FEATURE
( continued from page 25 ) Fig . 4 Fig . 5
CASE REPORT
The patient is a 14-year-old who was transported to children ’ s hospital ED by helicopter for bilateral blast injuries to hands , muffled hearing and blurred vision of left eye after a homemade explosive detonated in his left hand . The event occurred in the evening at a campfire when the patient ’ s friend handed him a homemade explosive device or “ smoke bomb .” He explained that he lit the explosive and everything “ went white ,” but he did not lose consciousness . Upon arrival to the ED , patient was given morphine . X-rays of the right hand showed fracture of the middle phalanx of index finger and soft tissue injury ; left hand films showed extensive trauma to phalanges .
The patient was evaluated by hand surgery for degloving injury of left hand with multiple fractures . On examination , the left thumb and index finger were barely attached , and there was a large missing portion of third finger . The fourth and fifth fingers were attached and with good blood supply . There were some minor injuries to these digits ( Fig . 1 ). Bilateral hemotympanum was present , and he had corneal abrasion . The patient also had several burns visible on chest and abdomen extending up onto neck and face with tattooing .
He was emergently taken to OR for evaluation of injuries , extensive debridement , and amputation of the crushed and avulsed left thumb and index finger 9 . The index finger was removed all the way from the base of the metacarpal of the carpometacarpal joint . The long finger was absent at the proximal part of the phalanx with loss of skin . There was also found to be pulp and nailbed laceration of the ring finger and superficial injuries to the small finger , which were repaired . The right hand sustained pulp and eponychial fold injuries to the index and long fingers , which also had thorough debridement and closure . He tolerated this well , was extubated , and transferred to PICU in stable condition .
In PICU , pain was controlled by local pain pump ( axillary catheter ) that was placed in OR as well as hydrocodone for moderate pain or morphine PCA for severe pain . He complained of blurry vision from the left eye after surgery . Ophthalmology was consulted for left lateral corneal abrasion , and they removed debris from corneas bilaterally at bedside by slit lamp .
Orbital CT showed no foreign objects nor any evidence of orbital fracture . ENT was consulted for hemotympanum , and the patient was found to have bilateral ruptured TMs .
He was taken back to the OR for a posterior interosseous artery flap , skin graft split thickness , and wound debridement , 10 with the left thigh used as donor site for skin graft ( Fig 2 and Fig 3 ).
He continued to receive outpatient therapy and was a very cooperative and motivated patient . He achieved full active and passive range of motion in the remaining fingers of his left hand .
Five and a half months later , he was taken back to the operating room to undergo a right second toe with metacarpal and dorsalis pedis free microvascular transfer to reconstruct the left thumb along with skin graft application 11 , 12 . He did very well with complete graft survival , ( Fig 4 and 5 ) and with therapy regained excellent sensation and function in his left hand , and is back in school with full hand function .
SUMMARY AND CONCLUSION
Firework injuries to the hand are quite common . Fortunately , most of the injuries are minor and do not lead to any significant functional deficit for the patient .
Our case of severe damage to the hand as a result of an IED explosion is presented . Adequate debridement , and well-planned reconstruction combined with a well-motivated and cooperative patient and good rehabilitation can and will result in excellent restoration of function even in a very complex injury 9 , 11 . 12 .
Dr . Gupta practices hand and upper extremity at Louisville Arm and Hand at Norton Brownsboro Hospital .
References
1 . Canner JK , Haider AH , Selvarajah S , et al . US emergency department visits for fireworks injuries , 2006-2010 . J Surg Res . 2014 ; 190 ( 1 ): 305-311 .
2 . Moore JX , McGwin G , Griffin RL . The epidemiology of firework-related
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