Have an Injury-Free Fourth!

Considered the official kickoff to summer, the Fourth of July is a fun-filled celebration commemorated with outdoor barbeques and festivities.  Unfortunately, too many find themselves in the emergency room over this holiday weekend as a result of firework-related accidents.

While unofficially those at highest risk for firework injuries are adolescent boys, the adult male population are a close second in the highest risk group – according to reports of ER physicians and orthopedic hand specialists….

And it is estimated that over 40 percent of firework injuries occur to the hand, wrist and elbow.

Injuries most commonly occur when an ignited firework seemingly fails to go off, though explodes when handled.  Other injuries occur as a result of the extreme heat many fireworks omit.  Even the unassuming “sparkler” can heat to over 2000 degrees, capable of causing 2nd and 3rd degree burns.

The fireworks most implicated in causing injury include small firecrackers, bottle rockets and sparklers, because they are assumed to be less dangerous.  Individuals mistakenly use less caution when handling these types of fireworks.

Some of the most common hand and upper extremity traumatic injuries resulting from firework-related accidents include:

  • Burns
  • Contusions and lacerations
  • Damage to bones, muscle, ligaments and nerves 

Medical Attention for a Traumatic Firework Injury

It is important to seek immediate attention for a traumatic firework injury, to avoid permanent damage to the hand and wrist.

The hand alone contains approximately 50 nerves, with 34 muscles moving the fingers and thumb, and over 120 known ligaments, 30 major joints, 30 bones and a myriad of connective tendons involved in carrying out our everyday activities.

Long-term hand function is dependent on not only immediate care but proper follow up.  If such injuries are not adequately addressed, permanent nerve and tendon damage can impair hand feeling and movement. And the early onset of osteoarthritis from post-traumatic bone and joint damage can further hinder hand function.

Reducing Risks of Traumatic Firework-Related Injury

While many of the tips for reducing risk of hand injury from fireworks seem common sense, they can be overlooked during the excitement.  They include:

  • Ignite all fireworks with extended lighters.
  • Remain a safe distance from ignited fireworks.
  • Allow sufficient time for fireworks to go off / explode before approaching (and handle previously ignited fireworks with an extended apparatus such as BBQ tongs).
  • Supervise young children holding sparklers, advise teens of the heat hazard of these and other small, seemingly harmless fireworks.
  • Protective glasses and gloves can also reduce risks.

 Have a happy and safe Fourth of the July!

Ring Avulsion, a Traumatic Finger Injury

Recently talk show host Jimmy Fallon explained to his audience how a seemingly minor fall nearly cost him a finger – shedding light on a rare yet serious finger trauma known as a Ring Avulsion injury.

Ring avulsion results from the mechanism of crushing, shearing and avulsion, inducing severe macroscopic and microscopic damage. This type of injury often occurs when a ring that an individual is wearing is caught on an object, usually during a fall or jump.  It can also occur when caught on fast moving equipment or just simply in a “freak” accident.

Damage from the abrupt and often harsh tug of the caught ring can range from a simple contusion to “degloving” of soft tissue – pulling the skin off circumferentially and stripping away the nerves, tendons and bone. Severe accidents may result in traumatic amputation of the finger.

Ring avulsion can be among one of the most devastating traumatic finger injuries, as often replantation following severe soft tissue damage is not possible – requiring revision amputation.

Fortunately, advances in microsurgery and interposition graft techniques have improved results with ring avulsion replantation.  Patients should see a hand specialist immediately after the injury is identified.

Symptoms of Ring Avulsion

While Fallon knew he had severely injured his finger in his fall, the extent of the damage and seriousness of the injury was not completely revealed until his examination and x-ray.  Prompt attention and surgical care from a specialized hand team fortunately saved his finger.

The severe damage that can occur in a ring avulsion case is not always evident to a patient. Immediate examination and x-ray assessment are necessary.

Symptoms may include:

  • Pain
  • Bleeding
  • Lack of sensation at the tip
  • Disfigurement
  • Finger discoloration or whitening

In severe cases, part of the finger is removed from the bone or completely severed (traumatic amputation).

Diagnosing and Treating Ring Avulsion

When a patient presents with this type of finger trauma, the wound is cleaned and inspected for visible avulsed vessel, nerve, and tendon.  Damaged skin edges are also assessed.  An x-ray may also be indicated before determining the type of avulsion a patient has incurred.  If a portion of the finger is separated, an x-ray is performed on both the amputated part and the remaining digit to fully asses damage and likelihood of replantation.

If there is a separated part, it is wrapped in a saline gauze and placed in a bag with ice water.  The patient is given antibiotics and tetanus prophylaxis.

The injury is then classified using one of several ring avulsion classification systems that exist.  Most commonly used is the Urbaniak Classification system.  The class of ring avulsion (Class 1, 2, or 3) will help determine treatment.

The goal of the hand surgeon is to salvage, maintain function and, if possible, provide an esthetic appearance.

Commonly used classification chart for Ring Avulsion injuries.

Commonly used classification charts for Ring Avulsion injuries.

Avoiding Risk of Ring Avulsion

It is difficult for patients to understand how otherwise inconsequential stumbles or movements can result in the damage or loss of a digit when a ring is involved.  We often forget that the bones and joints of the hand and wrist are small and capable of sustaining just so much force. Skin is the finger’s strongest part.  Once the skin tears, the remaining tissue quickly degloves. Though rare, the potential harm that a ring can pose should be considered – particularly when performing certain extracurricular or sports activities, or when working with machinery. Unfortunately many accidents resulting in a ring avulsion are not anticipated nor could be imagined.  Prompt attention is key to a successful outcome.

References

Flagg SV, Finseth FJ, Krizek TJ. Ring avulsion injury. Plast Reconstr Surg. 1977;59:241–8.

Brooks D, et al. Ring avulsion: injury pattern, treatment, and outcome. Clinics in Plastic Surgery April 2007 ;34(2):187-95, viii.

Fejjal N, Belmir R, Mazouz S El, Gharib NE, et al. Finger avulsion injuries:  A report of four cases.  Indian J Orthop. 2008 Apr-Jun; 42(2): 208–211.

Sears ED, Chung KC.  Replantation of finger avulsion injuries:  A systematic review of survival and functional outcomes.  J Hand Surg Am. 2011;36(4):686-94.