[Blast injuries of the hands. Patterns of trauma and plastic surgical treatment].

BACKGROUND Blast injuries of the hand represent a demanding surgical emergency for the reconstructive hand surgeon. Commercially available fireworks are often regarded as less dangerous compared to combat ammunition, but the following examples demonstrate their real potential for devastating hand injuries. Some of the closed injuries can represent a pitfall for correct assessment of trauma severity. PATIENTS AND METHODS Fifty patients who were seen after fireworks explosions from December 1995 until April 2005 were analyzed in respect to their patterns of injury and their subsequent surgical treatment. The severity was graded using the Hand Injury Severity Score (HISS). The majority of patients were injured during the New Year's day celebrations and presented with complex blast injuries due to commercially available, CE-certified fireworks. RESULTS Depending on the size of the explosives comparable patterns of injury were seen. Larger shells led to traumatic subtotal amputations of the exposed fifth finger ray and thenar ray. Complex destructions with multiple fractures and avulsions of the midhand were also present. Smaller explosives caused multiple lacerations in the palm of the hand, subcutaneous flexor tendon ruptures, and closed fingertip fractures. DISCUSSION Acute neurapraxias and neural compartment syndromes were clinically present. All patients (50) had to be operated primarily, and subsequent operations were necessary in 19 cases (number of operations 1-4, med. 1). In the HISS grading, 18 "minor" (HISS <20), 16 "moderate" (HISS 21-50), 7 "severe" (HISS 51-100), and 9 "major" (HISS >100) explosion injuries were present (range: 2-155, med. 47). CONCLUSION Blast injuries of the hand need a fast, strategically planned surgical approach. This is also true for presumably harmless, CE-certified fireworks. In a multiple patient scenario, triage based on surgical urgency may be necessary. A detailed clinical examination and surgical exploration is mandatory to avoid possible pitfalls like in closed injuries. Profound skills in reconstructive and microvascular hand surgery are essential to achieve an optimal clinical outcome.