Surgical Firework Injury of the Thumb: Injury Pattern and Treatment Algorithm

Purpose: Firework blast trauma most commonly affects the hands and occurs along a spectrum of severity ranging from minor burns to mangling injuries. This study presents a retrospective chart review of patients surgically treated for upper-extremity firework injuries at a major metropolitan level-l trauma center with a focus on injuries involving the thumb. A detailed treatment algorithm is proposed based on patterns of injuries with an additional two illustrative cases. Methods: Patients who underwent surgical management for firework-related hand injuries at a level-1 trauma center between January 2009 and December 2023 were retrospectively reviewed for demography, injury pattern, and treatment. Two cases involving the thumb and first web space injuries were selected for the case series. General descriptive statistics were performed. Results: Seventy-four patients who sustained severe firework blast injuries to the hand were reviewed. Thumb injuries were treated in 59 patients (80%). A majority of these, 52 patients involved both the thumb and the first web space (88%). A wide range of surgical treatments were employed, and often, several different techniques were used for the case. Amputation (60%, n = 45) was performed most frequently, followed by skin grafting (36%, n = 27) and primary closure (32%, n = 24). Local and free flaps were performed in 35% (n = 26) of the cases. Conclusions: A majority of surgical firework injuries to the hand involve the thumb and first web space. It is paramount to preserve or restore length, sensation, mobility of the thumb, and a supple first web space. Proximal thumb injuries tend to require more aggressive treatment of the first web space. In case of devastating proximal injuries involving the carpometacarpal joint, creating a stable and well-positioned sensate post is acceptable. We propose a treatment algorithm for the management of thumb and first web space blast injuries. Type of study/level of evidence: Therapeutic IIIB.