring after an amputation. The instruction in cognitive coping strategies, discussed in detail below, helps to restore a sense of self-efficacy that further benefits the patient.

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