pISSN: 0126-074X | eISSN: 2338-6223 RESEARCH ARTICLE MKB. 51(2):110–7

Pediatric Hand Blast Injury Profile in Emergency Roomhttps://doi.org/10.15395/mkb.v51n2.1643 of Dr. Hasan Sadikin General Hospital Bandung

Yoyos Dias Ismiarto, Yoan Putrasos Arif Department of Orthopaedics and Traumatology Faculty of Medicine Universitas Padjadjaran Dr. Hasan Sadikin General Hospital Bandung, Indonesia

Abstract

In the past, blast injuries were mainly caused by war-related incidents. However, despite the current lack of war- related activities, blast injuries are still seen due to unintentional low material blasts which are mostly of this study was to assess the incident, patterns, and severity of hand blast injuries among pediatric patients seentreated on in children’s Dr. Hasan hand. Sadikin However, General the Hospital. classification Twenty for two the pediatric severity patients of this type in Dr. of Hasan injury Sadikin is still Generalunclear. HospitalThe aim Bandung from 2013–2017 were included in this study. All data were extracted retrospectively from patient medical records and the degree of injury severity was assessed using Hand Injury Severity Score (HISS). There were 22 hand injuries caused by explosion identified in 18 boys with the age range of 5 to 15 years. Hand injuries from explosions have a specific pattern with the hand radial side experiencing the most severe damage including theblast thumb injuries (16 is cases),found among index fingerpediatric (16 patients cases), andwith middle the hand finger radial (14 side cases). tends The to suffer severity the ofmost the severeinjuries damage. varied from mild (3 cases) to moderate (4 cases), severe (7 cases), and major (8 cases). A high incidence of major hand Key words: Blast injury, injury pattern, pediatric hand, severity of injury

Profil Cedera Tangan Akibat Ledakan pada Anak di Ruangan Gawat Darurat RSUP Dr. Hasan Sadikin Bandung Abstrak

Cedera akibat ledakan di masa lalu terutama disebabkan oleh situasi peperangan. Saat ini cedera akibat ledakan masih terjadi terutama pada tangan anak yang disebabkan oleh ledakan bahan berdaya rendah yang penelitian ini adalah menganalisis insidensi, pola, dan derajat keparahan cedera terhadap pasien yang dirawat di tidakRumah disengaja. Sakit Hasan Namun, Sadikin. klasifikasi Penelitian untuk ini menentukanmelibatkan 22 derajat pasien keparahan anak di Rumah cedera Sakit masih Dr. belum Hasan jelas.Sadikin Tujuan Bandung dari periode 2013–2017. Semua data didapatkan secara retrospektif dari rekam medis pasien. Tingkat keparahan cedera dinilai menggunakan Hand Severity Severity Score (HISS). Dua puluh dua cedera tangan akibat ledakan

Cedera tangan akibat ledakan memiliki pola tertentu, dengan sisi radial tangan mengalami kerusakan paling teridentifikasi. Kelompok ini sebagian besar terdiri atas 18 anak laki-laki dengan rentang usia 5 hingga 15 tahun. parah di antaranya 15 kasus mengenai ibu jari, 16 kasus mengenai jari telunjuk, dan 14 kasus mengenai jari tengah.tinggi dalam Tingkat kategori keparahan berat cedera dengan bervariasi sisi radial dari tangan kasus cenderung ringan sebanyak menderita 3 kasus, kerusakan sedang paling sebanyak parah. 4 kasus, berat sebanyak 7 kasus, dan parah sebanyak 8 kasus. Cedera ledakan di tangan anak memiliki angka kejadian yang Kata kunci: Cedera akibat ledakan, derajat cedera, pola cedera, tangan anak

Corresponding Author: Yoan Putrasos Arif, Department of Orthopaedics and Traumatology Faculty of Medicine Universitas Email:

Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, Jl. Pasteur No. 38 Bandung, West Java, 40161 Indonesia, [email protected]

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Pediatric Hand Blast Injury Profile in Emergency Room of Dr. Hasan Sadikin General Hospital Bandung Introduction pathomechanism, severity, and management in pediatric patients. In the past, blast injuries were mainly caused by injuries during wars among both soldiers and civilians.1 Nowadays, blast injuries still Methods occur, mostly caused by low explosion such as The study was conducted retrospectively affected body part.2 The incidence of the injury using the medical records of patients admitted firecrackers,is seasonal, with with a hands peak duringas the mostholiday frequently seasons to the Emergency Department of Dr. Hasan and cultural events, such as during Eid Al- Sadikin General Hospital, Bandung, during the Fitr, Christmas, New Year, or during wedding period of January 2013 to December 2017. ceremonies.3 Available medical records, clinical photographs, during festivities due to their spectacular display collected to understand patient demographics. and firecrackers are often used radiographicThere were finding, 30 patients and surgical presented reports with handwere atmosphere in these events.1 blast injuries during the period studied. Inclusion ofused colors globally and loudin many sounds, kinds reflecting of festival, the festive such criteria of the study were hand blast injuries that asTihar in , Hari Raya They in areMalaysia frequently and Indonesia, Day in Morocco, Guy Fawkes excluded from this study due to the age of the requiredpatients (>15 surgical years interventions. old). Brief history Eight casestaking were was Independence Day and in United performed through analysis of medical records. NightStates, Bastille (Bonfire Day Night) in France, in Fallas United Day Kingdom, in Spain, The severity of hand injury was categorized into New Year’s Eve in Guatemala, Chinese New mild, moderate, and severe according to HISS Year in .1,2 based on clinical photographs, radiographic mainly affect children, with reported incidence 15 Most of the of 7/100,000 children Blast annually, injuries in from which fireworks 70% of patients received wound debridement, internal findings, and surgical reports. are categorized 4,5 into high primary sutures. themexplosives are between and low 10–14 explosives years according old. to their fixation,Patients and with soft mild tissue injuries repair only followed experienced with soft tissue wounds without accompanying bone or joint damage thus allowing for earlier detonationare categorized velocity. as low Fireworks explosives. and Thefirecrackers, severity mobilization after wound repair and better asof blast the mostinjuries frequent is affected causes by ofthe blast range injuries, of the prognosis. Moderate injuries were described explosives and size of the explosives. Various as soft tissue, bone, and/or joint damage types of injuries may occur, such as laceration, without amputation with any degree of residual avulsion, amputation, burn injuries, vascular stiffness of the hands. Severe injuries were injuries, compartment syndrome, fractures, and described as wounds accompanied with partial physeal plate injuries.6 Isolated blast injuries on the hands presented amputation surgery and caused disability. a certain pattern such as thumb hyperextension, or full amputation of the hand that may require interdigital space, traumatic amputation at Results thumb hyperabduction, laceration at first of such patterns includes tears of volar plate, distaldisinsertion fingers, of intrinsic and many muscles, others. tendon The rupture, etiology hand were found during the period of the study, Twentywith the five youngest cases of patientpediatric aged blast 5injury years of old.the 7,8 andstill ongoingaccompanying despite neurovascular the wide use ofdeficiencies. Hand Injury age range of 5–15 years. From the history taking, DebatesSeverity Score on classification for predicting of functional injury severity outcome are Theseit was cases revealed involved that 18 the boys injuries and 7 girlswere with caused the after healing due to its good accuracy. The 8,9 understanding of children’s anatomical bybe categorized low explosive as materialsseasonal injury such aswhich fireworks peaks managementstructure, pathomechanism, of this injury requiresand several extensive hand andduring firecrackers. religious festivitiesBlast injuries and at New the handYear Evesmay and rarely seen during the regular period. In this This study aimed at 8,10toevaluate the most study, the pediatric patients with blast injuries at commonreconstructive blast techniques.injury patterns as well as their the hand were admitted during Eid Al-Fitr, New

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Pediatric Hand Blast Injury Profile in Emergency Room of Dr. Hasan Sadikin General Hospital Bandung Table Hand Injury Severity Score15 Variables Motor Absolute 10

Wrist flexor or extensor (each) Extensor tendon Proximal to PIPJ 1 Weighted (See ‘Weighting Factors) Distal to PIPJ 3 Flexor profundus (incl. FPL) Zone 1 6 Zone 2 6 Zone 3 5 3 Distal to wrist 5 Zone 4, 5, belly Proximal to wrist 2 Flexor Superfiscialis Crush or avulsion of above DOUBLE the Score Neurovascular Absolute Nerve Main median n. 60 Main ulnar n. 60 Motor branch of ulnar n. 30 Deep branch of ulnar n. 30 Artery Radial artery 10 Ulnar artery 10

Digital nerve One 3 Weighted (See ‘Weighting Factors’) Both Digital artery One 3 4 Both 6 Crush or avulsion of neurovascular bundle DOUBLE the score Weighting Factors The following apply to weighted scores Thumb x 6 Ringx3 Index x 2 Littlex2 Middle x 3 Hand & Forearm x 1

Year Eve, and (Figure 1). of the palm. The majority of amputations affected The injury predominantly occurred in the the metacarpophalangeal and interphalangeal radial part when compared to the ulnar part. joints. Metacarpal bone fractures, physeal plate injuries, and carpometacarpal disarticulation were also found in several cases of hand blast Indexlaceration finger in waspalms the and most digits commonly shown affected in the injuries (Figure 2). fingermajority in of blastinjuries injuries. occur in The the radial distribution digits and of of injury was holding or throwing low explosive The most commonly identified mechanism center of the palm. Significant tissue damage occurred in first interdigital web space and center with the dominant hand. The most frequent 112 Majalah Kedokteran Bandung, Volume 51 No. 2, June 2019 Ismiarto, et al:

Pediatric Hand Blast Injury Profile in Emergency Room of Dr. Hasan Sadikin General Hospital Bandung

Chinese New Year

New Year

Eid Al-Fitr

Figure 1 Distribution of Blast Injuries at the Hand According to Annual Events presentation of the injury was hyperextension or hyperabduction of thumbs and other joints have healed and converted into scar flectiontissue.1 Theafter scar the skintissue folds may above adversely interphalangeal affect the ability to grab objects and may also affect other fingers. Joint hyperextension was correlated functions of the hand. with soft tissue avulsion, amputation, or finger disarticulationweb space was at correlated the radial with part ofthe the degree fingers. of 7 cases ). Thelaceration degree and of hyperabduction damage of the palmar of first softinterdigital tissues TheFractures highest incidencemay occur of at traumatic the thumb amputation (8 cases), (Figure 3). index finger ( ), or middle6 cases fingers) and ( 4thumbs cases ( ). Other injuries were found at the wasinterdigital for index web space finger and ( palms in 2 cases. Ring Figure 4 describes the types of injuries 4 cases according to the fingers. Thumb, index finger, involved soft tissue injuries with 7 cases and and middle finger were fingers that were most finger1 case ,and respectively, little finger and injuries with lower predominantly incidence frequently involved in trauma that caused soft when compared to the injuries occurring at tissue injury, with 8 cases happened to the thumbs,affect the 7 range cases ofto motionthe index (ROM) finger, during and 4 activecases to the middle finger. Soft tissue injuries directly thumbs, index finger, and middle finger (Figure 4). Tendon injuries (2 cases) and neurovascular

Figure 2 Severe Blast Injury of the Hand in a 12-years Old Boy (HISS=130)

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Pediatric Hand Blast Injury Profile in Emergency Room of Dr. Hasan Sadikin General Hospital Bandung

A B

C

D

Figure 3 Clinical Picture of Interdigital Web Space Hyperextension

(A) with documented physeal plate injury of first metacarpal base from plain radiographs (B) in 8-years old girl. (C) and (D) results after wound debridement, muscle repair, ORIF K-Wire, and primary suture.

Figure 4 Types of Injuriy based on Each Fingers (n=22)

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No Injury 0

Major 36.3

Severe 31.8 Percentage

Moderate 18.1

Mild 13.6

0 10 20 30 40

Figure 5 HISS of Children with Blast Injuries of the Hand (n=22) injuries (3 cases) were found only in the thumbs. severe cases. Injury Severity Score (HISS).15,16 This scoring cases,All 31.8%blast injuries were severe in this cases, study and were 36.3% managed were systemHand evaluates injuries werefour organsclassified of usingthe hand: the Handskin, surgically, with wound debridement, open bones, muscles, and neurovascular components and is widely used due to its descriptive soft tissue repair followed with primary suture. evaluation of severity in injuries distal to carpal reduction, internal fixation of the bones, and procedures were performed in any of the cases. discriminate between different mechanisms of No index finger pollicization and microsurgical bones.hand injuries. This classification system does not The HISS scoring have four degrees of severity Discussion and correlates with the functional outcomes of the hands.15,16 These degrees of severity are In this study, the age range was 5 15 years with mild (<20), moderate (21–50), severe (50–100), boys comprised the majority of the patients, and major (>100). Mild injuries include injuries that only involve soft tissue without bone or joint involvement while moderate injuries i.e.in children82%. In severalaged under other reports,15 years the old incidence ranges involve soft tissue injuries with bone and/ rate of fireworks and firecracker-related United States, injuries as a or joint involvement. Severe injuries involve 8,13 neurovascular damages in addition to the between 40 and 50%. moderate injuries and major injuries involve liberalexplosives country, compared has allowed to other the usecountries of fireworks with partial or full amputation of the hand. Low HISS or firecrackers with 7 times higher use of low6,10 score indicates milder injuries and correlates The most common blast injury in this study with good prognosis and good post-recovery stricter rules of fireworks and firecracker use. functional outcome.16 with varying degrees of thenar muscle injuries, wasdislocation laceration of ofdorsal first carpometacarpal interdigital web spacejoint, with each digit evaluated separately for its dislocation of the thumb, and injuries of 2nd–3rd componentsThe HISS (skin, score bones, is specific motoric for components, each wound metacarpals. In this study, many patients have and neurovascular components). The HISS score suffered from partial amputation of thumb, and is the sum of all digital components and its 2nd and 3rd digit of the hands. The pathomechanism weighting factors. The severity of the injuries of blast injury of the hand is as follows: hand is in this study, as assessed using HISS scoring system, is presented in Figure 5 with 13.6% of compriseddue to the ofsaddle 4 components, joint articulating with thumbs with beingCMC. the most mobile finger compared to the others all cases were mild cases, 18.1% were moderate

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Pediatric Hand Blast Injury Profile in Emergency Room of Dr. Hasan Sadikin General Hospital Bandung increase caution during such occasions. Parents are fully responsible to educate their children Index fingers is the second most mobile finger, on the dangers of low explosive materials and fixated on the center of metacarpals. The rest to monitor the use of low explosive materials by ofmechanical the fingers function are more when firmlygrasping fixated objects. on12 the their children. metacarpals, although each fingers still have a

To grasp an object, such as fireworks or References firecrackers,and stabilizes thumb the grip. and12 index finger emulates withtriggered other when fingers it is still as held supporting or in near structuresproximity 1. Rajeswari B, Shankari B, Selvaraj A. of the hand, several vectorsWhen acting the centrifugally explosive is may cause injuries to the hand. The vector of the in a tertiary burn care center. IRA-Int J App Epidemiology of cracker (fireworks) injuries space.12 The spread of vectors will then damage 2. Gopalakrishnan R, Shivakami T, Sugapradha saddleblast may joint cause of thetears thumb, of the firstthus interdigital causing dorsal web Sci.GR, 2016;et al. Prevalence 4(1):7–18 and patterns of cracker dislocation. blast injuries of the hand. Int Surg J. 2016; The centrifugal vectors will afterwards 3. Hatamabadi HR, Tabatabaey A, Heidari 3(2):831–6 continueresist the to vector, damage of otherwhich fingers damages and maythe centeroccur during Chaharshanbeh Soori festival inIran: ofif the the vector palm. Theexceeded MCP jointsthe resistance of other fingersof the K,A case Khoramian series study. MK. FirecrackerArch Trauma injuries Res. joints, causing tears starting from volar plate and increasing the degree of hyperextension.12 2013;2(1):46–9. the volar plates; thus there is a higher probability 4. Witsaman RJ, Comstock RD, Smith GA. Interphalangealthat amputation jointsoccurs are in more this area. firmly The fixated center at Pediatric303. fireworks related injuries in the of the palm consists of 2nd and 3rd metacarpals 5. UnitedMamoon States. R. Blast Pediatrics. injuries 2006;118(1):296– of the hand. In: Cheema T, editors. Complex Injuries of the hand with the axis located on the weakest point thatof the are structure. firmly attachedThe blast tovector carpal then bones may ofcause the fracture or physeal plate of the palm.16 6. Hand.Cernak London:I. Understanding JP Medicals Ltd;blast-induced 2014. p. This study has a limitation in terms of the 183–95.neurotrauma: how far have we come?. Concussion. 2017;2(3):1–19 not be fully accepted due to the lack of consensus 7. Champion HR, Holcomb JB, Young LA. classificationon whether physeal using HISS plate in pediatricinjury has patients a stronger may Injuries from explosions: Physics, biophysics, correlation with the functional outcome when compared to fractures of the hand. Multicenter pathology,Plurad DS. andBlast required injury. researchMil Med. focus. 2011; J Trauma. 2009;66(5):1468–77. studiesin children. need to be performed in order to acquire 8.9. higherPediatric data quality hand regardingblast injuries hand have blast injuriesa high 176:276–82. incidence rate in the major category with the FreelandHand Clin. AE, 2003;19(1):51–61. Lineaweaver WC, Lindley SG. hand radial side tends to suffer the most severe 10. Fracture fixation in the mutilated hand. damage. The blast injuries found in the study management of hand blast injuries. Int Surg. include lacerations, muscle tears, tendon rupture, Logan SE, Bunkis J, Walton RL. Optimum fractures or physeal plate injuries, and traumatic 11. amputation. The main mechanism of blast injury 1990;75:109–14. in this study was unintentional detonation of low 12. BergerAdhikari LR, S, Kalishman Bandyopadhyay S, Rivara FP.T, InjuriesSarkar explosive materials while being held by the hand from fireworks. Pediatrics. 1985;75:877–82. The high incidence of hand blast injuries in pathomechanics, patterns and treatment. J T,Emerg Saha Trauma JK. Blast Shock. injuries 2013;6(1):29–36. to the hand: government policies and regulation regarding 13. Hazani R, Buntic RF, Brooks D. Patterns childrenthe use of may low require explosives the implementationmaterial. Because of in blast injuries to the hand. Hand. 2009; this injuries are seasonal in nature, with higher incidences during festivities, it is necessary to 4(1):44–9. 14. Gelbart BR, Ukunda UNF, Muller J, Stuart W.

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