Article, Traumatology

Fireworks type, injury pattern, and permanent impairment following severe fireworks-related injuries

a b s t r a c t

Background: There is a paucity of clinical data on severe fireworks-related injuries, and the relationship between firework types, injury patterns, and magnitude of impairment is not well understood. Our objective was to de- scribe the relationship between fireworks type, injury patterns, and impairment.

Methods: retrospective case series (2005-2015) of patients who sustained consumer fireworks-related injuries requiring hospital admission and/or an operation at a Level 1 Trauma/Burn center. Fireworks types, injury pat- terns (body region, injury type), operation, and permanent impairment were examined.

Results: Data from 294 patients 1 to 61 years of age (mean 24 years) were examined. The majority (90%) were male. 119 (40%) patients were admitted who did not undergo surgery, 163 (55%) patients required both admis- sion and surgery, and 12 (5%) patients underwent outpatient surgery. The greatest proportion of injuries was re- lated to shells/mortars (39%). There were proportionally more rocket injuries in children (44%), more homemade firework injuries in teens (34%), and more shell/mortar injuries in adults (86%). Brain, face, and hand injuries were disproportionately represented in the shells/mortars group. Seventy percent of globe-injured patients ex- perienced partial or complete permanent Vision loss. Thirty-seven percent of hand-injured patients required at least one partial or whole finger/hand amputation. The greatest proportion of eye and hand injuries resulting in permanent impairment was in the shells/mortars group, followed by homemade fireworks. Two patients died. Conclusions: Severe fireworks-related injuries from homemade fireworks and shells/mortars have specific injury patterns. Shells/mortars disproportionately cause permanent impairment from eye and hand injury.

  1. Introduction

The United States Consumer Product Safety Commission (CPSC) es- timates approximately 10,500 individuals (3.3 per 100,000) were treat- ed in hospital emergency departments for fireworks-related injuries in 2014, a rate that has not significantly changed since 1999 [1]. federal law permits consumer fireworks sale and sets type-specific size limita- tions; however, state and local authorities may further regulate their utilization.

Prior studies have found fireworks-related injuries commonly result from legal fireworks and disproportionately occur in children and males [1-5]. Earlier work documented injury to both active users of fireworks

* Corresponding author at: 325 9th Avenue, Box 359796, Seattle, WA 98104, United States.

E-mail address: [email protected] (K.A. Keys).

and bystanders and reported high rates of fireworks misuse and mal- function [1,2,4-6]. The majority of injuries involved the hands or face, were burns, and were treated and discharged directly from the Emer- gency Department (ED) [1-5]. However, national database reviews have been limited by broad data elements with a large number of minor injuries obscuring severe injury patterns [1-3,7].

The relationship between fireworks types and specific injury pat- terns has not been well described. In particular, there remains a paucity of clinical data on severe fireworks-related injuries. Existing reports on severe injuries are small and do not provide detailed injury patterns [6, 8]. One case-control study specifically evaluated risk factors for fire- works-related injuries and found that while most injuries were from federally-legal fireworks, most hospitalizations were due to federally-il- legal fireworks; homemade types in particular were associated with the highest hospitalization rate [4]. Two national database reviews found severe injuries requiring hospitalization were more likely due to illegal

http://dx.doi.org/10.1016/j.ajem.2017.04.053 0735-6757/

fireworks than other fireworks types [2,7]. However, inconsistent grouping of fireworks types makes comparisons across studies difficult. Understanding the relationship between fireworks type and injury severity is important to clinicians, legislators and public health practi- tioners. Using data from a large Level 1 Trauma/Burn Center, we aimed to describe the relationship between fireworks type, injury pat- terns, and permanent impairment among patients with severe fire-

works-related injuries.

  1. Methods
    1. Study population

This case series was approved by the Institutional Review Board of the participating site. Patients of all ages who sustained fireworks-relat- ed injuries were identified from our hospital’s Trauma Registry by searching for Internal Classification of Diseases, Ninth Revision (ICD-9) external cause of injury code E923 (accident caused by explosive mate- rial not otherwise specified). Patients were eligible if they sustained an injury due to fireworks requiring either inpatient admission and/or an operation between July 2005 and September 2015 (n = 294). Patients injured at professional fireworks displays were excluded (n = 5). Minor injuries, defined as those treated non-operatively or in the outpa- tient setting only, were excluded (n = 98).

Fireworks type (homemade, shells/mortars, rockets, firecrackers, Roman candles, sparklers, and unknown) was abstracted from the med- ical record, as reported by the patient. We also abstracted demographic information, (gender, age, race), fireworks use behavior (active user or bystander), disposition from the ED (floor admission, intensive care unit admission, non-admit operating room only), and num- ber of operations.

Outcomes

The two main outcomes were injury patterns (combination of body region and injury type) and permanent impairment.

Specific injury types (soft-tissue, fractures, burns) were recorded for each body region (face, hand, arm, trunk, leg). For injuries affecting more than one body region, only injuries to body regions severe enough to warrant hospital admission or surgery were recorded; the exception was globe injuries, where all were recorded regardless of severity. With- in body regions, operative subcategories captured injuries necessitating surgery. Injury types and body regions were not mutually exclusive. Penetrating trunk injuries were recorded separately from trunk soft-tis- sue injuries. A face or limb with multiple fractures was counted as one fracture. Brain injuries were defined as those with intracranial hemorrhage.

Impairment ratings for eye and hand injuries were calculated as per- cent whole person impairment (WPI) according to the American Medical Association Guides to the Evaluation of Permanent Impairment [9]. Visual function was calculated using visual acuity and visual field measure- ments documented by formal ophthalmologic examination, and enucle- ations were documented. Patients with vision loss were then categorized as less or N 50% WPI. Hand impairment was calculated based on distribution and level of finger/hand amputation(s). Patients with finger/hand amputation(s) were then categorized as less or N 20% WPI. Impairment ratings represented minimum impairment as patients may have had additional injuries; the two WPI ratings were not mutu- ally exclusive and were not combined.

Statistical analysis

We examined demographic characteristics, fireworks use behavior, admission disposition, and number of operations to calculate propor- tions and means by fireworks type. To assess the amount of surgical care required to treat injuries, we examined the relationship between

fireworks type and number of operations. We assessed permanent im- pairment to eyes (visual defect) and hands (amputation distribution and level) by fireworks type, classified into four subcategories (no inju- ry, injury without impairment, low impairment, and high impairment).

  1. Results

The study population included 294 patients 1 to 61 years of age (mean 24 years) with one-third b 18 years. The majority of patients (90%) were male. There were 119 patients (40%) admitted who did not undergo surgery, 163 patients (55%) who required both admission and surgery, and 12 patients (5%) who underwent outpatient surgery. There were two deaths.

Injury patterns by fireworks types

The greatest proportion of injuries was related to shells/mortars (39%; Table 1). The proportion of injuries related to different fireworks types varied by age, with proportionally more rocket injuries in chil- dren, more homemade fireworks injuries in teens, and more shell/mor- tar injuries in adults (Table 2). Bystanders were more frequently injured by aerial-type fireworks (shells/mortars, rockets, Roman candles) than by non-aerial fireworks (55%) (Table 2). Number of operations ranged 0 to 15 (mean 1.6); the greatest proportion of surgeries was observed among the shells/mortars group (Table 2).

Soft-tissue injuries were mostly blast injuries and avulsions. Among burn injuries, most were non-operative (57/60 face burns, 69/71 hand burns, 36/41 arm burns, 23/27 trunk burns, and 21/30 leg burns). Eight out of ten penetrating trunk injuries were due to homemade fire- works, and half of penetrating trunk injuries caused internal organ dam- age. Brain, face, and hand injuries were disproportionately represented in the shells/mortars group (Table 3). Face injuries (including superficial and partial thickness flash burns) most frequently occurred with both homemade fireworks and shells/mortars, whereas more severe opera- tive face injuries (including fractures, deep burns, and soft-tissue avul- sions) more frequently occurred with shells/mortars. Globe injuries, and particularly those requiring enucleation, most frequently occurred with projectile fireworks (i.e., shells/mortars and rockets). Arm, trunk, and leg injuries requiring surgery, though infrequent, most commonly occurred with homemade fireworks. Firecrackers caused a larger pro- portion of leg injuries than other types of injuries (Table 3).

Permanent impairment by fireworks types

Twenty-one percent of patients sustained globe injuries. Over two- thirds (70%) of globe-injured patients experienced partial or complete permanent vision loss, and 18% of them underwent enucleation (Table 4). WPI ranged 1% to 77%, with unilateral enucleation resulting in 50% to 77%. Sixty-one percent of patients sustained hand injuries. Over one-third (37%) of hand-injured patients required at least one partial or whole finger/hand amputation (Table 4). There were six complete hand amputations. Impairment ratings ranged from 2% to 4% for ampu- tation of one fingertip to 54% for complete hand amputation. Shells/ mortars, followed by homemade fireworks, caused the greatest propor- tion of eye and hand injuries resulting in permanent impairment (Table 4).

  1. Discussion

Data from this study indicate that specific severe injury patterns from fireworks vary by fireworks type. Shells/mortars caused the highest proportion of severe injuries, disproportionately injuring the face, brain and hands. Shells/mortars resulted in more permanent im- pairment than other fireworks types as a result of eye and hand injuries.

Table 1

Consumer fireworks types and injury rates.

Fireworks type Description Federal

regulation

Injuries

Homemade Includes a variety of improvised Explosive devices such as pipe bombs (explosive powder in a closed container or pipe), sparkler bombs (bundles of sparklers bound with duct tape), hand-crafted ‘M-80’s’ ‘M-1000’s’ (cardboard tube with explosive powder and fuse), hand-crafted cannons representing improvised mortar tubes, etc.

Shells/mortars Shells are spherical explosives that are launched into the sky from a tube. They have an explosive charge which propels

the shell into the air anda timed fuse that then sets off the pyrotechnic composition inside making a colorful lighted explosion. Mortars are the tubes from which shells are designed to be fired; the tube remains on the ground. Shells are limited to a diameter of 1.75 in. and 60 g chemical composition.

Illegal 23% (n = 68)

Legal 39% (n = 114)

Firecrackers Small, paper-wrapped or cardboard tubes containing many “stars” (pellets of pyrotechnic composition); upon ignition, a noise and flash of light are produced. They are generally 0.25 x 1.4 in. and often come in packs. Many firecrackers strung together make repetitive “popping” sounds. Firecrackers are limited to 50 mg chemical composition.

Legal (b50 mg) Illegal (N 50 mg)

6% (n = 18)

Rockets Tubes that utilize a wooden stick for guidance and stability. The stick is placed into a bottle and, once lit, the rocket rises into the air and explodes, producing a burst of color and/or noise at the height of flight. Missile-type rockets are similar in size, composition, and effect, but use fins rather than a stick for guidance. Rockets may have a plastic nose cap. Rockets are limited to 20 g chemical composition.

Roman candles Heavy paper or cardboard tubes which expel up to ten individual “stars” (pellets of pyrotechnic composition) at several-second intervals. Designed to be placed on the ground but often held in one’s hand. Rockets are limited to 20 g chemical composition.

Legal 5% (n = 16)

Legal 4% (n = 13)

Sparklers Sticks or wires coated with pyrotechnic composition that produce a shower of sparks upon ignition. Legal 4% (n = 11) Unknown fireworks types were 18% (n = 54). Abbreviations: g, grams; mg, milligrams.

Fireworks types

In our analysis of severe injuries, we identified a different distribu- tion of fireworks types compared to previous reports which examined both minor and severe injuries. Specifically, in both children and adults, we found a higher proportion of injuries from shells/mortars, rockets, and homemade fireworks and fewer injuries from firecrackers [1,2,6, 7]. Two prior studies reported patients b 14 years old were most fre- quently injured by sparklers and firecrackers, with relatively few inju- ries from aerial devices [1,6]. This may be a reflection of fireworks availability and/or injury severity, as the current study excluded pa- tients who did not require hospital admission and/or surgery.

In contrast to a prior study of the same geographic region of the country which found federally-illegal fireworks responsible for the ma- jority of injuries requiring hospitalization, we found most were due to

legal fireworks types, particularly shells/mortars [4]. This difference may be a result of temporal changes in patterns of fireworks use, consid- ering this prior study occurred over 30 years ago. Our finding that shells/ mortars are associated with specific severe injury patterns is potentially supported by a recent study of the National Electronic Injury Surveil- lance System (NEISS) [1]. The CPSC conducted 31 telephone interviews on a subset of patients with more severe fireworks-related injuries and reported an increased frequency of injuries from shells/mortars (39%) compared the larger pool of all fireworks-related injuries [1].

Injury patterns

Body regions injured were similar to previous publications, with hand injuries most frequent, followed by face and globe [1-3,6]. Rockets and shells/mortars had an increased proportion of globe injuries, a

Table 2

Demographic characteristics by fireworks type.

Fireworks type

Homemade

Shells / mortars

Firecrackers

Rockets

Roman candles

Sparklers

Unknown

n = 68 (%)

n = 114 (%)

n = 18 (%)

n = 16 (%)

n = 13 (%)

n = 11 (%)

n = 54 (%)

Gender

Male

67 (99)

107 (94)

16 (89)

13 (81)

12 (92)

7 (64)

44 (82)

Female

1 (1)

7 (6)

2 (11)

3 (19)

1 (8)

4 (36)

10 (18)

Age (years)

1-10

5 (7)

5 (4)

2 (11)

7 (44)

3 (23)

1 (9)

13 (24)

11-17

23 (34)

11 (10)

8 (44)

5 (31)

5 (39)

1 (9)

8 (15)

18-61

40 (59)

98 (86)

8 (44)

4 (25)

5 (39)

9 (82)

33 (61)

Race/ethnicity

White

53 (78)

87 (76)

12 (67)

7 (44)

8 (62)

10 (91)

34 (63)

Black

2 (3)

1 (1)

0 (0)

0 (0)

1 (8)

0 (0)

5 (9)

Hispanic

5 (7)

7 (6)

1 (6)

4 (25)

0 (0)

0 (0)

7 (13)

Asian

3 (4)

5 (4)

1 (6)

3 (19)

1 (8)

1 (9)

2 (4)

AIAN

4 (6)

7 (6)

3 (17)

1 (6)

1 (8)

0 (0)

2 (4)

Unknown

1 (2)

7 (6)

1 (6)

1 (6)

2 (15)

0 (0)

4 (7)

Use behavior

Active User 65 (96)

102 (90)

16 (89)

10 (63)

8 (62)

11 (100)

40 (74)

Bystander 3 (4)

12 (10)

2 (11)

6 (38)

5 (39)

0 (0)

14 (26)

ED disposition

Floor

50 (74)

97 (85)

16 (89)

14 (88)

12 (92)

11 (100)

46 (85)

ICU

16 (24)

11 (10)

2 (11)

1 (6)

0 (0)

0 (0)

6 (11)

OR only

2 (3)

6 (5)

0 (0.0)

1 (6)

1 (8)

0 (0)

2 (4)

No. of operations, Mean (SD)

1.8 (2.8)

2.1 (2.0)

1.6 (1.7)

1.3 (1.8)

0.8 (1.0)

0.1 (0.3)

0.7 (1.6)

Abbreviations: AIAN, American Indian or Alaska Native; SD, standard deviation; ED, emergency department; OR, operating room

finding in part supported by Smith et al. who identified an association between rockets and eye injuries (OR 2.62) [6]. While Witsaman et al. concluded Roman candles most frequently injured the globe, we found they were more common among hand and leg injuries [2]. Brain injuries were related to either homemade fireworks, which are federally illegal, or shells/mortars. We found firecrackers frequently in- jured the hand. Several firecrackers in our study were illegal as they contained N 50 mg of powder. Smith et al. also identified an association between firecrackers and hand injuries (OR 2.42) [6].

Leg

19 soft tissue (41%)

6 fractures (13%)

30 burns (65%)

Operative n = 19 (%)

12 (63)

6 (32)

0 (0)

0 (0)

0 (0)

0 (0)

1 (5)

All

n = 46 (%)

16 (35)

8 (17)

6 (13)

3 (7)

3 (7)

0 (0)

10 (22)

Operative n = 27 (%)

14 (52)

4 (15)

4 (15)

2 (7)

1 (4)

0 (0)

2 (7)

Permanent impairment

Trunk 17 soft tissue (44%)

10 penetrating (26%)

27 burns (69%)

In 1970, the National Society for Prevention of blindness reported N 50% of eye injuries from fireworks resulted in partial or complete vi- sion loss [5,12]. Comparison of Ocular trauma from fireworks is compli- cated by large trauma registration systems with non-uniform reporting; however, in a systematic review of ocular trauma from fireworks, Wisse et al. reported 18% of eye injuries were severe (defined as b 10/200 acu- ity) and 4% required enucleation [13]. In our study, 69% of eye injuries resulted in partial or complete vision loss in at least one eye and 18% re- quired enucleation. Although one review of pediatric fireworks injuries attributed the highest proportion of eye injuries to Roman candles/ fountains, multiple smaller studies found rockets most frequently asso- ciated with severe eye injuries causing partial or complete blindness (71-100%) [2,6,12,14-17]. Smith et al. found rockets more likely to cause permanent eye injury than all other fireworks types (p = 0.03, OR 6.72) [6]. In this series, the greatest proportion of eye injuries resulting in permanent eye impairment was in the shells/mortars group, followed by rockets and homemade fireworks (Table 4).

Body Region Hand

97 soft tissue (54%)

104 fractures (58%)

71 burns (40%)

Arm

7 soft tissue (15%)

5 fractures (10%)

41 burns (85%)

Operative

n = 114 (%)

24 (21)

67 (59)

10 (9)

1 (1)

5 (4)

0 (0)

7 (6)

All

n = 48 (%)

16 (33)

17 (35)

2 (4)

0 (0)

1 (2)

1 (2)

11 (23)

Operative n = 13 (%)

8 (62)

4 (31)

0 (0)

0 (0)

0 (0)

0 (0)

1 (7)

All

n = 39 (%)

16 (41)

14 (36)

1 (3)

0 (0)

0 (0)

0 (0)

8 (21)

The high proportion of finger/hand amputations in our cohort

reflected the high proportion of fractures and blast-related tissue de- struction. Two small studies reviewing severe hand injuries reported Significant injuries with high rates of fractures and amputations; nei- ther correlated injury patterns or severity with fireworks type [8,18]. In this series, the greatest proportion of hand injuries resulting in per- manent hand impairment was in the shells/mortars group. Moore et al. evaluated 21 children with severe hand injuries and reported high rates of fractures (67%) and amputations (43%), multiple stage surger- ies, and prolonged hospital stays [8].

Operative n = 44 (%)

10 (23)

22 (50)

3 (7)

3 (7)

0 (0)

1 (2)

5 (11)

All

n = 179 (%)

39 (22)

79 (44)

12 (7)

3 (2)

8 (5)

9 (5)

29 (16)

Prevention and policy

Face 32 soft tissue (32%)

11 fractures (11%)

60 burns (60%)

The Trauma Center in this study serves five states with varying fire- works regulations. Indian Reservations within the area are only subject to federal regulations and thus have the least restrictive fireworks laws. Multiple studies have found fireworks-related injuries more common in locations with less restrictive legislation [3-5,13-16,19-22]. Indeed, most injuries in our study were from legal fireworks. Additionally, it has been shown that where local jurisdictions banned federally-legal fireworks, disparate regulations in nearby communities decreased ef- fectiveness of tighter local regulations [6].

Table 3

Injury type and body region Injured by fireworks type.

Brain

All

n = 6 (%)

1 (17)

5 (83)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

All

n = 100 (%)

32 (32)

34 (34)

6 (6)

6 (6)

1 (1)

1 (1)

20 (20)

Injury type and body region categories are not mutually exclusive.

While injury severity may be related to volume of chemical compo- sition within various fireworks, it may also be related to fireworks de- sign and method of use (i.e., hand-held, ground versus aerial device, etc.). Among aerial-type devices, shells/mortars have the largest allow- able total chemical composition; additionally, shells fit easily into the palm of one’s hand and thus are often manually thrown (or launched via a mortar tube) [10,11]. Assuming sparklers are more frequently used by the general population than shells/mortars, the actual number of injuries per shell/mortar exposure is quite high.

Globe

All

n = 61 (%)

16 (26)

27 (44)

2 (3)

7 (11)

2 (3)

0 (0)

7 (11)

Enucleation n = 11 (%)

0 (0)

8 (73)

0 (0)

2 (18)

0 (0)

0 (0)

1 (9)

This study has potential limitations. It is single-center and thus re- gional variation in fireworks utilization and regulation limits generaliz- ability to all patients in all settings. We are limited in examination of some fireworks types and association with injury to some body regions due to small numbers. We are also unable to examine individual expo- sure to estimate risk of injury since severe injury or operation was an

Fireworks type

Homemade Shells / mortars Firecrackers Rockets

Roman candles Sparklers Unknown

Table 4

Injury severity as percent whole person impairment by fireworks type.

Fireworks type

Homemade

Shells/mortars

Firecrackers

Rockets

Roman candles

Sparklers

Unknown

Eye injury severity

None, n = 233 (%) 52 (22)

87 (37)

16 (7)

9 (4)

11 (5)

11 (5)

47 (20)

Injury, no vision loss, n = 19 (%) 8 (42)

6 (32)

1 (5)

3 (16)

0 (0)

0 (0)

1 (5)

Injury, b50% impairment from vision loss, n = 23 (%) 6 (26)

9 (39)

1 (4)

2 (9)

2 (9)

0 (0)

3 (13)

Injury, >= 50% impairment from vision loss, n = 19 (%) 2 (11) Hand injury severity

None, n = 115 (%) 29 (25)

12 (63)

35 (30)

0 (0)

6 (5)

2 (11)

13 (11)

0 (0)

5 (4)

0 (0)

2 (2)

3 (16)

25 (22)

Injury, no amputation, n = 112 (%) 27 (24)

41 (37)

6 (5)

2 (2)

4 (4)

9 (8)

23 (21)

Injury, b20% impairment from amputation, n = 31 (%) 5 (16)

16 (52)

4 (13)

0 (0)

4 (13)

0 (0)

2 (6)

Injury, >= 20% impairment from amputation, n = 36 (%) 7 (19)

22 (61)

2 (6)

1 (3)

0 (0)

0 (0)

4 (11)

inclusion criterion. However, strengths include the large cohort of chil- dren and adults with comprehensive, clinically relevant injury descrip- tions and direct comparison of fireworks types.

  1. Conclusions

This study provides preliminary insight into fireworks types, injury patterns, permanent impairment among patients with severe fire- works-related injuries. These findings question the safety of federally- legal shells/mortars, as their injury patterns most closely parallel that of illegal fireworks devices and their injury severity is greater than all other legal fireworks types. These findings are relevant to legislation governing consumer fireworks; restricting availability of high-risk fire- works such shells/mortars could potentially prevent severe injuries, many resulting in life-altering disability and often at an early age. Addi- tionally, information gathered has the potential to inform trauma facil- ities and provide guidance to public health campaigns.

Financial disclosure statement

None of the authors have any conflicts of interest or any financial disclosures.

Funding

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Presented at

American Society of Plastic Surgeons Senior Residents Conference, Los Angeles, CA, September 24, 2016. Oral Presentation.

American Association for Hand Surgery, Waikoloa, HI, January 12, 2017. Poster Presentation.

References

  1. United States Consumer Product Safety Commission (2015). Fireworks annual report fireworks-related deaths, emergency department-treated injuries, and

enforcement activities during 2014. Available from: http://www.cpsc.gov//Global/ Research-and-Statistics/Injury-Statistics/Fuel-Lighters-and-Fireworks/Fireworks_ Report_2014.pdf; 2014.

  1. Witsaman RJ, Comstock RD, Smith GA. Pediatric fireworks-related injuries in the united states: 1990-2003. Pediatrics 2006;118:296-303.
  2. Canner JK, Haider AK, Selvarajah S, Hui X, Wang H, Efron DT, et al. US emergency de- partment visits for fireworks injuries, 2006-2010. J Surg Res 2014;190:305-11.
  3. McFarland LV, Harris JR, Kobayashi JM, Dicker RC. Risk factors for fireworks-related injury in Washington state. JAMA 1984;251:3251-4.
  4. Berger LR, Kalishman S, Rivara FP. Injuries from fireworks. Pediatrics 1985;75: 877-82.
  5. Smith GA, Knapp JF, Barnett TM, Shields BJ. The rockets’ red glare, the bombs burst- ing in air: fireworks-related injuries to children. Pediatrics 1996;98:1-9.
  6. Moore JX, McGwin Jr G, Griffin RL. The epidemiology of firework-related injuries in

the United States: 2000-2010. Injury 2014;45:1704-9.

  1. Moore R, Tan V, Dormans JP, Bozentka DJ. Major pediatric hand trauma associated with fireworks. J Orthop Trauma 2000;14:426-8.
  2. Andersson GBJ, Cocchiarella L. Guides to the evaluation of permanent impairment. 5th ed. American Medical Association; 2004.
  3. American Pyrotechnics Association. APA standard 87-1: standard for construction and approval for transportation of fireworks and novelties. Available from: https:// archive.org/details/gov.law.apa.87-1.2001.
  4. Fireworks Business Guidance. United States Consumer Product Safety Commission. Available from: http://www.cpsc.gov/en/Business-Manufacturing/Business-Educa- tion/Business-Guidance/Fireworks/.
  5. Wilson RS. Ocular fireworks injuries. Am J Ophthalmol 1975;79:449-51.
  6. Wisse RPL, Bijlsma WR, Stilma JS. Ocular firework trauma: a systematic review on incidence, severity, outcome and prevention. Br J Ophthalmol 2010;94:1586-91.
  7. Wilson RS. Ocular fireworks injuries and blindness: an analysis of 154 cases and a three-state survey comparing the effectiveness of model law regulation. Ophthal- mology 1982;89:291-7.
  8. Vernon SA. Fireworks and the eye. J R Soc Med 1988;81:569-71.
  9. Kuhn F, Morris R, Witherspoon CD, Mann L, Mester V, Modis L, et al. Serious fire- works-related eye injuries. Ophthalmic Epidemiol 2000;7:139-48.
  10. Singh DV, Sharma YR, Azad RV. visual outcome after fireworks injuries. J Trauma 2005;59:109-11.
  11. Hazani R, Buntic RF, Brooks D. Patterns in blast injuries to the hand. Hand 2009;4: 44-9.
  12. Harris JR. Injuries from fireworks. JAMA 1983;249:2460.
  13. Sheller JP, Muchardt O, Jonsson B, Mikkelsen MB. Burn injuries caused by fireworks: effect of prophylaxis. Burns 1995;21:50-3.
  14. Levitz LM, Miller KJ, Drusedau MUH. ocular injuries caused by fireworks. J Pediatr Ophthalmol Strabismus 1999;3:317-8.
  15. Chan WC, Knox FA, McFinnity FG, Sharkey JA. Serious eye and adnexal injuries from fireworks in northern Ireland before and after lifting the firework ban–an ophthal- mology unit’s experience. Int Ophthalmol 2004;25:167-9.

Leave a Reply

Your email address will not be published. Required fields are marked *