Psychosomatics 2014:55:372–380 & 2014 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Original Research Reports
Determinants of Disability After Fingertip Injuries
Arjan G.J. Bot, M.D., Jeroen K.J. Bossen, B.Sc, Chaitanya S. Mudgal, M.D.,
Jesse B. Jupiter, M.D., David Ring, M.D., Ph.D.
Background: Psychological factors, such as depression,
catastrophic thinking, and self-efficacy, account for
more of the variation in upper extremity disability than
motion and other impairments, but their influence in the
setting of hand trauma is less well studied. Objective:
The aim of this study was to determine which factors
account for variation in disability 1 month after fingertip
injuries. Methods: We enrolled 82 patients with finger
injuries distal to the proximal interphalangeal joint, and
70 patients completed the study. Questionnaires and
measurements were taken at the initial visit and
approximately 1 month later. Patients completed the
short version of the Disabilities of the Arm Shoulder and
Hand questionnaire, the pain self-efficacy questionnaire,
and the Patient Health Questionnaire to assess depres-
sive symptoms. Bivariate and multivariable analyses
determined factors associated with QuickDASH scores.
INTRODUCTION
Approximately 20% of the visits to the emergency
department are for injuries to the hand and wrist, and
finger injuries account for approximately 38% of the
upper extremity injuries.1,2 Prior studies of hand
injuries focused on the correlation of upper extrem-
ity–specific disability (the Disabilities of the Arm,
Shoulder and Hand [DASH] score3,4) with injury
severity.5,6
In patients with hand and upper extremity illness,
patient-specific factors,7,8 including psychological fac-
tors, such as symptoms of depression, catastrophic
thinking, and self-efficacy are the strongest determi-
nants of upper extremity disability.8–13 For instance, in
372 www.psychosomaticsjournal.org
Results: The mean disabilities of the arm shoulder and
hand questionnaire score was 35 at the initial visit (the US
norm is 10) and 17 approximately 1 month later. The best
model explained 54% of the variation in disabilities of the
arm shoulder and hand questionnaire 1 month after injury
and included symptoms of depression (Patient Health
Questionnaire; partial R2 0.43) and injury mechanism
(saw injury compared with sport injury; partial R2 0.14).
The criterion symptoms of depression was also the factor
most strongly associated with both pain intensity and time
off work. Conclusions: In patients with fingertip injury,
symptoms of depression account for most of the variability
in hand and arm-specific disability, pain intensity, and
days to return to work. Identification and treatment of
symptoms of depression might facilitate recovery from
fingertip injuries.
(Psychosomatics 2014; 55:372–380)
patients with ongoing nonspecific arm, disability
correlates with pain anxiety, heightened illness con-
cern, and catastrophic thinking.14–16 Pain intensity
and disability after minor hand surgery correlate with
symptoms of depression and self-efficacy.13 Psycho-
logical factors are also correlated with disability in
Received July 28, 2013; revised August 16, 2013; accepted August 16,
2013. From Orthopaedic Hand and Upper Extremity Service, Harvard
Medical School, Massachusetts General Hospital, Boston, MA. Send
correspondence and reprint requests to David Ring, M.D., Ph.D.,
Orthopaedic Hand and Upper Extremity Service, Massachusetts General
Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA
02114; e-mail: dring@partners.org
& 2014 The Academy of Psychosomatic Medicine. Published by
Elsevier Inc. All rights reserved.
Psychosomatics 55:4, July/August 2014

patients with carpal tunnel syndrome or lateral elbow
pain.17,18
Related to hand trauma, several studies have
estimated the prevalence of symptoms of PTSD
between 94% after 1 month and 25%-51% 6 months
after the injury.19–21
A recent study on patients with fingertip injuries
found that pain intensity and receiving workers
compensation explained more of the variation in
disability than job satisfaction or burnout.22
The aim of this study was to further clarify the
relationship of mood and coping strategies with pain
intensity and magnitude of disability among patients
with hand and upper extremity illness by examining a
common injury (fingertip injury) with a relatively
narrow range of pathophysiology and impairment.
Our primary null hypothesis was that symptoms of
depression and pain self-efficacy do not account for
variation in upper extremity–specific disability
1 month after injury after accounting for demo-
graphics, work status, or injury characteristics. Sec-
ondary null hypotheses addressed the same for pain
intensity, days off work, and range of finger motion.
METHODS
Study Design
For this study, we enrolled adult, English-speaking
patients with recent (within 25 days) finger injuries
distal to the proximal interphalangeal joint (PIP). All
patients visited our orthopedic hand and upper
extremity outpatient office from March 2011 to
September 2012. We excluded patients who were
pregnant, had a history of finger stiffness, and patients
with a central nervous system, muscular, or neurologic
disease that hindered active motion of their arm and
patients who had a revascularization.
We invited 97 patients to participate in our study.
Thirteen patients declined owing to lack of time or no
interest in participation. After screening, 1 patient's
injury was too old (1 month) and 1 patient also had a
hand injury in addition to his finger injury. Both
patients were excluded. These 82 patients were treated
by 3 different hand surgeons. All patients provided
informed consent at enrollment. This study was
approved by our Institutional Review Board. Twelve
patients did not complete the follow-up, so our cohort
consisted of 70 patients.
Psychosomatics 55:4, July/August 2014
Bot et al.
At enrollment, all patients completed question-
naires measuring magnitude of upper extremity–spe-
cific disability, pain intensity, symptoms of depression,
and pain self-efficacy, and finger motion was meas-
ured. We chose a follow-up interval of 1 month
because patients are still in the midst of recovery
but have made substantial progress by this point. Final
evaluation of disability and pain intensity was done
in-person or by phone as not all patients needed to
return to the office.
Evaluation
Questionnaires
The short form of the Disabilities of the Arm,
Shoulder and Hand (QuickDASH) questionnaire
was administered at enrollment and at the final
evaluation.3,4 The QuickDASH is a validated
11-item questionnaire with 5-point Likert scale
responses, which measures upper extremity–specific
disability.3 The QuickDASH is widely used in hand
surgery research.3,23 Test-retest reliability is 0.94, and
Cronbach α is 0.90.3 The score is scaled between 0
(no disability) to 100 (maximum symptoms and
disability), with an average value of 10 among the
general population of the United States of America.24
Pain intensity was measured on an 11-point
ordinal scale, where 0 represents no pain and 10 is
the worst imaginable pain.25
The Pain Self-Efficacy Questionnaire (PSEQ)
measures confidence in performing activities despite
pain.26,27 The PSEQ contains ten 7-point Likert scale
questions. The total score ranges from 0 to 60, with a
higher score reflecting greater self-efficacy.26 The
PSEQ is widely used and validated26 and has a test-
retest of r ¼ 0.79 and Cronbach α of 0.92.26,28
Depressive symptoms were measured using the
PHQ-9,29 which has 9 questions.29 The scores on the
PHQ-9 range from 0 (no depressive symptoms) to 27
(severely depressed). The PHQ-9 was validated in a
sample of 6000 patients and showed excellent test-
retest and internal consistency values (α ¼ 0.89).29 It
has been estimated that a PHQ-9 score of 5 represents
mild depression, 10 represents moderate depression,
15 represents moderately severe depression, and 20
means severe depression.29 A cutoff score of Z10 is
considered to represent an estimated diagnosis of
major depression.29
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Determinants of Disability After Fingertip Injuries
Patients completed the aforementioned question-
naires at the initial visit in the office, at their regular
follow-up in the clinic, or over the phone. Phone
administration to obtain follow-up data is frequently
used for the PHQ, PSEQ, and QuickDASH question-
naires.29–36
Range of Motion
At the initial visit, the arc of proximal interphalan-
geal joint motion (maximal flexion minus flexion
contracture [deficit in extension]) was measured with
a goniometer and the distance between the fingertip
and the distal palmar crease (DPC) of the affected
finger (or fingers) was measured in millimeters using a
ruler. We also measured the DPC of the healthy side
and adjusted the measurements for DPC accord-
ingly.37 The administration of the questionnaires
and the measurements were done by an independent
research assistant who was not involved in the care of
the patients.
Statistical Analyses
Owing to a miscommunication, our study was
initially powered for a correlation between PSEQ
and QuickDASH at enrollment, with a mean effect
size of 0.3, with α ¼ 0.05, which revealed that 82
patients would provide 80% power. The principal
investigator always intended to study the relationships
1 month after injury, so a post hoc power analysis was
done, which showed that with the correlation of 0.59
measured, 99% power was achieved with the 70
patients completing the final evaluation.
Most outcome measures at the final evaluation
were not normally distributed and therefore we used
nonparametric tests for our analyses. We reported
baseline characteristics and the outcomes of our main
measures at the enrollment and at the final evaluation.
To compare the outcomes of the questionnaires at
enrollment and at the final evaluation, a paired
Wilcoxon signed rank test was used on the subset of
patients with complete data.
To detect differences between the patients who
completed the study and the patients that did not
(noncompleters), we used Mann-Whitney U test for
continuous parameters and Chi-square test for cate-
gorical variables.
374 www.psychosomaticsjournal.org
The correlation of continuous explanatory varia-
bles with the dependent measures was tested with
Spearman correlation. The association between the
dependent measures and dichotomous explanatory
variables was tested with a Mann-Whitney U test
and the Kruskall-Wallis test for categorical variables.
For the dichotomous outcome measure return to work
within 1 month, Mann-Whitney U test and Chi-square
tests were used.
The response variables were QuickDASH (pri-
mary), pain intensity, days of work missed, DPC, and
arc of the PIP joint at the final evaluation. For each
response variable, explanatory variables with p o 0.10
or r 4 0.20 in the bivariate analysis were entered into a
stepwise linear regression with backward elimination.
We also conducted a stepwise binary logistic regres-
sion (likelihood) with backward elimination for the
variable did not return to work within 1 month. We
used coding with dummy variables for the analysis of
the influence of different type of injury (2 compar-
isons), number of fingers (2 comparisons), and injury
mechanisms (7 comparisons) when those variables
were inserted in the stepwise modeling regression. The
analyses of the outcome measures days of work
missed, return to work within 1 month (yes/no), arc
of PIP joint motion, and DPC concerned subgroup
analyses as not all patients worked (56 did work) and
range of motion measurements were done with 34
patients at the final evaluation.
One patient had missing data for days of work
missed and 1 patient was not allowed to remove the
bandage to do the measurements, which made it
impossible to do the measurements at enrollment.
We imputed the group mean for these missing values.
RESULTS
After enrollment, 11 patients could not be contacted
and did not complete the final evaluation and 1 patient
could only be contacted 9 days after the injury for
follow-up and we excluded the follow-up of this patient.
The 70 patients who underwent a second evaluation
were enrolled a mean of 9 days (range, 1-21 days) after
injury. There were 45 men and 25 women with a mean
age of 43 years. Except for the number of fingers injured
(p ¼ 0.027), there were no differences in the baseline
characteristics at enrollment between completers and
noncompleters of the protocol. The second evaluation
occurred an average of 33 days after the injury
Psychosomatics 55:4, July/August 2014
 Bot et al.

(range, 18-51 days). Thirty-four patients returned to the
office and completed the questionnaires, 36 completed
the questionnaires over the phone (Table 1).
There were 3 main diagnostic groups: laceration in
21 patients (14 skin only, 4 nerve, and 2 tendon),
fracture in 44 patients (29 distal phalanx, 15 middle
phalanx), and amputation in 17 patients (without
revascularization) (8 amputations at the level of the
distal phalanx, 8 tip amputations, and 1 amputation at
the level of the middle phalanx) (Table 2). We used the
groups of type of injury as one measure of impairment
and pathophysiology.
There was a wide variety of injury mechanisms
(Table 2). Procedures were defined as any procedure
(e.g., suturing of a laceration, fracture pinning,
irrigation and debridement, or revision amputation)
whether done in the emergency department or in the
operating room (Table 2).
The mean QuickDASH score at final evaluation
was 17 (SD 17), which is 7 points more than the norm
for the United States population (Table 3). The mean
PHQ-9 was 2.8.
The correlation of the dependent measures with
each other ranged between r ¼ 0.036 (p ¼ 0.84) of
PSEQ and PIP arc and r ¼ 0.61 (p o 0.001) of
QuickDASH with days of work missed.
Factors associated with QuickDASH scores at
1 month included days between injury and final
evaluation, PSEQ score, PHQ-9 score, and additional
procedure (Tables 4 and 5). Diagnosis and injury

TABLE 1. Patient Demographics

Parameter Cohort (n ¼ 82) Completers (n ¼ 70) Noncompleters (n ¼ 12) p value

Mean SD Range Mean SD Range Mean SD Range

Age (y) 43 15 19–77 43 15 19–77 42 13 22–62 0.83
Number % Number % Number %
Gender 0.74
Female 28 34 25 36 3 25
Male 54 66 45 64 9 75

Working status 0.48

Employed 60 73 52 74 8 67
Unemployed 12 15 10 14 2 17
Self-employed/Business owner 6 7.3 4 5.7 2 17
Retired 4 4.9 4 5.7 0 0
Diagnoses 0.27
Fracture 44 54 40 57 4 33
Laceration 21 26 16 23 5 42
Amputation 17 21 14 20 3 25

Number of fingers injured 0.027

One 69 84 61 87 8 67
Two 10 12 8 11 2 17
Three 3 3.7 1 1.4 2 17

Injury mechanism 0.48

Sports 20 24 19 27 1 8.3
Home/kitchen 19 23 16 23 3 25
Work related 12 15 10 14 2 17
Door 11 13 8 11 3 25
Saw 10 12 8 11 2 17
Fall 5 6.1 5 7.1 0 0
Transport 3 3.7 3 4.3 0 0
Bite 2 2.4 1 1.4 1 8.3

Procedure 1.0
No 24 29 21 30 3 25
Yes 58 71 49 70 9 75

Dominant hand affected 0.35

No 41 50 33 47 8 67
Yes 41 50 37 53 4 33

Psychosomatics 55:4, July/August 2014 www.psychosomaticsjournal.org 375

Determinants of Disability After Fingertip Injuries

TABLE 2. Outcome Measures

Questionnaires Initial (n ¼ 82) Final evaluation (n ¼ 70) p value

Mean SD Range Mean SD Range

QuickDASH 35 19 0–93 17 17 0–75 o0.001

Pain 2.8 2.3 0–8 1.2 1.2 0–6 o0.001

Explanatory Variables

PSEQ 50 11 13–60 55 8.7 17–60 o0.001

PHQ-9 2.8 3.9 0–17 1.9 3.6 0–20 0.011

QuickDASH ¼ short version of the Disabilities of the Arm, Shoulder and Hand Questionnaire; PSEQ ¼ Pain Self-Efficacy
Questionnaire; PHQ-9 ¼ Patient Health Questionnaire.

mechanism were not significant but met the criteria for
entry into the multivariate analyses. The final regres-
sion model explained 54% of the QuickDASH score
(shrunken R2 value of 0.54) and included higher
depressive symptoms as measured on the PHQ-9
and injury mechanism (saw compared with sport).
Factors associated with pain intensity at 1 month
included days between injury and final evaluation,
PSEQ, and PHQ-9. Injury mechanism met the criteria
for entry in the regression. The final regression model
included higher PHQ-9 score and injury mechanism
(work compared with sport and door compared with
sport) and explained 34% of the variation in pain
intensity (shrunken R2 was 0.34). PSEQ was strongly
correlated with PHQ-9.
Factors associated with days of work missed at
1 month included the PSEQ, PHQ-9, additional
procedure, diagnosis, and injury mechanism.
The variable number of fingers was not significant,
but met the criterion for entry into the multivariable

TABLE 3. Bivariable Analysis with Outcome Measures at Final Evaluation

Spearman correlation QuickDASH Pain Days of work missed Þarc of PIP joint Distance to PMC
(n ¼ 70) (n ¼ 70) (n ¼ 56)* motion (n ¼ 34)* (n ¼ 34)*,†

Correlation p Correlation p Correlation p Correlation p Correlation p

Age 0.13 0.30 0.039 0.75 0.16 0.25 0.19 0.29 0.10 0.56
Days injury to final evaluation 0.31 0.009 0.25 0.034 0.21 0.13 0.36 0.038 0.38 0.025
PSEQ 0.59 o0.001 0.26 0.031 0.52 o0.001 0.032 0.86 0.062 0.73
PHQ-9 0.59 o0.001 0.33 0.006 0.54 o0.001 0.036 0.84 0.01 0.95

Mann-Whitney U test Z p Z p Z p p

Sex NS NS NS NS NS
Procedure 2.7 0.006 NS 2.6 0.009 NS NS
Dominant side affected NS NS NS NS NS
Kruskal-Wallis p p p p

Injury type 0.065 NS 0.008 NS 0.097

Injury mechanism 0.050 0.054 0.007 NS NS
Number of fingers NS NS 0.075 NS NS
Work status NS NS NS NS NS

QuickDASH ¼ short version of the Disabilities of the Arm, Shoulder and Hand Questionnaire; PSEQ ¼ Pain Self-Efficacy
Questionnaire; PHQ-9 ¼ Patient Health Questionnaire.
n
Subgroup analysis. Days of work missed contains only patients who were employed (n ¼ 57). PIP arc and Distance to PMC only have
patients with range of motion measurements (n ¼ 34) Þarc of PIP joint motion ¼ flexion in the proximal interphalangeal joint corrected for
flexion contracture for the affected finger(s).
†
Distance to PMC ¼ distance of the affected finger(s) to the palmar crease.

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 Bot et al.

TABLE 4. Multivariable Analysis

Multivariable analysis Model Shrunken R²‡ p value Part R2§
QuickDASH final evaluation
0.54 o0.001
PHQ-9* 0.43
Injury mechanism
Saw compared with sport 0.14
Pain 4 multivariable analysis
0.34 o0.001

PHQ-9* 0.27
Injury mechanism
Work compared with sport 0.10
Door compared with sport 0.092

Days of work missed (n ¼ 56)†

0.24 0.001
PHQ-9* 0.078
Additional procedure 0.073
Injury mechanism NS 0.048
door vs sport

Distance to palmar crease (n ¼ 34)†

0.14 0.016
Days injury to final evaluation

QuickDASH ¼ short version of the Disabilities of the Arm, Shoulder and Hand Questionnaire; PHQ-9 ¼ Patient Health Questionnaire.
n
PHQ ¼ Patient Health Questionnaire only has patients with range of motion measurements (n ¼ 34).
†
Subgroup analysis. Days of work missed contains only patients who were employed. Distance to PMC only has patients with range of
motion measurements (n ¼ 34).
‡
Percentage of the overall variability in the dependent variable explained or accounted for by the independent variables in the model.
§
Shrunken R2: the individual contribution of each variable to the adjusted R².

analyses (Tables 4 and 5). The final regression model mechanism (door compared with sport, odds ratio 14
included a higher PHQ-9 score, additional procedure, (1.07–175) and work compared with sport, odds ratio
and injury mechanism (door compared with sport) and 41, 3.2–524)).
explained 24% of the days of work missed (shrunken
R2 value of 0.24).
TABLE 5. Return to Work Within 1 Month (n ¼ 56)
Days between injury and final evaluation was the Mann-Whitney U test Z p
only variable that was associated with the arc of PIP
Age NS
joint motion at the 1-month evaluation, so no regres- Days of injury to final evaluation NS
sion was done. Millimeters from the DPC were PSEQ NS
correlated with days between injury and final evalua- PHQ-9 1.9 0.088
tion. Type of injury met the criteria for entry in the Chi-square X p
regression. The final model included fewer days Self-employed (y/n) NS
Sex NS
between injury and the final evaluation and had a
Procedure NS
shrunken R-squared value of 0.14, indicating that the Dominant side affected NS
model explained 14% of the variation in DPC. Out of Injury type NS
work for more than 1 month was significantly asso- Injury mechanism 15 0.021
Number of fingers NS
ciated with injury mechanism, and PHQ-9 met the
criteria for entry into the regression. The final logistic PSEQ ¼ Pain Self-Efficacy Questionnaire; PHQ-9 ¼ Patient
regression model (Nagelkerke R-square 0.37, Omni- Health Questionnaire.
bus test: Chi-square ¼ 11, p ¼ 0.03) included injury

Psychosomatics 55:4, July/August 2014 www.psychosomaticsjournal.org 377

Determinants of Disability After Fingertip Injuries
DISCUSSION
Psychological factors, such as depression, catastrophic
thinking, and self-efficacy, are important predictors of
upper extremity disability.8–13 This study showed that
psychological factors are the strongest determinants of
illness behavior (symptoms, disability, and time off
work) after fingertip injury, with injury type and
mechanism having a limited influence. Symptoms of
depression, as measured with the PHQ-9 score, were
the strongest predictor of self-assessment of disability,
pain intensity, and time off work.
Depressive symptoms are consistently more
important contributors to disability than objective
impairment.13,15 Disability (QuickDASH) correlated
with self-efficacy (PSEQ score), but PSEQ was not
retained in the final multivariable model, most likely
because self-efficacy was highly correlated with
depression and the model retained depression
instead.13 The association of greater self-efficacy with
lower disability is in agreement with earlier find-
ings.12,13,38 Pain intensity was strongly associated with
symptoms of depression. The substantial contribution
of depressive symptoms to pain intensity and disability
after injury is consistent throughout the body.8,39,40
The results of this study must be viewed in light of
several limitations. For practical reasons, the evalu-
ations occurred at variable time points; however, the
multivariable statistics was able to account for this to
some extent. The outcome measurements days of
worked missed, arc of motion, and DPC were
subgroup analyses that were likely underpowered
as not all patients worked and only 34 patients had
measurements of finger motion. We planned for and
accepted a final evaluation by phone as the correla-
tion of QuickDASH and PSEQ was our main study
aim understanding that this would limit our secon-
dary analysis. Owing to a miscommunication, our
power analysis was based on a secondary study
question, but post hoc power analysis showed suffi-
cient power for our primary outcome measure.
Another concern regarding power was that we used
many tests in the regression for our categorical
predictors with dummy variables. There was 1 miss-
ing value for days off work and initial hand measure-
ments. This is a relatively low number of missing
values and we imputed the group mean for these
missing values.41,42
378 www.psychosomaticsjournal.org
It can be argued that patients that had a follow-up
in person had more symptomatology, but this should
be the focus of another study. A study in patients with
a nonoperatively treated distal radius fracture did not
find this connection; only younger age was a predictor
of not attending a scheduled follow-up.43
Depression was a predictor of disability, pain
intensity, and days of work missed. The only patho-
physiological factor associated with disability, pain,
and days off work in the multivariable models was
mechanism of injury and it accounted a very small
amount of the variation in these factors.
It is remarkable that we could explain half the
variation in disability, and it is interesting that most of
that variation related to symptoms of depression as
measured with the PHQ-9 score. Patients with fingertip
injuries and the hand specialists who care for them
should be mindful of the important role of symptoms of
depression in the recovery process. Mood can be
optimized by evidence-based treatments such as cogni-
tive-behavioral therapy and medications, but also via
empathy and optimal support systems.44 The evidence
presented in this article indicates that the care of hand
injuries must address the entire person, not just the
physical wounds. Unfortunately, a false mind-body
dichotomy, the strong intuitive reactions of humans to
pain, and the stigma associated with rethinking these
reactions are powerful forces that are not easily swayed.
In our opinion, the best approach may be empathic
communication (empathy regarding the counterintuitive
aspects of illness in particular); care to avoid language
and concepts that reinforce catastrophic thinking,
depression, and pain-avoidant behavior; limited use of
low-yield tests and treatment that risk reinforcing mal-
adaptive coping strategies and squandering hope; the
option of skill building courses to improve adaptation
and resiliency (with the caveat that one should restrain
enthusiasm until the patient has insight and requests
assistance); and proactive and collaborative discussions
about return to daily activities, vocation, and avocations.
These hypotheses merit additional study.
Disclosures:
Arjan G.J. Bot, MD
Grants
“AnnaFonds Travel grant” (Dutch Orthopaedic
travel grant)
“VSB-fonds” a non-medical study grant
Psychosomatics 55:4, July/August 2014

“Prins Bernhard Cultuurfonds/Banning-de Jong
fonds” a non-medical study grant for excellent Dutch
students
Jeroen K.J. Bossen, MD
Grants
Vrije Universiteit Amsterdam, Netherlands. Small
grant for Medicine students
Chaitanya S. Mudgal, MD
Payment for Lectures
AONA faculty—stipend
Jesse B. Jupiter, MD
Consultant
AO foundation, no payment
Grants
AO foundation
Stock options
OHK company, no remuneration to date
David Ring
Study Specific Grants
Skeletal Dynamics
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