Firework-related hand injuries: A novel classification system

Correspondenc / American Journal of Emergency Medicine 36 (2018) 875906 897

Most physicians (75%) agreed that avoiding opioids as first line ther- apy for many pain related complaints would improve quality of patient care. However, only 7% agreed that avoiding opioids as first line therapy would improve patient satisfaction. Responding physicians identified sources of pressure to prescribe more opioids at ED discharge as peer- review journals (100%) and patient expectations (95%) and less opioids at discharge from personal motivation (71%), media (43%), and govern-


8 August 2017

mental agencies (43%). A majority of physicians (52%) reported that they prescribe opioids to b 25% of patients with low acuity pain com- plaints, such as dental or Musculoskeletal pain. Conversely, 16% report- ed prescribing opioids to N 50% of such patients. Median number of opioid tablets prescribed at discharge was 12 (range 4-30), regardless of opioid prescribed. Most physicians agreed that an institutional opioid prescribing policy would contribute to greater Job satisfaction (66%) and improve quality of patient care (55%), but few thought this would increase patient satisfaction (13%).

Overall results suggest physicians believe patients often want Opioid pain medications, they patients are more satisfied when they receive opioids, and pressures to prescribe are primarily from patients. It is un- clear if this is because physicians thought patients want opioids specif- ically or if they simply want pain to be well- controlled and opioids are an effective medication in this regard. Interestingly, less than one third of physicians felt that patient Satisfaction survey scores were actually higher when opioids were given. This is consistent with prior research showing administration of opioids during an ED visit does not increase patient satisfaction survey scores [11]. Perhaps the most likely explana- tion for this discrepancy is physicians do not believe patient satisfaction surveys are accurate measures of quality of care or patient experience as indicated by our results [3,7,12,13]. These findings are in contrast to pre- vious research regarding other types of medication administration (e.g. antibiotics), which are associated with improved patient satisfaction survey scores [10,14]. The most commonly cited pressure to prescribe less opioids was personal motivation. This gives credence to the fact that physicians believe the dangers of opioids often outweigh potential benefits. It also suggests that physicians feel responsible for the safety of hand injuries: A novel “>patients when determining an appropriate pain management plan.

Although previous research has addressed the connection between administration of opioids in the ED and patient satisfaction survey scores, this is believed to be the first to evaluate connections between Opioid prescription at ED discharge and these survey scores from the standpoint of physician perception.

Matthew S. Merriman, MD Steven Nelson, MD

Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Box 655, Rochester, NY 14642, United States

Nicole M. Acquisto, PharmD Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave., Box 655, Rochester, NY 14642, United States Department of Pharmacy, 601 Elmwood Ave. Box 638, Rochester, NY 14642 Emergency Medicine Research, Emergency Medicine and Public Health Services, University of Rochester, 601 Elmwood Ave., Box 655, Rochester, NY

14642, United States

Corresponding author.

E-mail address: [email protected].

Courtney M.C. Jones, PhD, MPH

Timmy Li, PhD Molly McCann, MS, PhD candidate David H. Adler, MD, MPH

Emergency Medicine Research, Emergency Medicine and Public Health Services, University of Rochester, 601 Elmwood Ave., Box 655, Rochester,

NY 14642, United States

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  • Firework-related hand injuries: A novel classification system?,??,?,??

    In 2013, the United States Consumer Product Safety Commission reported that an estimated 11,400 people were treated in hospital emergency departments for fireworks-related injuries, representing the highest number since 1998 [1]. Males represented the majority of those injured, with 57% of total cases. The 25-44 year age group was most likely to be injured by firework accidents and 65% of the in- juries occurred during the 4th of July holiday. Hands were the most commonly injured body part, accounting for 36% of all injuries. Recent data published in the American Journal of Emergency Medicine by Sandvall et al. indicated the proportion of hand injuries may be even

    ? This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

    ?? A.G. is part owner of AG Brothers, LLC. The other authors declare that they have no

    conflict of interest.

    ? This study was approved by the Institutional Review Board at the University of

    Southern California (reference number HS-15-00257). All procedures followed were in ac- cordance with the ethical standards of the responsible committee on human experimen- tation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).

    ?? Informed consent was obtained from all patients for being included in the study.

    898 Correspondence / American Journal of Emergency Medicine 36 (2018) 875906

    Fig. 1. Our classification system based on extent of digital involvement: (a) type I, thumb and index finger injury; (b) type II, thumb, index, and middle fingers injury; (c) type III, thumb, index, middle, ring, and small fingers with or without distal carpal row injury.

    Fig. 2. Schematic of our classification system demonstrating increased zone of damage with types I, II, and III injuries.

    higher. In their cohort of 294 patients ages 1-61 with firework inju- ries, 61% had hand injures and 90% of treated patients were males [2]. We performed an IRB-approved retrospective review of firework- related hand injuries managed surgically at our level I trauma center over a seven-day period (three days before and after) around the July Fourth holiday from 2012 to 2015. We excluded patients with minor injuries consisting of superficial wounds or burns alone. A total of fifteen patients were included in the study. Data was collected regarding demographics, injury sustained, type of firework used, alco-

    hol use prior to injury, and method of Operative treatment.

    From our observations, we proposed a classification system for fire- work-related hand injuries based on the extent of involvement of the hand. Patients are divided into three groups (Figs. 1 and 2). In type I inju- ries, the thumb and index are involved in isolation. In type II injuries, there is additional involvement of the middle finger. In type III injuries, there is greater involvement of the ulnar aspect of the hand with injury to the ring and small fingers and variable involvement of distal carpal row.

    In our cohort, 93% (14/15) of patients were male with a median age at injury of 35.8 years (range 21-53). In 53% (8/15) of cases, the non-

    Correspondenc / American Journal of Emergency Medicine 36 (2018) 875906 899

    dominant hand was injured with the radial aspect involved every time. One patient (#10) had injury to bilateral hands. 80% (12/15) of patients had been drinking alcohol at the time of injury. All cases involved a hand-held device; in twelve cases, a firecracker or similar device was involved.

    Our least severe cases involved injury to the thumb and index finger

    with variable degrees of volar soft tissue injury (Type I). Five patients sustained injuries fitting this category. All patients had debridement of devitalized soft tissue. Two patients required revision amputation of the thumb and index finger, one required revision amputation of the thumb alone, and one required amputation of the index finger alone with stabilization of the thumb basilar joint. As the injuries progressed in severity, the first web space was involved, and there was bony injury to the middle finger (Type II). Four patients had injuries fitting this category. In addition to revision amputations of unsalvage- able digits, these patients required a combination of other procedures including fixation of fractures, repair of digital nerves, and revasculari- zation of dysvascular digits. The six remaining patients had generalized hand involvement and carpal disruption (Type III). Two patients (#13, 14) had predominantly carpometacarpal disruption involving multiple digits and required operative stabilization. The remaining patients re- quired extensive debridement of devitalized tissue, revision amputa- tion of unsalvageable digits, and stabilization of multiple fractures or dislocations. Due to the large amount of soft tissue damage, one patient eventually required soft tissue coverage to the dorsum of the hand with a reverse posterior interosseous artery flap.

    Upon review of the literature, it is clear that there are distinct geograph-

    ical differences observed based on the type of firework most commonly used. We observed handheld fireworks to be the most common cause of hand injuries as did previous studies from Iran and the Netherlands [3,4]. In India, however, flare/fountains were the most popular firework of choice [5]. In the most recent American cohort, mortar type fireworks were the most common cause of injury, followed by homemade devices [2].

    We propose our classification system to aid in a clearer understand- ing and description of these injuries based on the likely mechanism of injury with handheld fireworks. While Wenzweig and Wenzweig [6] and Hahn et al. [7] have previously proposed Classification systems for explosion injuries to the hand, these are too complex for clinical use with more than six patterns of injury. Furthermore, the latter study was not specific to firework injuries but instead described generalized patterns of explosion. We observed a common pattern of firework inju- ry with varying degrees of severity, ranging from I to III. We believe this will be a useful tool for the emergency physician to rapidly assess and categorize the severity of injury at the time of initial presentation and to communicate injury severity to a consulting hand surgeon.

    Siamak Yasmeh, MD Nicholas A. Trasolini, MD* Alidad Ghiassi, MD

    Department of Orthopaedic Surgery, Keck School of Medicine, University of

    Southern California, Los Angeles, CA, United States

    *Corresponding author at: Department of Orthopaedic Surgery, Keck School of Medicine, 1200 N. State Street CT A7D, Los Angeles, CA 90033,

    United States.

    E-mail address: [email protected] (N.A. Trasolini).

    Wai-Yee Li, MD, PhD Department of plastic surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States

    Helen Yang, BA

    Keck School of Medicine, University of Southern California, Los Angeles, CA,

    United States


    1. Tu Y, Granados D. 2013 fireworks annual report: fireworks-related deaths, emergency department-treated injuries, and enforcement activities during 2013. Washington DC: U.S. Consumer Product Safety Commission; 2014.
    2. Sandvall BK, Jacobson L, Miller EA, Dodge RE, Quistberg A, Rowhani-Rahbar A, et al. Fireworks type, injury pattern, and permanent impairment following severe fire- works-related injuries. Am J Emerg Med 2017 Oct;35(10):1469-73.
    3. Tavakoli H, Khashayar P, Amoli HA, et al. Firework-related injuries in Tehran’s Persian Wednesday Eve Festival (Chaharshanbe Soori). J Emerg Med 2011;40:340-5.
    4. Kon M. Firework injuries to the hand. Ann Chir Main Memb Super 1991;10:443-77.
    5. Puri V, Mahendru S, Rana R, Deshpande M. Firework injuries: a ten-year study. J Plast Reconstr Aesthet Surg 2009;62:1103-11.
    6. Weinzweig J, Weinzweig N. The “Tic-Tac-Toe” classification system for mutilating in- juries of the hand. Plast Reconstr Surg 1997;100:1200-11.
    7. Hahn P, Brederlau J, Krimmer H, Lanz U. Explosion injuries of the hand: spatial rela- tionship and injury pattern. J Hand Surg Br 1996;21:785-7.

      Which position for resuscitation should we take? A randomized crossover manikin study


      The ability to perform high quality cardiopulmonary resuscitation by medical rescue teams is a key skill that directly affects the survival of patients with cardiac arrest [1,2]. The guidelines of both the European Resuscitation Council and the American Heart Association put a lot of emphasis on high-quality chest compressions, which consist of deep and frequent enough compressions, as well as minimizing interruptions

      30 July 2017

      Fig. 1. Resuscitation positions: (A) on the side of the victim (control group); (B) from behind the victim’s head (experimental group).

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