ers , Roman candles , shells , mortars and homemade fireworks like improvised explosive devices ( IEDs ) such as pipe bombs , tennis ball bombs and altered consumer fireworks . Shells / mortars ( 59 percent ) were the most common fireworks type causing injury to the hand 5 .
Currently , 37 states plus the District of Columbia ban rockets , 25 states ban firecrackers , and 27 states ban shells and mortars 6 .
It is very important that we teach firework safety . Never hold a firework when it is lit , ever . It is imperative to avoid using shells and mortars and homemade fireworks like IEDs . People should be able to have a good time safely enjoying firework displays without having to face a lifetime of complications .
Stricter regulations and public education campaigns have been clearly shown to reduce the incidence of firework injuries 7 .
PATTERNS OF INJURY
The vast majority of the injuries occurred on the radial side of the hand and involved the thumb and the first web space 3 , 4 , 5 , 7 .
The hand and the digits hyperextend and hyperabduct as the blast tears the first web and palmar tissues causing soft tissue avulsions , comminuted fractures and dislocations and amputations . In severe blasts , there may be injuries to other parts of the body such as the face , ears and eyes as well as burns and tattooing of the torso and extremities .
EVALUATION OF THE PATIENT
A thorough and complete evaluation of the whole patient is mandatory before focusing on the injured extremity . It is far too easy to be distracted by an obviously gory and complex hand injury and ignore potentially life threatening internal injuries from projectiles and burns 8 , 9 .
The treating physician should start with the basics of ensuring adequate airway , breathing and circulation , then assess the patient for internal injuries before focusing on the injured hand 5 , 7 , 8 , 9 . There may be associated flash burns and tattooing of the torso and limbs , injuries to the eyes , or ear drum ruptures with consequent vision or hearing loss .
In taking the history , seek exact information on the type of firework that injured the hand . Accurate evaluation of the extent of injury and the expected structural damage depends on this information .
EVALUATING THE INJURED HAND
FEATURE
After years of taking care of mangled hands , I have come to the conclusion that little useful information is gained by subjecting the patient to a painful examination in the emergency room . The anesthesiologist applies a regional block and then the surgical team can proceed to take inventory of the injury .
The examiner should note active bleeding , which of course needs to be controlled but also indicates adequate perfusion and vascularity ; the extent of devascularization , which in turn defines the extent of the débridement and the revascularization that is needed ; the status of the skin , as any reconstruction will be threatened without a stable envelope and accompanying soft-tissue coverage ; the posture of the fingers , which may indicate tendon injuries needing repair and which directly affects the outcome and treatment plan ; any deformities signifying fractures or dislocations , which necessitate appropriate preparation and operative planning ; and the location and extent of the wound , which , together with the posture of the extremity during the injury , indicates the structures that were most probably injured 8 , 9 .
( continued on page 26 )
Fig . 1 Fig . 2 Fig . 3
JUNE 2018 25