|Year : 2016 | Volume
| Issue : 2 | Page : 57-60
Isolated blast injuries to the hands in irrua, Nigeria
Oluwafemi Olasupo Awe1, Ikponmwosa O Gold2
1 Department of Surgery, Irrua Specialist Teaching Hospital, Irrua; Department of Surgery, Faculty of Clinical Sciences, College of Medicine, Ambrose Alli University, Ekpoma, Edo State, Nigeria
2 Department of Surgery, Irrua Specialist Teaching Hospital, Irrua, Nigeria
|Date of Web Publication||8-Jun-2016|
Oluwafemi Olasupo Awe
Department of Surgery, Plastic Surgery Unit, Irrua Specialist Teaching Hospital, Km 86, Benin Abuja Expressway, PMB 008 Irrua, Edo State
Source of Support: None, Conflict of Interest: None
Introduction: Blast injuries to the hands are more common in the war zones as part of the multiple injuries sustained by the patients. However, there have been few reports of the same injuries among the civilians. Isolated blast injuries to the hands are usually due to accidental explosions of firecrackers or fireworks and gunshot injuries. There has been a sudden increase in these injuries and their severity in our hospital in the last few years. Materials and Methods: This is a retrospective study of patients that presented to the Plastic Surgery Unit of the Irrua Specialist Teaching Hospital over a period of 3 years. All the data were retrieved from the patient case files, preoperative radiographs, clinical photograph, s and the operation records. These data were collated and analyzed. Results: There were 22 patients that presented to the unit, during the period reviewed, via the emergency room. Male constitutes 82% (18), whereas the rest were females. The majority were in the pediatric age group 63.6% (14). The injuries ranged from the simple lacerations to complex injuries with fractures, crush, avulsion, degloving, and autoamputation. The right dominant hand was more common than the left in the unilateral injury. Unilateral injuries occur in almost all the cases except one, which presented 10 days after the injury with associated acute kidney injury. About 82% of them presented during the Christmas and New Year celebrations. Conclusion: Isolated blast injuries to the hand from the fireworks and firecrackers affect mainly the children with severe injuries and profound morbidity. There is a need for the government to strictly enforce the law that regulates the use of fireworks and other low-order explosives. There is also need to encourage the development of hand surgery and therapy in the subregion to improve outcome.
Keywords: Blast, fireworks, hand injuries, isolated, Nigeria
|How to cite this article:|
Awe OO, Gold IO. Isolated blast injuries to the hands in irrua, Nigeria. Saudi Surg J 2016;4:57-60
| Introduction|| |
Blast injuries to the hands primarily occur during the wartime affecting both soldiers and civilians alike. These have also been noticed frequently in the recent time in major trauma centers. , Isolated blast injuries to the hands are not common, and those that have been reported were usually due to fireworks (firecrackers). The common mechanism of injury has been described as a young man holding or throwing a low-order explosive (LE) held in the dominant hand. ,,
The blast injuries to the hands have been noticed to present in crops to our hospital during the Christmas and New Year Yuletide. Few others presented during the burial ceremony of special people in the communities where cannon and fireworks were used. 
Explosives are mainly categorized as high-order explosives or LEs depending on the speed at which they expand. Fireworks are in the category of the LEs. The extent of injury depends on the closeness or the proximity of the hand and also the size of the explosive. Blast injuries present with different range of wounds, i.e. laceration, avulsion, amputation, burn, vascular, compartment syndrome, crush injury, and degloving injury. 
The pattern of injury is that of palmar hyperextension, hyperabduction of the thumb and the fingers, and dorsal dislocations. This resulted in rupture of the volar plate, disinsertion of the intrinsic muscles, and tendon along with the neurovascular disruption. Management of these injuries requires a broad understanding of hand trauma and familiarity with various reconstructive techniques along with the judgment that comes with experience. Probably, no other injury demands such as a rich interplay of art and science of hand surgery. ,, We present the epidemiology and severity of this injury in our locality.
| Materials and Methods|| |
This is a retrospective study of patients that presented to the Plastic Surgery Unit, Department of Surgery of Irrua Specialist Teaching Hospital, Irrua Edo State, Nigeria. This is one of the few teaching hospitals located in the Suburban area along the Benin-Abuja Expressway. It is presently 350 bedded and treat mainly trauma because of its location. These patients presented through the emergency unit within the first 48 h postinjury except one of the patients that was referred for hemodialysis.
We reviewed all the blast injuries to the hand that presented to the hospital from January 2013 to December 2015. Medical notes, radiographs, clinical photographs, and operation records were used to compile standard patient demographics. We identify all the 22 patients with the blast hand injuries. The inclusion criteria consist of all hand injuries resulting from blast that required operative procedure.
| Results|| |
Twenty-two patients were identified that had blast hand during the period reviewed, and of these, 82% (18) were males with an average age of 20 (range 10-54 years). Most of the cases, 63.6% (14), are in the pediatric age group who did not understand the danger associated with these explosives [Figure 1].
The injury to the dominant hand occurred in 82% of cases, only one patient presented with bilateral hand injuries. The types of LEs involved were mainly fireworks, whereas others were gunshot and black powder [Table 1]. These are readily available in open market and even in rural areas, especially during celebrations.
The review of the overall finger involvement indicates a radial to ulnar trend with the index finger being the most frequently injured digit. The distribution of the lacerations in the palm and digits indicates a predominance of injuries to the radial fingers and mid-palm. Significant tissue destruction was noted primarily at the first web space and mid-palm [Figure 2]a-d.
Most amputations occurred at the metacarpophalangeal and interphalangeal (IP) joints. Fractures of the metacarpal bones, carpometacarpal disarticulations, and avulsions of the hand were less common [Figure 3],[Figure 4],[Figure 5] and [Figure 6].
Common mechanism of injury was identified in 18 cases where a young person holding or in the process of throwing an LE in the dominant hand. The apparent pattern was hyperextension and hyperabduction of the hand and digits. The joint hyperextension was associated with soft tissue avulsion and finger disarticulation amputations worse on the radial digits. The hyperabduction of the web spaces was associated with palmar soft tissue tear and destruction.
The management of these injuries was done mainly using tissue repair than reconstruction. Many of the patients had immediate wound excision and primary repair using fillet flaps from degloved digits. No pollicization of the index finger was done. No microsurgical procedures were done because the unit has no microsurgical facility yet.
| Discussion|| |
The incidence of the blast hand injuries among the civilians due to LEs on the increase because there is an increased use of this explosives in both urban and suburban areas of the nation. The isolated injuries are very common with this LEs, especially fireworks.
The study revealed that most of our patients are in the pediatric age group which has also been documented severally. It is at variance with the study done in California, USA, where the average age is 27 years. 
The analysis of our patients' demographics reveals a profile of a child holding an explosive in his dominant at the time of explosion. Blast injuries are usually due to fireworks (firecrackers). The impact of the blast is most noticeable in the radial aspect of the hand as evident in the number of injuries involving the thumb, index finger, thenar eminence, first web space, and the mid-palm. The magnitude of the explosion and proximity of the hand are probably associated with these findings. ,,,,
The severity of these injuries most of the time make the classification very difficult. Although there are several classifications of mutilating hand injuries or classification of the mangled limb adapted from the lower extremity. These have application in blast injuries to the hand. Hazani et al. (2009) have proposed that injuries that are amenable to simple primary closure as lacerations. Larger wounds repaired with skin grafting or secondary healing was labeled as deep abrasions. Any region of the palm reconstructed with free tissue transplant was classified as a tissue avulsion. This is basically a clinical classification because a broad spectrum of injuries exists between simple laceration and deep avulsion.
Revascularization of ischemic tissues and reimplantation of amputated parts are time-honored procedures, repair at the acute setting after explosion has been limited because of the destructive forces exerted during the blast. Completion of amputation, delayed primary closure, serial debridement, and local wound care are the mainstay of the initial treatment. ,
During the early phase, debridement and skeletal fixation are essential components in preparation for the major reconstructive surgery.  Logan et al.  described a sequence of management which includes an initial, reparative, reconstructive, and rehabilitative phase.
Several procedures have been attempted to restore function which include toe-to-thumb transplantation, to regain prehension for proper grip and grasp. For soft tissue coverage, an array of flaps for resurfacing is available which includes rectus abdominis muscle flap, lateral forearm flap, and groin flaps used for mid-palm injuries, coverage of thenar and hypothenar avulsions, and widening of the first web space. ,
Limitations of this study are the small sample size of the patient and the shortness of the duration. There is a need to have a multicenter study which will give a better representation of these injuries in the country.
| Conclusion|| |
Blast hand injuries are on the increase in our community with wide spectrum of wounds with distinct pattern. The common mechanism of injury of a young person holding or in a process of throwing an LE. There is a wake-up call on our government to enforce strictly the law restricting the sale and use of these explosives. The extensiveness of the injuries characterized by hyperextension and hyperabduction ranging from lacerations to complete amputation will necessitate the need to develop the hand surgery and therapy units. This will help to restore function and improve the outcome of these patients in the West African Subregion.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Adhikari S, Bandyopadhyay T, Sarkar T, Saha JK. Blast injuries to the hand: Pathomechanics, patterns and treatment. J Emerg Trauma Shock 2013;6:29-36.
Hazani R, Buntic RF, Brooks D. Patterns in blast injuries to the hand. Hand (N Y) 2009;4:44-9.
Moore RS Jr., Tan V, Dormans JP, Bozentka DJ. Major pediatric hand trauma associated with fireworks. J Orthop Trauma 2000;14:426-8.
Puri V, Mahendru S, Rana R, Deshpande M. Firework injuries: A ten-year study. J Plast Reconstr Aesthet Surg 2009;62:1103-11.
Hatamabadi HR, Tabatabaey A, Heidari K, Khoramian MK. Firecracker injuries during Chaharshanbeh Soori festival in Iran: A case series study. Arch Trauma Res 2013;2:46-9.
Mamoon R. Blast injuries of the hand. In: Cheema T, editors. Complex Injuries of the Hand. London: JP Medicals Ltd.; 2014. p. 183-95.
Garner J, Brett SJ. Mechanisms of injury by explosive devices. Anesthesiol Clin 2007;25:147-60, x.
Champion HR, Holcomb JB, Young LA. Injuries from explosions: Physics, biophysics, pathology, and required research focus. J Trauma 2009;66:1468-77.
Plurad DS. Blast injury. Mil Med 2011;176:276-82.
Freeland AE, Lineaweaver WC, Lindley SG. Fracture fixation in the mutilated hand. Hand Clin 2003;19:51-61.
Logan SE, Bunkis J, Walton RL. Optimum management of hand blast injuries. Int Surg 1990;75:109-14.
Alphonsus CK. Principles in the management of a mangled hand. Indian J Plast Surg 2011;44:219-26.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]