Giessler G A, Leopold A, Germann G, Heitmann C
Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Plastische und Handchirurgie der Universität Heidelberg, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Deutschland.
Unfallchirurg. 2006 Nov;109(11):956-63. doi: 10.1007/s00113-006-1139-9.
Blast injuries of the hand represent a demanding surgical emergency for the reconstructive hand surgeon. Commercially available fireworks are often regarded as less dangerous compared to combat ammunition, but the following examples demonstrate their real potential for devastating hand injuries. Some of the closed injuries can represent a pitfall for correct assessment of trauma severity.
Fifty patients who were seen after fireworks explosions from December 1995 until April 2005 were analyzed in respect to their patterns of injury and their subsequent surgical treatment. The severity was graded using the Hand Injury Severity Score (HISS). The majority of patients were injured during the New Year's day celebrations and presented with complex blast injuries due to commercially available, CE-certified fireworks.
Depending on the size of the explosives comparable patterns of injury were seen. Larger shells led to traumatic subtotal amputations of the exposed fifth finger ray and thenar ray. Complex destructions with multiple fractures and avulsions of the midhand were also present. Smaller explosives caused multiple lacerations in the palm of the hand, subcutaneous flexor tendon ruptures, and closed fingertip fractures.
Acute neurapraxias and neural compartment syndromes were clinically present. All patients (50) had to be operated primarily, and subsequent operations were necessary in 19 cases (number of operations 1-4, med. 1). In the HISS grading, 18 "minor" (HISS <20), 16 "moderate" (HISS 21-50), 7 "severe" (HISS 51-100), and 9 "major" (HISS >100) explosion injuries were present (range: 2-155, med. 47).
Blast injuries of the hand need a fast, strategically planned surgical approach. This is also true for presumably harmless, CE-certified fireworks. In a multiple patient scenario, triage based on surgical urgency may be necessary. A detailed clinical examination and surgical exploration is mandatory to avoid possible pitfalls like in closed injuries. Profound skills in reconstructive and microvascular hand surgery are essential to achieve an optimal clinical outcome.
手部爆炸伤对于手部重建外科医生而言是一项极具挑战性的外科急症。与战斗弹药相比，市售烟花通常被认为危险性较低，但以下案例表明其对手部造成毁灭性损伤的真实可能性。一些闭合性损伤可能成为正确评估创伤严重程度的陷阱。
对1995年12月至2005年4月间因烟花爆炸受伤的50例患者的损伤模式及后续手术治疗情况进行分析。采用手部损伤严重程度评分（HISS）对严重程度进行分级。大多数患者在元旦庆祝活动期间受伤，因市售的、获得CE认证的烟花导致复杂的爆炸伤。
根据爆炸物大小，可见类似的损伤模式。较大的烟花弹导致外露的小指列和大鱼际列发生创伤性近完全离断。还存在伴有多根骨折和手部中部撕脱的复杂毁损。较小的爆炸物造成手掌多处撕裂伤、皮下屈肌腱断裂和闭合性指尖骨折。
临床上出现急性神经失用和神经间隔综合征。所有50例患者均需首先进行手术，19例患者需要进行后续手术（手术次数为1 - 4次，平均1次）。在HISS分级中，有18例“轻度”（HISS <20）、16例“中度”（HISS 21 - 50）、7例“重度”（HISS 51 - 100）和9例“极重度”（HISS >100）爆炸伤（范围：2 - 155分，平均47分）。
手部爆炸伤需要快速、策略性规划的手术方法。对于看似无害的、获得CE认证的烟花造成的损伤也是如此。在多名患者的情况下，可能需要根据手术紧迫性进行分诊。必须进行详细的临床检查和手术探查，以避免闭合性损伤中可能出现的陷阱。重建和显微血管手部手术的精湛技术对于实现最佳临床效果至关重要。
