FEATURE
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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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