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Research: Research Article

Increases in Firework-Related Upper Extremity Injuries Correspond to Increasing Firework Sales: An Analysis of 41,195 Injuries Across 10 Years

Morrissey, Patrick J. BA; Scheer, Ryan C. BS; Shah, Neil V. MD, MS; Penny, Gregory S. MD; Avoricani, Alba BA; Koehler, Steven M. MD

Author Information
Journal of the American Academy of Orthopaedic Surgeons: July 1, 2021 - Volume 29 - Issue 13 - p e667-e674
doi: 10.5435/JAAOS-D-20-00201
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Abstract

Fireworks represent a diverse group of products ranging from simple incendiary compounds to complex multicomponent combustible devices with shells/fragmentary constituents.1 With such a wide variety of products currently on the market, operator misuse is common.2,3 As a result, injury can occur to both the individual using the device and spectators within the vicinity.3,4 These injuries can be devastating, resulting in significant pain and permanent disability. In addition to patient morbidity, firework injuries are associated with substantially increasing healthcare expenditure, with annual costs over $100 million.5,6

Of the associated bodily injuries, the hand and upper extremity are most likely to be affected, representing 32% of all insults.2,3,7 These injuries represent a broad spectrum of pathologies, including burn, fracture, dislocation, and partial or complete amputation (Figure 1).8-10 Such conditions often require acute surgical management, with some even necessitating secondary surgical interventions for revision and reconstruction.7,8,11-13

F1
Figure 1:
Clinical photographs of two patients following blast injuries to their upper extremity following firecracker explosion. A, Near-complete amputation of the left thumb at the metacarpophalangeal joint and deep laceration down to the index finger flexor mechanism. B, Mangled left hand, including near-complete amputation of the thumb, amputation of the index finger, and degloving injury of the long finger with dysvascular digits and tendon avulsions.

In response to this public health issue, both the American Society for Surgery of the Hand and the Centers for Disease Control have released bulletins cautioning against the use of fireworks.2,14 Despite such advisory advisements and the inherent danger of firework use, the industry continues to grow. Between 2008 and 2017, the American Pyrotechnics Association (APA) reported a 41% increase in revenue from firework sales, with total sales of $885 million in 2017.15 Given the public health risks and increasing popularity of these devices, we sought to examine the temporal trend in prevalence, epidemiology, injury type, and location of upper extremity firework injuries in the United States. We hypothesized that increasing sales, as a surrogate for use of firework products, would correlate with increased prevalence of upper extremity injury.

Methods

Data Source

We conducted a review of the National Electronic Injury Surveillance System (NEISS), a product of the US Consumer Product Safety Commission (CPSC). The NEISS is a nationally representative probability sample of hospitals in the United States and its territories, which collects injury-related data from approximately 100 emergency departments (EDs).16 At participating hospitals, critical demographic and injury-related information is collected from patients during their ED visit. An NEISS coordinator reviews all ED records daily and codes visits based on the NEISS Coding Manual for inclusion into the national data set. Coders include demographic data, cause/mechanism of injury, intent of injury, and principal diagnosis in a manner consistent with the International Classification of Diseases, Ninth Revision, Clinical Modification coding rules and guidelines. Once data are transmitted to the NEISS, they undergo additional quality assurance review by trained coders. Each case is assigned a weight based on the hospital's size and location. National injury incidence estimates are calculated by summing the weights of a particular injury type or pattern over a specific time period.17

Data on consumer firework usage (approximated by sales revenue figures) were extracted from publicly available annual reports from the APA, a 70-year-old industry-run publication.18

Extracted Variables

The NEISS was queried for firework-related injuries of the upper extremity reported between January 1, 2008, and December 31, 2017. Product codes for Fireworks (1313) and Flares (1718), as well as the following body location filters (shoulder [30], elbow [32], lower arm [33], wrist [34], upper arm [80], hand [82], and finger [92]), were used. Incidence, temporal trends, patient demographics (ie, sex and age), injury type (ie, burns, avulsion, fracture, laceration, puncture, amputation, and other), location (ie, shoulder, elbow, upper and lower arm, wrist, hand, and finger), and disposition (ie, treated and released, admitted, transferred to another hospital, left against medical advice, and held for observation) were collected. Narrative text fields were reviewed using text analysis formulas to determine the finger or fingers involved in each injury and burn severity (eg, partial versus full-thickness). Cases that could not be categorized by this method were reviewed manually (<5%); all manually reviewed records were also reviewed by the senior author for confirmation/accuracy, with no discrepancies identified. Text analysis was performed using Microsoft Excel (Microsoft).

Statistical Analysis

Descriptive statistics were reported as either percentages or as means with standard deviations. Proportions of the different upper extremity injury types and locations were computed. Temporal trends were analyzed by summing the injury incidence per year (sum of weights) and performing linear regression analysis of these sums. Spearman rank-order correlation was used to compare year-by-year changes in national firework sales revenue, as reported by the APA, versus national firework-related injury incidence per NEISS. All statistical analyses were performed using SPSS version 25 (IBM Corp) while using a P value <0.05 as threshold for statistical significance.

Results

A total of 1,079 patients, representing an estimated 41,195 firework-related upper extremity injuries, presented to US EDs from 2008 to 2017. The overwhelming majority of firework-related injuries were observed in males, at 77%. The 11 to 19 (n = 10,923; 26.5%) and 20 to 29 (n = 10,171; 24.7%) age groups represented roughly half of injuries (Table 1). The 10 and under (n = 7,239; 17.6%), 30 to 39 (6,916; 16.8%) and 40+ (n = 5,947; 14.4%) age groups shared the remaining injury burden. The average age of injured persons was 23.5 years, and the distribution of injuries demonstrated a positive skew.

Table 1 - Location and Age Bracket of All Firework-Related Hand/Upper Extremity Injuries Between 2008 and 2017
Factor All Ages 10 and Under 11-19 20-29 30-39 40+
n 41,195 7,239 10,923 10,171 6,916 5,947
% 100 17.6 26.5 24.7 16.8 14.4
Hand 21,712 2,649 5,895 5,545 4,159 3,464
Finger 13,643 2,968 3,615 2,974 2,189 1,896
Wrist 687 107 248 269 47 16
Elbow 228 43 31 71 68 15
Lower arm 2,900 858 848 831 157 205
Upper arm 1,334 591 233 154 101 255
Shoulder 692 22 54 327 193 96
Total 41,195 7,239 10,923 10,171 6,916 7,156

The estimated number of injuries increased significantly from 2,576 in 2008 to 5,101 in 2017 (R2 = 0.85, R = 0.92, P < 0.001) (Figure 2). The 10 and under and 20 to 29 age groups both experienced significant increases in injuries over the study period (401-891, P = 0.019 and 649-1,213, P < 0.001, respectively). Injuries in the 11 to 19 (778-1,345, P = 0.08), 30 to 39 (302-947, P = 0.085), and 40+ (446-706, P = 0.65) age groups also increased, though not significantly (P > 0.05). A Spearman rank-order correlation determined that there was a strong, positive correlation between the increase in yearly firework sales revenue and the increase in injuries (rs = 0.939, P < 0.01).

F2
Figure 2:
Firework-related hand/upper extremity estimated injury incidence between 2008 and 2017, broken down by sex, with trend in annual consumer firework sales revenue depicted.

The most common race reported by injured patients was Caucasian (n = 24,346; 59.1%), followed by African American (n = 3,087; 7.4%) and Hispanic (n = 2,255; 5.5%). The hand (21,712, 52.7%) and finger (13,643, 33.1%) were the most commonly injured body parts, followed by the forearm (4,234, 10.3%) and wrist (687, 1.7%) (Table 2). Among finger injuries, the thumb was most commonly injured (n = 6,998; 51.3%), followed by the index finger (n = 3.134; 22.3%) and combined thumb-index injuries (n = 530; 3.9%). The middle (n = 734; 5.4%) and ring (n = 572; 4.2%) fingers were involved in a minority of accidents, and no small finger injuries were reported. All other injuries were either multifinger or not well categorized (n = 2,206, 16.2%). Most injuries occurred between June and August (n = 31,582; 76.7%).

Table 2 - Location and Mechanisms of All Firework-Related Hand/Upper Extremity Injuries Between 2008 and 2017
Body Site All Ages Burns Amputation Avulsion Fracture Laceration Puncture Other
Hand 21,712 16,305 308 47 796 2,487 160 878
Finger 13,643 8,758 1,640 240 1,260 1,094 106 390
Wrist 687 187 0 0 232 0 15 87
Elbow 228 120 0 0 22 16 0 0
Lower arm 2,900 2,021 0 72 182 148 6 162
Upper arm 1,334 803 0 0 90 107 103 71
Shoulder 692 428 0 0 102 0 0 117
Total 41,195 28,622 1,949 358 2,683 3,852 390 1,703

Burns were the most common injury type (28,662, 69.6%). Detailed data on the clinical extent of burns were available for 11,889 (41%) of all reported injuries. Of those, 1,982 (16.7%) were superficial (first degree), 8,158 (68.6%) were partial thickness (second degree), and 1,749 (14.7%) were full thickness (third degree). The next most common type of injury was laceration (n = 3,852; 9.3%), followed by fracture (n = 2,683; 6.5%) and amputation (n = 1,949; 5%). Burn injuries were most common across all body sites except the wrist, where fractures were more common (Table 2). The most common site of amputation was the finger (n = 1,640).

Disposition data revealed five outcomes: treated and released (84.0%), admitted (7.1%), transferred to another hospital (7.4%), left against medical advice (1.1%), and held for observation (<1%). The estimated number of admitted or transferred patients increased from 349 in 2008 to 878 in 2017 (R2 = 0.43, R = 0.66, P = 0.038). The proportion of patients requiring either admission or transfer remained stable throughout the study period. The diagnoses leading to the highest proportion of admitted patients were amputation (75.0%), fracture (39.0%), and full-thickness burns (37.0%).

Discussion

Over 250 million pounds of fireworks were sold in the United States in 2017, accounting for $885 million in consumer revenue.3,15 Given the increase in prevalence of injuries attributed to such devices over the past decade, we sought to examine the epidemiologic impact rising firework sales have had on the amount and type of upper extremity injuries in the United States during this time period.

Firework-related laws are legislated at the state level. As the focus of this study was the US cohort as a whole, and due to lack of granularity in the data set regarding state of injury, epidemiologic trends across the individual 50 states could not be assessed. However, there are state-level data that demonstrate how loosening of firework restrictions can be detrimental to the cohort.15,19,20 For example, studies from Washington and West Virginia state health systems demonstrated an increase in firework-related injuries following legislation, making these items more readily available.19,20 Of note, Arizona, Rhode Island, New York, New Jersey, Kentucky, Utah, New Hampshire, Maine, Michigan, Georgia, West Virginia, and Iowa have all liberalized firework laws during the timeframe in which this study took place (2008 to 2017).15 To date, only Massachusetts maintains a total ban on consumer firework sales.15

Widespread legalization has proven to be a double-edged sword. Industry experts argue that legalization of fireworks helps keep dangerous, illegal devices, such as quarter sticks, cherry bombs, and silver salutes off of the market and out of the public.15,21 Meanwhile, the CPSC continues to make updated recommendations to maintain public safety. For example, recent guidelines mandate that these devices must be devoid of harmful compounds, emit a limited external flame, and detonate between a specific time interval so as to avoid operator misuse.22 Nonetheless, increased consumer availability has led to a 41% increase in firework revenues from 2008 to 2017, thus making these items more readily available; as such, it is not unreasonable to suspect that this increase has contributed to increased rates of injury presented in this study.15

The present study's focus on the upper extremity in the context of firework usage allowed for a granular examination of firework-related injuries. Moreover, it addresses a paucity of population-level data examining injuries to the hand/wrist as a result of firework use in the United States. In the United States, most studies are retrospective in nature and evaluate cohorts that range from 7 to 105 patients.7,8,13 A study out of the Netherlands reported a similarly high incidence of upper extremity burns secondary to firework accidents (69%)23; the present study demonstrated a 79% predominance of burns to this body region. It is important to note that the management of these injuries can be quite complicated. Burn injuries to the hand/digits can lead to neurovascular compromise, rendering surgical repair difficult, increasing length of hospital stays, and worsening long-term function.4,7,8,10,12,13,24,25 Our study demonstrated most upper extremity injuries occurring at the level of the hand (52.7%) and digits (33.1%). More than half of these insults involved the thumb. While not surprising, this is a devastating finding given the thumb's importance in prehension and overall function of the hand.26 Ortiz et al8 reported a median of four surgeries required for effective repair of first web space soft-tissue injury or thumb fracture and/or traumatic amputation. These findings were supported by Sandvall et al,7 who observed that 84% of patients in their cohort of 105 sustained thumb and/or first web space injuries, with 25% of hands requiring revision amputation of the thumb and a range of 1 to 7 surgeries required for acute reconstruction (nearly 20% required 3 or more surgeries). Although illegal firework use is declining, increased consumer education and outreach for the current products on the market is required to decrease future burn injuries.3,27

It is imperative to identify high-risk months for firework injury. Although the CPSC reported in 2018 that 62% of all firework injuries occurred between June 22 and July 22, our study indicated that over 75% of these injuries occurred between the months of June and August.3 However, it may be more important to focus efforts toward increased awareness and counseling around times of celebration, which vary across cultures.2,5,24,28-31 For example, mass education programs in preparation for the Persian Fire Festival, which rings in the Iranian New Year, were shown to decrease the burden of injuries related to this celebration.29 In addition, public health initiatives could be deployed to increase public awareness of the hazards of fireworks and to improve handling safety. Product label warnings used on cigarettes, particularly those with graphic imagery, have led to greater avoidance of these products and may be used to similar effect with firework labeling.32-34 Focused advertising campaigns and school-based interventions, as used in motor vehicle and substance avoidance programs, may also be considered. In this context, policy-based interventions restricting the availability and type of fireworks seem to be of particular benefit. Myers et al10 concluded that the liberalization of firework laws in the United States has had a moderate effect on the incidence of firework-related injuries in the pediatric cohort and a dramatic negative effect on the severity of such injuries. Accordingly, states in which consumer fireworks are banned or heavily restricted have significantly decreased rates of firework injury compared with those in which consumer access is not restricted.35 Similarly, banning of fireworks in other countries has led to decreased rates of ocular firework injury.31,36,37

Although most firework injury studies focus on the pediatric cohort, our analysis included all age brackets. Surprisingly, most of the patients injured were older than 20 years. This represents a shift in patient demographics from the study by Moore et al,11 examining firework injuries using the same database from 2000 to 2010. This shift is predominantly reflected by the significant increase in injuries to patients aged 20 to 29 years and should have major implications for and warrant further prevention campaigns in the adult firework-using cohort.

Given the vast and growing usage of fireworks in the United States, it is important to quantify the societal costs of injuries associated with such devices. Van Yperen et al38 reported total costs, including societal and medical, from firework-related injuries to be $6,842 per patient in an ED setting. Applied to the present study's cohort, the total societal costs would be nearly $282 million for the 10-year period analyzed. Moreover, severe cases requiring amputation average nearly $12,000 in preliminary hospital expenditures for the pediatric cohort alone.39 This does not include future costs, such as wound care, rehabilitation, and repeat procedures, which are quite common.39 Predictably, long-term disability associated with hand amputations is not a rare occurrence. Sandvall et al7 reported that among patients who experienced hand injuries related to firework use, 20% ultimately required amputation, resulting in significant impairment.

This investigation has inherent limitations. First, the NEISS database only provides data pertaining to patients presenting to the hospital/ED with firework injuries with specific initial variables. Thus, in addition to likely underestimating the firework-related injury rates, we were unable to account for certain parameters, such as other injury mechanism categories. Therefore, it is logical to assume that the true total number of firework-related injuries to the upper extremity is higher than what we have reported. Second, misclassification within the NEISS database may occur, potentially due to fear among patients to report injuries secondary to illegal or inappropriate firework use. Last, while providing an effective analysis on the national level, variable state laws make harm reduction analysis difficult. Nonetheless, we believe that our findings establish a clear picture of the epidemiologic trends of upper extremity firework injuries in the United States.

Fireworks have a nostalgic foothold in the American consciousness as indispensable to some celebrations. As healthcare workers with first-hand experience treating the sequelae of firework-related injuries, orthopaedic surgeons are obligated to shed light on the perilous nature of these incendiary devices. Although most firework-related ED visits are due to superficial burns, thousands result in life-altering injuries. The amputation of a thumb or index finger is an unacceptable result for a seemingly innocent summer night pastime. We need to speak loudly and clearly with objective data that demonstrate to law and policymakers what is at risk by loosening firework regulations.

Conclusion

Over the course of a decade, between 2008 and 2017, firework sales revenue has increased an estimated 41%. During this same time period, we demonstrated a strong, positive correlation between increases in firework sales and increases in firework-related upper extremity injuries. These injuries represent significant morbidity, disability, and emotional distress to patients as well as rising healthcare expenditures.2,3,5-7 This study provides previously absent population-level data to provide a framework for discussion among policy makers and physicians alike in an attempt to mitigate the use of fireworks and their associated, potentially life-altering, upper extremity injuries.

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