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Firework injuries: a ten-year study
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 1103e1111
REVIEW
Firework injuries: a ten-year study Vinita Puri*, Sanjay Mahendru, Roshani Rana, Manish Deshpande Department of Plastic, Reconstructive Surgery and Burns, Seth G.S. Medical College and King Edward Memorial Hospital, Parel, Mumbai e 400 012, INDIA Received 28 July 2007; accepted 22 December 2007
KEYWORDS Fireworks; Firecrackers; Firework injuries in India; Diwali injuries; Blast injuries
Summary Fireworks are used worldwide to celebrate popular events (e.g. festivals, official celebrations, weddings). The festival of lights (Diwali) is celebrated with fireworks in India. During this period, many patients from all age groups present to hospital with injuries due to fireworks. Prevalence, period of occurrence, sex and age variation, adult supervision, causative fireworks, mode of lighting, age groups prone to injury, patterns of injury caused by individual fireworks, and the body parts injured were studied. One hundred and fifty-seven cases (92 retrospective, 65 prospective) with injury due to fireworks presenting to the Department of Plastic Surgery at KEM Hospital between 1997 and 2006 were studied. The prevalence of injuries has decreased steadily over the last 10 years (41 cases in 1997, 3 cases in 2006). The maximum number of injuries (35%) was seen in the age group 5e14 years; 92% of these children were unsupervised. The commonest cause of injury was firework misuse (41% of cases), followed by device failure (35%). Device failure was commonest with flares/ fountains (ground firework emitting sparks upwards) and aerial devices. Flare/fountains caused most injury (39%), sparklers the least (0.6%). Flare/fountains, ground spinners, sparklers, and gunpowder (explosive material from cracker, obtained by tearing paper wrapper and obtaining chemicals) caused only soft tissue burns; stringbombs (high-intensity fire cracker made by wrapping chemicals with jute strings/coir in layers) and rockets (aerial device that zooms upwards and bursts) caused blast injuries, leading to soft tissue disruption and bony injuries. Emergency surgery was done if indicated: tendon and/or neurovascular repair, fracture fixation, flap cover or amputation. Superficial burns were treated with dressings. Certain wounds needed only thorough cleansing of the wound and primary suturing. We concluded that, over a 10-year period, the prevalence of firework injury decreased due to increased awareness in the community. Aggressive awareness campaigns by government and non-government organisations was the cause. We can minimise the number and severity of
* Corresponding author. Tel.: D91 22 24136051; fax: þ91 22 24143435. E-mail addresses: [email protected], [email protected] (V. Puri). 1748-6815/$ - see front matter ª2009British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.12.080
1104
V. Puri et al. accidents by raising awareness regarding safety precautions, encouraging professional displays and motivating manufacturers to adhere to strict quality control. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Fireworks are used worldwide to celebrate popular events (e.g. festivals, official celebrations, weddings). The festival of lights (Diwali) is celebrated with fireworks in India (Figure 1), but Diwali may lead to anguish due to firework-related accidents. In India, an increasing number of organizations have raised awareness about the proper use and danger of fireworks (Figure 2). Education is disseminated via newspapers, magazines, television, posters, pamphlets and booklets. In schools, children are educated regarding safety precautions. Nevertheless, many individuals suffer due to inadequate safety measures taken during the preparation and use of fireworks.
Materials and methods We studied 157 consecutive cases with injury due to fireworks presenting to the Department of Plastic Surgery
at KEM Hospital from 1997 to 2006. Data from 1997 to 1999 (92 cases) were studied retrospectively; data from 2000 to 2006 (65 cases) were studied prospectively. The history of injury was obtained from the patient or accompanying persons (in the case of children). Patients were separated into five groups according to age. This was on the basis of behavioural characteristics at a particular age: children aged <5 years of age are usually unaware of firework hazards children aged 5e15 years, though aware, are inquisitive and typically active, and therefore prone to injury young adults aged 15e25 years tend towards adventurous and reckless behaviour, and are therefore prone to accidents adults aged 25e45 years are considered to be mature
Figure 1 a Various types of fireworks. Flares/fountain, stringbomb (high-intensity fire cracker made by wrapping chemicals with jute strings/coir in layers), aerial device (bottle rocket), cracker (exploding device) and sparkler. b Flares/fountain after lighting. c Ground spinner after lighting.
Firework injuries: a ten-year study
1105
Figure 2
Print campaigns.
adults 45 years are not actively involved in firework manipulation. Presence/absence of adult supervision was noted in patients aged <15 years. The month of injury, the type of firework and mode of lighting were also noted. The cause of injury could be identified only in prospective cases (2000e2006) and were grouped into four types: misuse behaviour (e.g. holding firework in hand while lighting, altering fireworks, being too close to firework, picking up misfired firework for reuse) device failure (firework behaved in an unpredictable way) personal failure (delayed withdrawal from lit firework or improper lighting) innocent victims and bystanders. Injuries were classified as burns; contused lacerated wounds (CLWs); soft tissue injury (STI; e.g. avulsion, crush, tendon, neurovascular); and bony injuries. Emergency surgery was done if indicated: tendon and/or neurovascular repair, fracture fixation, flap cover or amputation. Superficial burns were treated with dressings. Certain wounds needed only thorough cleansing of the wound and primary suturing.
Results The number of patients with firework injuries treated by KEM Hospital in each year is shown in Table 1; there is a considerable decline from 1999 onwards.
Of the 157 cases, 150 presented during the festival season (October and November; Table 2). Prevalence was higher in males (87%) than females (13%; 7:1). Table 3 details the number of cases according to age group. Thirty-five percent of patients were aged 5e14 years, 28% were 15e24 years, and 25% were 25e44 years. Of the 66 children aged <15 years, only five were supervised by adults, 92% were unsupervised. Of the 11 cases aged <5 years, only one was supervised. Sparklers, incense sticks, matchsticks and candles were most commonly used to light fireworks. The mode of lighting could not be ascertained in 25 cases.
Table 1
Incidence of fireworks injury
Year Retrospective 1997 1998 1999 Prospective 2000 2001 2002 2003 2004 2005 2006 Total
Number of cases 41 40 11 18 15 11 5 0 13 3 157
1106 Table 2
V. Puri et al. Period of occurrence
Year
Jan
Feb
Mar
Apr
May
Jun
July
Aug
Sept
Oct
Nov
Dec
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Total
e e e e 1 e e e e e 1
e e e e e e e e e e e
e e e e e e e e e e e
e e e e e e e e e e e
e e e e 1 e e e e e 1
e e e e e e e e e e e
e e e e e e e e e e e
e e e e e e e e e e e
e e e e 3 1 e e e e 4
e 25 11 e 8 1 e e 13 3 61
41 15 e 18 1 9 5 e e
e e e e 1 e e e e
89
1
Prospective cases (65 patients) were included in evaluation of injury cause because detailed data regarding injury cause was unavailable in retrospective cases. Table 4 shows the various causes of injury identified in these prospective cases. Forty-one percent of patients were injured due to firework misuse, the commonest reason being handheld fireworks. Device failure was the next commonest cause of injury (35%). Of the remaining cases, 17% were due to personal failure and four patients (6.1%) were injured as innocent victims. For example, one patient was sleeping in a hut outside a stadium where celebrations were occurring. A device fired from the stadium fell through the roof of his hut. He picked it up to throw it out but it exploded, causing a blast injury to his hand. Various age groups had different causative factors of injury. Table 5 shows that misuse (handheld) and personal failure (delayed withdrawal from ignited firework) was common in children until the age of 14 years, and device failure (unexpected blast) was common in the age group 15e24 years. Multiple body parts were injured in 15 cases. The hand was most commonly injured (131 injuries, 74%), followed by the face (33 injuries, 19%), trunk (8 injuries, 4.5%) and lower limb (4 injuries, 2.3%). Table 6 shows the type of firework causing injury and the various injuries caused. Flare/fountains were the commonest (39%), followed by stringbombs (23%); sparklers were the least (0.6%). Flare/fountains, ground spinners, sparklers, and gunpowder caused only burns, whereas others caused a combination of injuries. Stringbombs, crackers and rockets caused not only burns, but also CLWs, soft tissue injuries and bony injuries.
Table 3
Age distribution
Age group (Years)
Number of cases n Z 157
Percentage
<5 5e14 15e24 25e44 45
11 55 44 39 8
7 35 28 25 5
Discussion The prevalence of firework injury has decreased over the last 10 years in India. The decline is welcome and the reasons are not difficult to assess. Increased public awareness due to aggressive campaigning by government and non-government organisations is the cause, but injuries still occur during Diwali. Age distribution (Table 3) Our study showed that the age groups 5e14 years and 15e24 years collectively comprised 99 out of 157 (63%) of injuries. This could be due to the typically active, enthusiastic, experimental nature of children (age 5e14 years) and the adventurous young adults aged 15e24 years who are prone to risky behaviour. For example, a 20-year-old male inserted the tip of an umbrella rod into a firecracker and lit it. The resultant blast split the umbrella rod, the force was transmitted proximally, and his index finger was completely degloved. In our study, patients aged <14 years formed 42% of cases, whereas other documented studies showed results of 51%,1 68%,2 and 70%3 in the same age group. Clarke and Langley2 showed a maximum number of cases in the upper spectrum of children aged <15 years.
Table 4 study)
Prevalence of various causes of injury (prospective
Cause
Cases (n Z 65)
Percentage
Misuse Handheld (HH) Altered firework (AFW) Close watch (CW) Pick up spent firework (PU) Device failure Unexpected blast (UB) Erratic flight (EF) Personal failure Delayed withdrawal (DW) Incorrect use (IU) Innocent victim
27 15 3 5 4 23 19 4 11 10 1 4
41.5
35.4
17
6.1
Firework injuries: a ten-year study Table 5
1107
Relationship of injury cause and age (prospective study)
Cause
Number of cases <5 years
5e14 years
15e24 years
25e44 years
>45 years
Misuse (MU) e Handheld firework Misuse (MU) e Altered firework Misuse (MU) e Close watch Misuse (MU) e Spent firework Device failure (DF) eUnexpected blast Device failure (DF) - Erratic flight Personal failure (PF) eDelayed withdrawal Personal failure (PF) eImproper use Innocent victim
1 e e e 3 e 2 e e
6 1 5 4 3 1 6 e 1
3 1 e e 8 e e 1 2
5 1 e e 4 2 2 e e
e e e e 1 1 e e 1
Total
6
27
15
14
3
The mean age of patients in our study was 19.8 years. The mean age was 14 years in a study in Northern Ireland by Fogarty and Gordon4; 8.9 years in a study in Australia by Abdulwadud and Ozannesmith5; and 11.6 years in a study in India by Mehta et al.6 Prevalence according to sex 134 (87%) of cases were males; they are more inclined towards high-risk behaviour. In India, women are busy with household duties while men, along with children, play with fireworks. Our finding is consistent with other studies,1,4,5,6,7 in which the injured male population was 71e93%. Adult supervision 92% of children were unsupervised. Only one child out of 11 was supervised in the <5 years age group. A study by Mehta et al6 found that 78% of children suffering injuries were unsupervised. In a study done in the USA,7 54% of children were supervised. Along Table 6 Relationship between firework type and injuries (prospective study) Firework
Number Number of injuries of cases Burn CLW Soft Bony Total tissue Injury injury
Flare/fountain
61 38.8% Ground spinner 3 1.9% Sparkler 1 0.6% Stringbomb 37 23.5% Cracker 29 (others) 18.4% Rocket 6 3.8% Aerial (others) 3 1.9% Gunpowder 7 4.5% Unknown 10 6.5% Total
157
64
0
0
0
3
0
0
0
64 (33%) 3
1
0
0
0
1
25 12
9
11
22
9
2
1
2
3
1
1
3
1
0
3
7
8
0
0
0
8
10
0
1
1
12
138 25
13
17
193
57 (29.5%) 34 (17.6%) 7
with awareness/education in schools regarding firework hazards, raising awareness among parents is equally important. Modes of lighting Various materials were used to light fireworks (e.g. sparklers, incense sticks, candles, matchsticks, lamps, paper, flare/fountains). In one case, a stringbomb was lit with a sparkler, causing a premature explosion possibly due to the sparkler lighting at multiple points. In three patients, a lit flare/fountain was used to light another flare/fountain. These were classified as ‘misuse behaviour’. Manufacturer recommendations on the box advising the mode of lighting the cracker would help curtail this type of injury. Cause of injury (Table 4) and its relationship to age (Table 5) Misuse (41%) was followed by device failure (35%) as the commonest cause of injury. Children aged <5 years were commonly injured by personal failure (delayed withdrawal from ignited firework) and device failure (early or late blast). The age group 5e14 years showed all types of misuse behaviour, as well as personal failure (delayed withdrawal). Misuse behaviour was rampant in the age group 5e24 years using flare/fountains and crackers (particularly stringbombs). Holding a firework in the hand is extremely dangerous, and may cause injury due to fuse failure or delayed human reaction. Injury is less likely if the firework is on the ground. Alteration of fireworks, close proximity to lighted fireworks, and picking up misfired fireworks should be condemned. It may be common in the lower socio-economic class because they cannot afford to buy enough fireworks. This group should be targeted for educational campaigns in schools and the media. They should be taught the dangers of fireworks and the harmful effects of chemicals used. While playing with fireworks, there should be strict adult supervision not only during lighting, but also when choosing fireworks. They should be taught safety precautions and the importance of strict adherence to them. Device failure was the cause of injury in 16 out of 32 cases (50%) in those aged >15 years. These injuries may be controlled to some extent if manufacturing and sales processes are standardized through legal restrictions. This age group has been using fireworks for many years, leading to a misplaced confidence in handling fireworks. Some may also tend towards high-risk behaviour, which sets a wrong example for younger children who may imitate it, but who
1108
V. Puri et al.
Figure 3 a Tattooing due to gunpowder (pre- and postoperative). b Blast injuries to the hand due to a stringbomb. c Face burns due to bending over fountain while lighting it. d Lower lip rupture due to lighting a cracker under the influence of alcohol, after mistaking it as a cigarette.
may not be able to act swiftly and safely in an emergency. Adults should be made aware of the severity of injury that fireworks can cause. Most are misinformed that fireworks cause only minor burns. They should be made aware of the devastating fractures, neurovascular injuries, amputations and functional and cosmetic deformities for which patients
may have to undergo a number of surgeries. This may help not only to deter adults from reckless use of fireworks, but also encourage them in supervising children using fireworks. Type of firework causing injury (Table 6) Flare/fountains were the fireworks that caused injury to most people (61 out of 157 of cases; 39%). Stringbombs were responsible
Firework injuries: a ten-year study
1109
Figure 3
for injury in 37 out of 154 cases (23%), mostly due to misuse (e.g. holding firework in hand while lighting). A study by Mehta et al6 showed flare/fountains to be the cause of injury in only 10% of cases, whereas crackers accounted for 34% of cases. Flare/fountains, due to composition and design, throw sparks like a fountain after ignition. These flare/fountains are at risk of explosion, or they may change direction while emitting sparks. Flare/fountains are widely misused because they are considered to be safe. Dangerous practices such as holding it in the hand while lighting, holding it in hand and directing the sparks, lighting one flare/ fountain with another flare/fountain, and bending over it while lighting it, are very common. In our study, injury cause could be ascertained in 16 cases of flare/fountain injuries. Of these flare/fountain injuries, 56% were due to device failure (unexpected explosion) and 25% were due to misuse (e.g. holding it in the hand). A study in Washington state by McFarland et al9 also found that ground display
(continued).
fireworks emitting sparks are the commonest cause of injury (36%), followed by crackers (34%), similar to our study. Similar to the study by Mehta et al,6 Fogarthy and Gordon4 and Witsaman et al8 found bangers (63%) and crackers (29.6%) to be the fireworks causing injury to most people. Flare/fountains should be subject to strict standardisation because a sub-standard flare/fountain is prone to explode unexpectedly. Ground spinners and sparklers were relatively safe, causing burns only due to personal failure. Stringbombs and other crackers caused all types of injuries due to misuse behaviour and personal failure, which are controllable factors. Aerial devices, including rockets, caused injuries due to erratic flight. Aerial devices should be banned or at least standardised so that they have a fixed direction of trajectory, and components do not fall off when it explodes in the air. Type of injuries and firework All the injuries caused by flare/fountains were burns, 88% of which were to the
1110
V. Puri et al.
Figure 3
hands. Ground spinners also caused only hand burns. Sparklers caused injury only in one case, a face burn. In the UK,10 sparkler burns have been increasing in number over the years. Stringbombs caused burns in 44% of cases, compared with CLWs (21%), soft tissue loss (16%) and bony injuries (19%). In our study, gunpowder injuries (Figure 3a) caused only burns (six cases of hand burns, one face burn, and one abdominal burn). Injury type: Injuries are often a combination of burns, lacerations, abrasions, soft tissue losses, and bony injuries. In our study of 193 injuries, burns were the commonest (72%). Burns were the leading injury, followed by blast injury, in other studies.1,5,7,8 In a study by Fogarty and Gordon,4 blast injury was the commonest injury (53% of cases). In our study, blast injury accounted for 28% of total injuries, and was subdivided into CLWs, soft tissue losses (including neurovascular injuries) and bony injuries. Of all burn injuries, 80% were hand burns, followed by facial burns (19%). Other burnt areas were trunk, feet, and shoulders. Minor burns were the commonest injury and were treated conservatively, but more serious injuries cannot be ignored, even though they were few. These included finger fractures, neurovascular and soft tissue damage requiring multiple surgery and sometimes leading to amputation, disfigurement and functional disabilities. Body part injured: In our study, the hand (Figure 3b) was the commonest body part injured (160 out of 193 cases; 83%), followed by the face (29 out of 193; 15%; Figure 3c). Sixty percent of bony injuries were to the thumb, and 67% were due to stringbombs. The hand is prone to injury because it is closest to the firework at the time of lighting. Another reason is the malpractice of holding the firework in the hand while lighting. The hand has been the most commonly injured body part in other
(continued).
studies.4,11 Of the two lower limb injuries in our study, one patient was in squatting posture when a stringbomb ignited near his foot; the other sustained burns of the hand and legs due to an aerial device falling from above, igniting his clothes. The trunk was injured when a patient pocketed a firework, considering it doused. The face is also prone to injury if the person lighting the firework bends over it to watch it closely. Facial injury has been found to be common in many studies. Studies by Berger et al,1 Fogarthy and Gordon,4 Smith et al7 and Witsaman et al8 found eye injury to be the commonest. Facial injury occurred in only 15% of cases in our study. One of the patients burnt gunpowder over paper, causing flash burns to his face. In another case, as the person was leaning over the firework, delayed withdrawal from the lit firework led to facial injury. Soft tissue injury of the face was caused in a patient under the influence of alcohol who put a small cracker in the mouth and lit it, mistaking it as a cigarette; his lower lip was severely damaged (Figure 3d).
Summary For prevention of these avoidable injuries, children aged <5 years should be prohibited from handling fireworks; those aged 5e14 years should be supervised by adults and educated about safe handling of fireworks in schools; those aged 15e24 years should be educated regarding firework hazards; and adults should behave responsibly and supervise younger people. Fireworks should be subject to strict standardisation, and only standardised fireworks should be marketed. Manufacturer’s recommendations regarding mode of lighting, expected time to blast, and age group who can use it safely must be printed on the packaging. Personal use of fireworks should be discouraged and more
Firework injuries: a ten-year study public displays arranged. The general public should be encouraged to use other safe ways of celebration. Use of fireworks is a very deep-rooted tradition in India, and many people make a living from this activity. Banning this practice may be impractical, but good quality control should help. An ideal solution remains to be found but, until then, the number and severity of accidents can be minimized by providing advice to the community regarding safety precautions, encouraging professional displays and motivating the manufacturers to adhere to strict quality control.
References 1. Berger LR, Kalishman S, Rivara FP. Injuries from fireworks. Pediatrics 1985;75:877e82. 2. Clarke JA, Langley JD. Firework related injury in New Zealand. N Z Med J 1994 Oct. 26;107:423e5. 3. Vassilia K, Eleni P, Dimitrios T. Firework-related childhood injuries in Greece: a national problem. Burns 2004 Mar;30: 151e3.
1111 4. Fogarty BJ, Gordon DJ. Firework related injury and legislation: the epidemiology of firework injuries and the effect of legislation in Northern Ireland. Burns 1999;25:53e6. 5. Abdulwadud O, Ozannesmith J. Injuries associated with fireworks in Victoria; an epidemiological overview. Inj Prev 1998 Dec;4:272e5. 6. Mehta Devesh, Suri Manav, Patel Chintan, et al. Fireworks injuriese epidemiology & prevention. Indian Journal of Burns 2004;12:48e50. 7. Smith GA, Knapp JF, Barnett TM, et al. The rockets red glare, the bombs bursting in air; fireworks related injuries to children. Pediatrics 1996 Jul;98:1e9. 8. Witsaman RJ, Comstock RD, Smith GA. Pediatric Fireworks related injuries in the United States: 1990-2003. Pediatrics 2006 July;118:296e303. 9. McFarland LV, Harris JR, Kobayashi JM, et al. Risk factors for fireworks-related injury in Washington State. JAMA 1984;251: 3251e4. 10. Singh S. Sparklers as major hazard for burn injury. Burns 1997; 23:369e72. 11. American Academy of Pediatric: Committee on Injury and Poison Prevention. Fireworks e related injuries to children. Pediatrics 2001 July;108:190e1.
REVIEW
Firework injuries: a ten-year study Vinita Puri*, Sanjay Mahendru, Roshani Rana, Manish Deshpande Department of Plastic, Reconstructive Surgery and Burns, Seth G.S. Medical College and King Edward Memorial Hospital, Parel, Mumbai e 400 012, INDIA Received 28 July 2007; accepted 22 December 2007
KEYWORDS Fireworks; Firecrackers; Firework injuries in India; Diwali injuries; Blast injuries
Summary Fireworks are used worldwide to celebrate popular events (e.g. festivals, official celebrations, weddings). The festival of lights (Diwali) is celebrated with fireworks in India. During this period, many patients from all age groups present to hospital with injuries due to fireworks. Prevalence, period of occurrence, sex and age variation, adult supervision, causative fireworks, mode of lighting, age groups prone to injury, patterns of injury caused by individual fireworks, and the body parts injured were studied. One hundred and fifty-seven cases (92 retrospective, 65 prospective) with injury due to fireworks presenting to the Department of Plastic Surgery at KEM Hospital between 1997 and 2006 were studied. The prevalence of injuries has decreased steadily over the last 10 years (41 cases in 1997, 3 cases in 2006). The maximum number of injuries (35%) was seen in the age group 5e14 years; 92% of these children were unsupervised. The commonest cause of injury was firework misuse (41% of cases), followed by device failure (35%). Device failure was commonest with flares/ fountains (ground firework emitting sparks upwards) and aerial devices. Flare/fountains caused most injury (39%), sparklers the least (0.6%). Flare/fountains, ground spinners, sparklers, and gunpowder (explosive material from cracker, obtained by tearing paper wrapper and obtaining chemicals) caused only soft tissue burns; stringbombs (high-intensity fire cracker made by wrapping chemicals with jute strings/coir in layers) and rockets (aerial device that zooms upwards and bursts) caused blast injuries, leading to soft tissue disruption and bony injuries. Emergency surgery was done if indicated: tendon and/or neurovascular repair, fracture fixation, flap cover or amputation. Superficial burns were treated with dressings. Certain wounds needed only thorough cleansing of the wound and primary suturing. We concluded that, over a 10-year period, the prevalence of firework injury decreased due to increased awareness in the community. Aggressive awareness campaigns by government and non-government organisations was the cause. We can minimise the number and severity of
* Corresponding author. Tel.: D91 22 24136051; fax: þ91 22 24143435. E-mail addresses: [email protected], [email protected] (V. Puri). 1748-6815/$ - see front matter ª2009British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.12.080
1104
V. Puri et al. accidents by raising awareness regarding safety precautions, encouraging professional displays and motivating manufacturers to adhere to strict quality control. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Fireworks are used worldwide to celebrate popular events (e.g. festivals, official celebrations, weddings). The festival of lights (Diwali) is celebrated with fireworks in India (Figure 1), but Diwali may lead to anguish due to firework-related accidents. In India, an increasing number of organizations have raised awareness about the proper use and danger of fireworks (Figure 2). Education is disseminated via newspapers, magazines, television, posters, pamphlets and booklets. In schools, children are educated regarding safety precautions. Nevertheless, many individuals suffer due to inadequate safety measures taken during the preparation and use of fireworks.
Materials and methods We studied 157 consecutive cases with injury due to fireworks presenting to the Department of Plastic Surgery
at KEM Hospital from 1997 to 2006. Data from 1997 to 1999 (92 cases) were studied retrospectively; data from 2000 to 2006 (65 cases) were studied prospectively. The history of injury was obtained from the patient or accompanying persons (in the case of children). Patients were separated into five groups according to age. This was on the basis of behavioural characteristics at a particular age: children aged <5 years of age are usually unaware of firework hazards children aged 5e15 years, though aware, are inquisitive and typically active, and therefore prone to injury young adults aged 15e25 years tend towards adventurous and reckless behaviour, and are therefore prone to accidents adults aged 25e45 years are considered to be mature
Figure 1 a Various types of fireworks. Flares/fountain, stringbomb (high-intensity fire cracker made by wrapping chemicals with jute strings/coir in layers), aerial device (bottle rocket), cracker (exploding device) and sparkler. b Flares/fountain after lighting. c Ground spinner after lighting.
Firework injuries: a ten-year study
1105
Figure 2
Print campaigns.
adults 45 years are not actively involved in firework manipulation. Presence/absence of adult supervision was noted in patients aged <15 years. The month of injury, the type of firework and mode of lighting were also noted. The cause of injury could be identified only in prospective cases (2000e2006) and were grouped into four types: misuse behaviour (e.g. holding firework in hand while lighting, altering fireworks, being too close to firework, picking up misfired firework for reuse) device failure (firework behaved in an unpredictable way) personal failure (delayed withdrawal from lit firework or improper lighting) innocent victims and bystanders. Injuries were classified as burns; contused lacerated wounds (CLWs); soft tissue injury (STI; e.g. avulsion, crush, tendon, neurovascular); and bony injuries. Emergency surgery was done if indicated: tendon and/or neurovascular repair, fracture fixation, flap cover or amputation. Superficial burns were treated with dressings. Certain wounds needed only thorough cleansing of the wound and primary suturing.
Results The number of patients with firework injuries treated by KEM Hospital in each year is shown in Table 1; there is a considerable decline from 1999 onwards.
Of the 157 cases, 150 presented during the festival season (October and November; Table 2). Prevalence was higher in males (87%) than females (13%; 7:1). Table 3 details the number of cases according to age group. Thirty-five percent of patients were aged 5e14 years, 28% were 15e24 years, and 25% were 25e44 years. Of the 66 children aged <15 years, only five were supervised by adults, 92% were unsupervised. Of the 11 cases aged <5 years, only one was supervised. Sparklers, incense sticks, matchsticks and candles were most commonly used to light fireworks. The mode of lighting could not be ascertained in 25 cases.
Table 1
Incidence of fireworks injury
Year Retrospective 1997 1998 1999 Prospective 2000 2001 2002 2003 2004 2005 2006 Total
Number of cases 41 40 11 18 15 11 5 0 13 3 157
1106 Table 2
V. Puri et al. Period of occurrence
Year
Jan
Feb
Mar
Apr
May
Jun
July
Aug
Sept
Oct
Nov
Dec
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Total
e e e e 1 e e e e e 1
e e e e e e e e e e e
e e e e e e e e e e e
e e e e e e e e e e e
e e e e 1 e e e e e 1
e e e e e e e e e e e
e e e e e e e e e e e
e e e e e e e e e e e
e e e e 3 1 e e e e 4
e 25 11 e 8 1 e e 13 3 61
41 15 e 18 1 9 5 e e
e e e e 1 e e e e
89
1
Prospective cases (65 patients) were included in evaluation of injury cause because detailed data regarding injury cause was unavailable in retrospective cases. Table 4 shows the various causes of injury identified in these prospective cases. Forty-one percent of patients were injured due to firework misuse, the commonest reason being handheld fireworks. Device failure was the next commonest cause of injury (35%). Of the remaining cases, 17% were due to personal failure and four patients (6.1%) were injured as innocent victims. For example, one patient was sleeping in a hut outside a stadium where celebrations were occurring. A device fired from the stadium fell through the roof of his hut. He picked it up to throw it out but it exploded, causing a blast injury to his hand. Various age groups had different causative factors of injury. Table 5 shows that misuse (handheld) and personal failure (delayed withdrawal from ignited firework) was common in children until the age of 14 years, and device failure (unexpected blast) was common in the age group 15e24 years. Multiple body parts were injured in 15 cases. The hand was most commonly injured (131 injuries, 74%), followed by the face (33 injuries, 19%), trunk (8 injuries, 4.5%) and lower limb (4 injuries, 2.3%). Table 6 shows the type of firework causing injury and the various injuries caused. Flare/fountains were the commonest (39%), followed by stringbombs (23%); sparklers were the least (0.6%). Flare/fountains, ground spinners, sparklers, and gunpowder caused only burns, whereas others caused a combination of injuries. Stringbombs, crackers and rockets caused not only burns, but also CLWs, soft tissue injuries and bony injuries.
Table 3
Age distribution
Age group (Years)
Number of cases n Z 157
Percentage
<5 5e14 15e24 25e44 45
11 55 44 39 8
7 35 28 25 5
Discussion The prevalence of firework injury has decreased over the last 10 years in India. The decline is welcome and the reasons are not difficult to assess. Increased public awareness due to aggressive campaigning by government and non-government organisations is the cause, but injuries still occur during Diwali. Age distribution (Table 3) Our study showed that the age groups 5e14 years and 15e24 years collectively comprised 99 out of 157 (63%) of injuries. This could be due to the typically active, enthusiastic, experimental nature of children (age 5e14 years) and the adventurous young adults aged 15e24 years who are prone to risky behaviour. For example, a 20-year-old male inserted the tip of an umbrella rod into a firecracker and lit it. The resultant blast split the umbrella rod, the force was transmitted proximally, and his index finger was completely degloved. In our study, patients aged <14 years formed 42% of cases, whereas other documented studies showed results of 51%,1 68%,2 and 70%3 in the same age group. Clarke and Langley2 showed a maximum number of cases in the upper spectrum of children aged <15 years.
Table 4 study)
Prevalence of various causes of injury (prospective
Cause
Cases (n Z 65)
Percentage
Misuse Handheld (HH) Altered firework (AFW) Close watch (CW) Pick up spent firework (PU) Device failure Unexpected blast (UB) Erratic flight (EF) Personal failure Delayed withdrawal (DW) Incorrect use (IU) Innocent victim
27 15 3 5 4 23 19 4 11 10 1 4
41.5
35.4
17
6.1
Firework injuries: a ten-year study Table 5
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Relationship of injury cause and age (prospective study)
Cause
Number of cases <5 years
5e14 years
15e24 years
25e44 years
>45 years
Misuse (MU) e Handheld firework Misuse (MU) e Altered firework Misuse (MU) e Close watch Misuse (MU) e Spent firework Device failure (DF) eUnexpected blast Device failure (DF) - Erratic flight Personal failure (PF) eDelayed withdrawal Personal failure (PF) eImproper use Innocent victim
1 e e e 3 e 2 e e
6 1 5 4 3 1 6 e 1
3 1 e e 8 e e 1 2
5 1 e e 4 2 2 e e
e e e e 1 1 e e 1
Total
6
27
15
14
3
The mean age of patients in our study was 19.8 years. The mean age was 14 years in a study in Northern Ireland by Fogarty and Gordon4; 8.9 years in a study in Australia by Abdulwadud and Ozannesmith5; and 11.6 years in a study in India by Mehta et al.6 Prevalence according to sex 134 (87%) of cases were males; they are more inclined towards high-risk behaviour. In India, women are busy with household duties while men, along with children, play with fireworks. Our finding is consistent with other studies,1,4,5,6,7 in which the injured male population was 71e93%. Adult supervision 92% of children were unsupervised. Only one child out of 11 was supervised in the <5 years age group. A study by Mehta et al6 found that 78% of children suffering injuries were unsupervised. In a study done in the USA,7 54% of children were supervised. Along Table 6 Relationship between firework type and injuries (prospective study) Firework
Number Number of injuries of cases Burn CLW Soft Bony Total tissue Injury injury
Flare/fountain
61 38.8% Ground spinner 3 1.9% Sparkler 1 0.6% Stringbomb 37 23.5% Cracker 29 (others) 18.4% Rocket 6 3.8% Aerial (others) 3 1.9% Gunpowder 7 4.5% Unknown 10 6.5% Total
157
64
0
0
0
3
0
0
0
64 (33%) 3
1
0
0
0
1
25 12
9
11
22
9
2
1
2
3
1
1
3
1
0
3
7
8
0
0
0
8
10
0
1
1
12
138 25
13
17
193
57 (29.5%) 34 (17.6%) 7
with awareness/education in schools regarding firework hazards, raising awareness among parents is equally important. Modes of lighting Various materials were used to light fireworks (e.g. sparklers, incense sticks, candles, matchsticks, lamps, paper, flare/fountains). In one case, a stringbomb was lit with a sparkler, causing a premature explosion possibly due to the sparkler lighting at multiple points. In three patients, a lit flare/fountain was used to light another flare/fountain. These were classified as ‘misuse behaviour’. Manufacturer recommendations on the box advising the mode of lighting the cracker would help curtail this type of injury. Cause of injury (Table 4) and its relationship to age (Table 5) Misuse (41%) was followed by device failure (35%) as the commonest cause of injury. Children aged <5 years were commonly injured by personal failure (delayed withdrawal from ignited firework) and device failure (early or late blast). The age group 5e14 years showed all types of misuse behaviour, as well as personal failure (delayed withdrawal). Misuse behaviour was rampant in the age group 5e24 years using flare/fountains and crackers (particularly stringbombs). Holding a firework in the hand is extremely dangerous, and may cause injury due to fuse failure or delayed human reaction. Injury is less likely if the firework is on the ground. Alteration of fireworks, close proximity to lighted fireworks, and picking up misfired fireworks should be condemned. It may be common in the lower socio-economic class because they cannot afford to buy enough fireworks. This group should be targeted for educational campaigns in schools and the media. They should be taught the dangers of fireworks and the harmful effects of chemicals used. While playing with fireworks, there should be strict adult supervision not only during lighting, but also when choosing fireworks. They should be taught safety precautions and the importance of strict adherence to them. Device failure was the cause of injury in 16 out of 32 cases (50%) in those aged >15 years. These injuries may be controlled to some extent if manufacturing and sales processes are standardized through legal restrictions. This age group has been using fireworks for many years, leading to a misplaced confidence in handling fireworks. Some may also tend towards high-risk behaviour, which sets a wrong example for younger children who may imitate it, but who
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Figure 3 a Tattooing due to gunpowder (pre- and postoperative). b Blast injuries to the hand due to a stringbomb. c Face burns due to bending over fountain while lighting it. d Lower lip rupture due to lighting a cracker under the influence of alcohol, after mistaking it as a cigarette.
may not be able to act swiftly and safely in an emergency. Adults should be made aware of the severity of injury that fireworks can cause. Most are misinformed that fireworks cause only minor burns. They should be made aware of the devastating fractures, neurovascular injuries, amputations and functional and cosmetic deformities for which patients
may have to undergo a number of surgeries. This may help not only to deter adults from reckless use of fireworks, but also encourage them in supervising children using fireworks. Type of firework causing injury (Table 6) Flare/fountains were the fireworks that caused injury to most people (61 out of 157 of cases; 39%). Stringbombs were responsible
Firework injuries: a ten-year study
1109
Figure 3
for injury in 37 out of 154 cases (23%), mostly due to misuse (e.g. holding firework in hand while lighting). A study by Mehta et al6 showed flare/fountains to be the cause of injury in only 10% of cases, whereas crackers accounted for 34% of cases. Flare/fountains, due to composition and design, throw sparks like a fountain after ignition. These flare/fountains are at risk of explosion, or they may change direction while emitting sparks. Flare/fountains are widely misused because they are considered to be safe. Dangerous practices such as holding it in the hand while lighting, holding it in hand and directing the sparks, lighting one flare/ fountain with another flare/fountain, and bending over it while lighting it, are very common. In our study, injury cause could be ascertained in 16 cases of flare/fountain injuries. Of these flare/fountain injuries, 56% were due to device failure (unexpected explosion) and 25% were due to misuse (e.g. holding it in the hand). A study in Washington state by McFarland et al9 also found that ground display
(continued).
fireworks emitting sparks are the commonest cause of injury (36%), followed by crackers (34%), similar to our study. Similar to the study by Mehta et al,6 Fogarthy and Gordon4 and Witsaman et al8 found bangers (63%) and crackers (29.6%) to be the fireworks causing injury to most people. Flare/fountains should be subject to strict standardisation because a sub-standard flare/fountain is prone to explode unexpectedly. Ground spinners and sparklers were relatively safe, causing burns only due to personal failure. Stringbombs and other crackers caused all types of injuries due to misuse behaviour and personal failure, which are controllable factors. Aerial devices, including rockets, caused injuries due to erratic flight. Aerial devices should be banned or at least standardised so that they have a fixed direction of trajectory, and components do not fall off when it explodes in the air. Type of injuries and firework All the injuries caused by flare/fountains were burns, 88% of which were to the
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V. Puri et al.
Figure 3
hands. Ground spinners also caused only hand burns. Sparklers caused injury only in one case, a face burn. In the UK,10 sparkler burns have been increasing in number over the years. Stringbombs caused burns in 44% of cases, compared with CLWs (21%), soft tissue loss (16%) and bony injuries (19%). In our study, gunpowder injuries (Figure 3a) caused only burns (six cases of hand burns, one face burn, and one abdominal burn). Injury type: Injuries are often a combination of burns, lacerations, abrasions, soft tissue losses, and bony injuries. In our study of 193 injuries, burns were the commonest (72%). Burns were the leading injury, followed by blast injury, in other studies.1,5,7,8 In a study by Fogarty and Gordon,4 blast injury was the commonest injury (53% of cases). In our study, blast injury accounted for 28% of total injuries, and was subdivided into CLWs, soft tissue losses (including neurovascular injuries) and bony injuries. Of all burn injuries, 80% were hand burns, followed by facial burns (19%). Other burnt areas were trunk, feet, and shoulders. Minor burns were the commonest injury and were treated conservatively, but more serious injuries cannot be ignored, even though they were few. These included finger fractures, neurovascular and soft tissue damage requiring multiple surgery and sometimes leading to amputation, disfigurement and functional disabilities. Body part injured: In our study, the hand (Figure 3b) was the commonest body part injured (160 out of 193 cases; 83%), followed by the face (29 out of 193; 15%; Figure 3c). Sixty percent of bony injuries were to the thumb, and 67% were due to stringbombs. The hand is prone to injury because it is closest to the firework at the time of lighting. Another reason is the malpractice of holding the firework in the hand while lighting. The hand has been the most commonly injured body part in other
(continued).
studies.4,11 Of the two lower limb injuries in our study, one patient was in squatting posture when a stringbomb ignited near his foot; the other sustained burns of the hand and legs due to an aerial device falling from above, igniting his clothes. The trunk was injured when a patient pocketed a firework, considering it doused. The face is also prone to injury if the person lighting the firework bends over it to watch it closely. Facial injury has been found to be common in many studies. Studies by Berger et al,1 Fogarthy and Gordon,4 Smith et al7 and Witsaman et al8 found eye injury to be the commonest. Facial injury occurred in only 15% of cases in our study. One of the patients burnt gunpowder over paper, causing flash burns to his face. In another case, as the person was leaning over the firework, delayed withdrawal from the lit firework led to facial injury. Soft tissue injury of the face was caused in a patient under the influence of alcohol who put a small cracker in the mouth and lit it, mistaking it as a cigarette; his lower lip was severely damaged (Figure 3d).
Summary For prevention of these avoidable injuries, children aged <5 years should be prohibited from handling fireworks; those aged 5e14 years should be supervised by adults and educated about safe handling of fireworks in schools; those aged 15e24 years should be educated regarding firework hazards; and adults should behave responsibly and supervise younger people. Fireworks should be subject to strict standardisation, and only standardised fireworks should be marketed. Manufacturer’s recommendations regarding mode of lighting, expected time to blast, and age group who can use it safely must be printed on the packaging. Personal use of fireworks should be discouraged and more
Firework injuries: a ten-year study public displays arranged. The general public should be encouraged to use other safe ways of celebration. Use of fireworks is a very deep-rooted tradition in India, and many people make a living from this activity. Banning this practice may be impractical, but good quality control should help. An ideal solution remains to be found but, until then, the number and severity of accidents can be minimized by providing advice to the community regarding safety precautions, encouraging professional displays and motivating the manufacturers to adhere to strict quality control.
References 1. Berger LR, Kalishman S, Rivara FP. Injuries from fireworks. Pediatrics 1985;75:877e82. 2. Clarke JA, Langley JD. Firework related injury in New Zealand. N Z Med J 1994 Oct. 26;107:423e5. 3. Vassilia K, Eleni P, Dimitrios T. Firework-related childhood injuries in Greece: a national problem. Burns 2004 Mar;30: 151e3.
1111 4. Fogarty BJ, Gordon DJ. Firework related injury and legislation: the epidemiology of firework injuries and the effect of legislation in Northern Ireland. Burns 1999;25:53e6. 5. Abdulwadud O, Ozannesmith J. Injuries associated with fireworks in Victoria; an epidemiological overview. Inj Prev 1998 Dec;4:272e5. 6. Mehta Devesh, Suri Manav, Patel Chintan, et al. Fireworks injuriese epidemiology & prevention. Indian Journal of Burns 2004;12:48e50. 7. Smith GA, Knapp JF, Barnett TM, et al. The rockets red glare, the bombs bursting in air; fireworks related injuries to children. Pediatrics 1996 Jul;98:1e9. 8. Witsaman RJ, Comstock RD, Smith GA. Pediatric Fireworks related injuries in the United States: 1990-2003. Pediatrics 2006 July;118:296e303. 9. McFarland LV, Harris JR, Kobayashi JM, et al. Risk factors for fireworks-related injury in Washington State. JAMA 1984;251: 3251e4. 10. Singh S. Sparklers as major hazard for burn injury. Burns 1997; 23:369e72. 11. American Academy of Pediatric: Committee on Injury and Poison Prevention. Fireworks e related injuries to children. Pediatrics 2001 July;108:190e1.