Analysis of Thumb and First Webspace Injuries Due to Fireworks

Purpose

Firework-related hand injuries can be devastating. We hypothesize that thumb and first webspace injuries are common among firework blasts and have distinct patterns of injury.

Materials and Methods

We reviewed our hospital database to identify patients with firework-related injuries from 2005-2015. Patients with operative hand injuries were included. Chart review identified injury patterns, management, complications, and time to reconstruction.

Results

103 patients had operative firework-related hand injuries. There were 100 males, 3 females, and mean age was 28 years. 6 underwent complete hand amputation through wrist or forearm. 16 patients (16%) had bilateral injuries. 86 patients (83%) in the group sustained thumb ray injuries and there were: 76 thumb fractures, 10 thumb soft tissue-only injuries, 51 thumb carpometacarpal (CMC) joint fracture dislocations, and 50 thumb fractures outside the thumb CMC joint. 25 patients had both thumb CMC joint fracture dislocations as well as additional thumb fractures. 23 required thumb revision amputation.

59 patients had deep first webspace injuries, and 12 required flaps for first webspace reconstruction. 5 required secondary reconstruction of a first webspace contracture (4 local tissue rearrangement, 1 flap).  An external fixator was applied to 6 hands to maintain the first webspace; none of these required secondary web reconstruction.

Among patients with thumb injuries, the number of surgeries for acute reconstruction ranged 1 to 7 (mean 1.6), with 16 patients (19%) requiring 3 or more.  

Later-stage surgeries included: pin removal (35), flap debulking (1), tenolysis (3), osteotomy (2), nail ablation (2), stump revision (5), flap (groin or toe transfer) (3), neuroma excision (1), digital nerve reconstruction (1), capsulotomy (5), first webspace deepening (6), dressing changes in children (3). Excluding isolated pin removals and dressing changes under anesthesia, 17 patients (20%) required later-stage surgeries.

Conclusions

Thumb injuries from fireworks result from high-energy avulsion, hyperextension, and hyperabduction, frequently injuring the thumb, destabilizing the thumb CMC joint, and seriously damaging the first webspace. The first webspace requires particular consideration as deep injury may result in adduction contracture and require secondary reconstruction with tissue outside the zone of injury if not prevented. In our experience, application of thumb stabilization with either a miniature external fixation device or Kirschner wires to stabilize the CMC joint is imperative to maintain the first webspace and prevent thumb adduction contracture.