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