1 Introduction

Injuries caused by fireworks can be devastating, often leading to permanent damage or amputation. Nationally, these injuries have been on the rise in recent years and have been disproportionately affecting young adult males and children.^1,2 In 2021, 11,500 people were treated in emergency departments across the United States for firework injuries, resulting in 9 deaths in total. Firework-related injuries are often clustered around three national holidays: New Year's Eve, New Year's Day, and Independence Day.¹ Moreover, in 2021, 74 % of the injuries occurred during Independence Day throughout the United States.³

The National Electronic Injury Surveillance System (NEISS) reported data on firework injuries showed the most frequent location of injury from this mechanism is hand and finger injuries.^3,4 However, burns to the face and chest, and damage to other bodily structures are common.^5,6 Fracture or dislocation to the thumb is also common with previous literature reporting its incidence as high as 87 %.⁵ Firework injuries can be complex because the blast affects tissues differently. Bones may be crushed while vasculature stretched or lacerated.⁷

There is currently a paucity of literature focusing on the long-term outcomes of patients who suffer firework-related hand injuries. However, it can be theorized that with the severe injuries often seen, rehabilitation and recurrent follow-ups are necessary, and return to work may often be impossible, which can be challenging for patients in medically underserved areas and for those without insurance. Patients requiring inpatient admission for firework hand injuries have been found to undergo a median of three surgeries and incur a hospitalization charge of greater than $30,000.^4,8 Furthermore, many of these patients require many occupational therapy sessions and consistent follow-up.⁷

This study provides a comprehensive analysis of firework-related hand injuries at a single Level 1 Trauma Center. The center is located in Miami-Dade County. Miami-Dade is uniquely positioned as one of the most diverse and densely populated urban cities with limited restrictions on firework purchase/use. Our particular focus is to understand the injury patterns sustained, firework modalities used that caused injury, and trends in frequency over time.

2 Materials and methods

After obtaining Institutional Review Board (IRB) approval, we performed a retrospective analysis of patients who presented to our institution, a Level I tertiary referral center, with orthopedic injuries sustained as a result of a firework-related mechanism. Our institution is the largest of two Level I trauma centers in the region and serves as the primary referral center for complex upper extremity trauma. As such, we believe our patient population is representative of the most severe fireworks-related hand injuries in the region. Electronic medical records from January 2013 to January 2023 were used to identify patients and collect data, screening patient charts from 14 days prior and after each of the aforementioned holidays to assess the timeframes with the highest frequency of injury. This date range was selected because 2013 was the start of a department wide database collection. Without the ability to verify records prior to this, a 10-year sample was selected. Inclusion criteria allowed for the enrollment of any patient with a firework-associated hand/wrist injury. Information regarding patient demographics, mechanism of injury, injury characteristics, treatment course, and length of stay in the hospital was recorded. Our primary focus was on hand and wrist injuries because these are the most common and devastating fireworks-related injuries requiring complex reconstruction and rehabilitation.

Demographic data included age, gender, race/ethnicity, and zip code of home address. The date of each patient's injury, consult and admission date were recorded, as was their length of stay. A firework explosion was the mechanism of injury for all our subjects. Details of the treatment course included primary and secondary injuries (fracture, vascular/nerve injury, burns, etc.), procedures performed, time to washout, and post-operative infection. We also noted hand dominance, diabetic status, and use of drugs or alcohol. Data were collected regarding patient demographics, fireworks use, hospital course, and injury characteristics. Descriptive statistics were calculated for all variables.

3 Results

3.2

3.2 Injury characteristics and outcomes

The average length of hospital stay in these patients was 4.64 days. Hospital to hospital transfer was required in 11.4 % (n = 4) of patients. The majority of primary injuries were on the right hand (62.9 %), followed by the left hand (31.4 %), and both hands (5.7 %). At least 42.9 % (n = 15) of patients had a dominant hand injury. Most patients received formal surgical treatment in the operating room (82.9 %), with the remainder receiving bedside management (17.1 %). Fracture was diagnosed in 77.1 % of patients while 34.3 % of patients sustained traumatic amputation. The incidence of vascular injury was 45.7 %, while the incidence of nerve injury was 48.6 % (Table 2). More than one-third (n = 13; 37.1 %) of patients sustained additional (non-hand) injuries. These included burns to the face (n = 8), chest (n = 6), abdomen (n = 3), lower extremities (n = 2), tympanic membrane damage (n = 2), and orbital fractures (n = 1).

Table 2 Hospital course and injury characteristics, Miami, Florida, 2013–2022.

Average length of stay (days)	4.64
Outside hospital transfer
Yes	4 (11.4 %)
No	31 (88.6 %)
Location of primary injury
Right hand	22 (62.9 %)
Left hand	11 (31.4 %)
Both hands	2 (5.7 %)
Dominant hand injury
Yes	15 (42.9 %)
No	7 (20.0 %)
N/A	13 (37.1 %)
Treatment Modality
Surgical	29 (82.9 %)
Non-surgical	6 (17.1 %)
Additional digit amputation?
Yes	9 (25.7 %)
No	26 (74.3 %)
Vasculature Injury?
Yes	16 (45.7 %)
No	19 (54.3 %)
Nerve Injury?
Yes	17 (48.6 %)
No	18 (51.4 %)

The mechanism of injury in most cases was caused by the patient holding the firework in their hand (88.6 %). The injuries occurred on dates surrounding the Independence Day (54.3 %) and New Year (45.7 %) holidays. The peak of firework-related injuries occurred in 2015 and has demonstrated an upward trend in injuries since 2017 (Fig. 1).

Close

Fig. 1 Year-over-year trend of firework injuries.

Export to PPT

Most patients with firework-related injuries came from Miami-Dade County (33147), which has an average income of $51,700 (Fig. 2). Twenty-two of the 35 patients in the study (62.8 %) lived in zip codes that earned less than $60,000 per household annually (Fig. 3).

Close

Fig. 2 South Florida heat map of firework injuries by zip code.

Export to PPT

Close

Fig. 3 South Florida breakdown of firework injuries by average income by zip code.

Export to PPT

The most common surgical procedures performed for these injuries were irrigation and debridement (n = 26, 74.3 %), revision amputation (n = 21, 60 %), and open reduction with internal fixation (ORIF) (n = 16, 45.7 %). Nerve and vascular repair were required in 5 of the 35 cases (Fig. 4).

Close

Fig. 4 Types of surgical treatment required.

Export to PPT

4 Discussion

This study evaluated the characteristics of firework injuries at a Level-1 Trauma center in South Florida and sought to identify injury trends over nearly a decade. Firework injuries can be catastrophic for patients. Surgery was provided to 83 % of the patients in this study, nearly half had vascular and/or nerve damage, and 25.7 % required surgical amputation. Consistent with previous literature, our study found that young adult males sustained the greatest frequency of injuries.¹

Contrary to the 2021 Annual Report finding of most firework injuries occurring around Independence Day (74 %),³ our dataset found a more even split of injuries between New Year (45.7 %) and Independence Day (54.3 %) holidays. It can be hypothesized this finding is due to Miami's social culture and weather influencing a larger influx of tourists and events for New Year celebrations, as well as the warmer and more temperate climate being more conducive to outdoor activity rather than passive observation of firework displays.

The majority of the included patients lived in a zip code with an average annual income of less than $60,000. A nationwide epidemiological study of firework injuries showed that most people who sustain them have a household income of less than $20,000.¹ In 2010, the average charge of a hospital bill for a firework-related injury was $11,582, but many of these patients required follow-up care including surgeries and rehabilitation not covered in the original hospital bill.⁷ Ortiz et al. found that these patients undergo a median of three surgeries.⁴ Unfortunately, many patients that suffer traumatic amputation and firework-related injury undergo significant financial burden in addition to their physical injury, with a median cost of $30,743 per admission.⁸ One study found that only 33 % of hand injuries from a blast achieve functional recovery and 27 % of patients were able to return to work.⁹

Moreover, one study found that 11 % of the firework injuries presenting to the ED were from black populations between 2000 and 2010.¹⁰ The NEISS has shown an increase in the black population accounting for 5.4 % of injuries in 2013 to an average of higher than 15 % from 2019 to 2021.³ In an epidemiologic study observing the last 10 years, many of the injuries came from urban areas and the Midwest and South regions of the United States, but predominantly from lower-income populations.¹ With this information, efforts are being made to increase awareness regarding the safety and concerns of fireworks and their relations to public health interventions. However, few studies have taken a closer look at characterizing these injuries and their relations to demographic trends.

With regard to victims of a handheld firework explosion injury, one 49-year-old, African American, plumber presented to our institution on July 4, 2022, after sustaining a blast injury to his right, dominant hand, by a firework. He was evaluated in the trauma bay, copiously irrigated, and debrided at bedside, dressed, and taken to the operating room for surgical treatment where he underwent further irrigation and debridement, revision amputations of index finger (middle phalanx), small finger (proximal phalanx), third metacarpal, fourth metacarpal, fifth metacarpal, thumb ray amputation, as well as open reduction and percutaneous pinning of small finger metacarpal base fracture. Nearly one year after his injury, he is back to work as a plumber, however he is limited in the use of his right hand (Fig. 5).

Close

Fig. 5 49-year-old plumber who sustained a firework injury to his right hand on April 7, 2022. Images from initial injury/operative treatment and 10-month follow-up. Radiographic evaluation of the same patient at time of injury, immediately after initial operative fixation, and at 10-month follow-up.

Export to PPT

The Social Vulnerability Index (SVI) ranks the level of social vulnerability of communities and helps public health officials and emergency managers allocate resources more effectively.¹¹ In 2020, Miami-Dade County was assigned a high SVI score of 0.9007 (out of 1.0), suggesting that residents may face increased barriers to accessing timely care and rehabilitation following preventable injuries such as fireworks-related hand trauma.³ Our finding that the majority of patients came from zip codes with high SVI scores suggests that social and economic disadvantages may contribute to the risk of fireworks-related hand injuries and affect timely access to specialized surgical care and rehabilitation. Prevention efforts and resource allocation should consider underlying social determinants that may make certain communities more vulnerable.

Despite numerous safety interventions, people continue to put themselves at risk for firework-related injuries. Nationally from 2008 to 2017, the number of firework-related injuries continued to rise over time.¹ The fluctuations observed, including the peak in 2015 and the drop in 2017 as described in Fig. 1, may be multifactorial, reflecting variations in local enforcement, public awareness, or social behaviors. We did not identify any major legislative changes during this timeframe that would fully explain these trends. In addition, many firework injuries come from rural areas where access to healthcare is less accessible.¹² In the present study, 11.4 % of patients required transfer from a different hospital. Literature has shown that there is often a lack of available coverage for emergency hand trauma, especially in rural areas.^12,13 This places people in rural or medically underserved areas at a higher risk of not receiving the care they need in a timely fashion. Without access to qualified surgeons, patients are put at risk of further complications such as infection. Some studies have suggested interventions like supplementing emergency department staff on high-risk holidays or bolstering the access to healthcare for low-income populations.¹ Furthermore, the number of qualified orthopedic and plastic surgery residents deciding to pursue a hand surgery fellowship continues to fall thereby exacerbating the state of emergent hand care.^14–16

In Florida, according to Chapter 791 and Statute 791.08, firework use is illegal except on the designated holidays of New Year's Eve (December 31), New Year's Day (January 1), and Independence Day (July 4).¹⁷ This policy is similar to that of Iowa's which was passed in 2017. In Iowa, after passing Senate Bill 489 which allows for firework use on the same three holidays as in Florida, pediatric firework injuries increased tremendously evidenced by increased emergency department visits and admissions.

Previous studies have analyzed the incidence of firework-related injuries after interventions or legal changes. Cardin et al. saw a 71 % reduction in injuries at their institution following a firework safety and injury prevention campaign presented via different media outlets.¹⁸ Myers et al. found an increased length of hospital stay and an increased number of injuries requiring inpatient admission in children following loosening of state regulations.¹⁹ It has been found that states with laws banning fireworks in the private setting and only allowing them for public display have seen a decrease in the incidence and severity of injuries.²⁰

Since 2016, West Virginia has laws allowing the sale of fireworks year-round. Not surprisingly, since 2016 they have seen a 39 % increase in the injury rate, especially to young adult males and within 7 days of a celebrated United States holiday.²¹ Myers et al. found that with regard to pediatrics, the liberalization of fireworks laws significantly increased the length of hospital stay and the number of injuries requiring inpatient admission while the average age decreased.¹⁹ In comparison, states that ban fireworks except for public display have a greatly reduced incidence of injuries and those who sustain them have less severe injuries.²⁰ This has led to a call for action from the community for increased awareness, legislation, and targeted public education about the dangers of fireworks to reduce the incidence of these injuries.²²

This study has several limitations. The data herein was extracted from a single level-1 trauma center located in South Florida. Therefore, what was seen at the current institution may not be generalizable to other areas with different laws, patient populations, and healthcare infrastructure. There was a relatively small sample size (n = 35) however given the frequency of this injury the published literature on these injuries is sparse. This is the largest single-center data set on firework injuries to the hand used for similar purpose since 2006.^{4–8,10,12,18–20,23} It is also possible a few outlier injuries were missed due to the analysis of high-yield, timeframes of data collection for firework-related injuries when legal use was permitted.

Guardian/patient's consent

This study was a retrospective chart review and did not require patient or guardian consent.

Availability of data and materials

Data is available upon request.

Credit author statement

Weinerman, Jonathan: Conceptualization, Methodology, Supervision, Visualization, Writing – Original Draft, Writing – Review & Editing.

Syros, Alina: Data Curation, Formal analysis, Writing – Original Draft, Writing – Review & Editing.

Patel, Nikhil: Data Curation, Formal analysis, Investigation, Writing – Original Draft, Writing – Review & Editing.

Mesenger, Jacob: Formal analysis, Investigation, Writing – Original Draft, Writing – Review & Editing.

Luxenburg, Dylan: Data Curation, Formal analysis, Writing – Original Draft, Writing – Review & Editing.

Minaie, Arya: Formal analysis, Project administration, Supervision, Writing – Original Draft, Writing – Review & Editing.

Baron, Max: Investigation, Writing – Original Draft, Writing – Review & Editing.

Hui-Chou, G. Helen: Conceptualization, Project administration, Supervision, Writing – Original Draft, Writing – Review & Editing.

Author contributions

All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the article are appropriately investigated and resolved. All authors listed have significantly contributed to the manuscript. All authors listed have read and approved all versions of the manuscript.

Ethical statement

We certify this study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. We received institutional review board (IRB) approval (IRB # 20200308) from The University of Miami. This study was carried out in accordance with relevant regulations of the US Health Insurance Portability and Accountability Act (HIPAA).

Funding

The authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. There are no relevant disclosures.