Emergency Medicine

Pumpkin carving knife injuries: National incidence and trends of hand injury

a b s t r a c t

Introduction: Seasonal media reports often describe the dangers of pumpkin carving, yet little data exists regard- ing the actual incidence of hand injuries resulting from pumpkin carving. The purpose of this study is to describe, quantify, and trend ED encounters associated with pumpkin-related knife injuries.

Methods: The National Electronic Injury surveillance System (NEISS) was queried for pumpkin-related knife in- juries from 2012 to 2021. Patient demographic and injury data was collected and analyzed to describe trends in incidence, patient demographics, and injury patterns associated with an ED encounter for a pumpkin-related knife injury.

Results: There were an estimated 20,579 (95% CI: 17,738-23,420) pumpkin-related knife injuries from 2012 to 2021. The incidence of pumpkin-related knife injuries remained stable over time (R2 = 0.195, P = 0.201). Hand injuries comprised 87.6% of all injuries, with the thumb (33.5%) and index finger (25.0%) most commonly affected. Men and women were injured at similar rates (51.6% vs 48.4%). The most common demographic injured were 10 to 19-year olds (31.5%) followed by children <10-years old (19.5%). Women ages 10 to 19-years old were the most commonly injured subgroup (10.0% of all injuries). Most ED presentations occurred on Saturdays (16.5%) or Sundays (23.3%). The large majority occurred during the months of October (83.5%) followed by November (11.2%), with almost half of all cases (45.6%) occurring in the last week of October. Peak incidence of injury occurred on October 30th.

Conclusion: Pumpkin-related knife injuries are a preventable cause of hand injury with predictably high- incidence in fall months. Additionally, our data suggests further precautions should be taken to prevent injury in pediatric patients. Understanding at-risk populations in addition to implementing public safety initiatives and education on safe pumpkin-carving techniques could prevent Serious injuries in the future.

(C) 2022

  1. Introduction

Pumpkin carving is a popular fall activity for many American house- holds, particularly around Halloween. The tradition of carving pump- kins was brought to America by immigrants from Ireland, England and Scotland in the 19th century, who discovered that pumpkins were more amenable to carving than the smaller root vegetables like turnips, beets and potatoes that had been carved for centuries in Great Britain [1]. In 2021, as many as 44% of American households surveyed indicated that they intended to carve pumpkins for Halloween [2]. Since 2001, pumpkin production in the United States has nearly doubled, with many of these pumpkins being used for holiday festivities [3].

* Corresponding author.

E-mail address: [email protected] (C.A. Daly).

Many seasonal media reports have been published that discuss the dangers of pumpkin carving [4,5]. It is well-known among both the lay media and medical professionals that pumpkin carving is a poten- tially dangerous activity that results in a large number of emergency room visits each year [5,6]. The United States Consumer Product Safety Commission (CPSC) estimates 44% of Halloween-related injuries result from pumpkin carving [7]. One of the reasons for the pumpkin’s propen- sity to cause injury may be its unique structure. Pumpkins are enclosed in a tough, ribbed outer rind that overlies the softer pulp or flesh of the fruit. The innermost region of the pumpkin has a much lower density and is composed of fibrous strands that contain the seeds of the fruit. Prospective carvers often use a great deal of force to penetrate the outer rind with their knives which can result in slippage. This can cause lacerations to the non-dominant hand, which is typically used for stability during carving. According to the American Society for Surgery of the Hand (ASSH), using knives not designed for pumpkin-

https://doi.org/10.1016/j.ajem.2022.07.052

0735-6757/(C) 2022

carving, such as kitchen knives, tend to be much sharper than tools sold specifically for carving pumpkins and can increase the likelihood of in- jury [8].

While the association of hand injuries with pumpkin carving appears to be well-documented [4-6], there remains a lack of epidemi- ologic data regarding the national incidence of hand injuries related to pumpkin carving. The purpose of this study is to describe trends in incidence, patient demographics, and injury location in pumpkin carving-related knife injuries over the last 10 years (2012-2021). In

addition, we aim to delineate best practices for safely carving pumpkins,

with an emphasis on preventing hand injuries.

  1. Methods

The U.S. Consumer Product Safety Commission, National Electronic Injury Surveillance System is a nationally representative proba- bility sample of all ED encounters associated with a consumer product. The NEISS has been used extensively for examining injury trends and patterns associated with consumer products in the U.S., including hand-related injuries [9-14]. Each year, approximately 100 hospital EDs are sampled, including children’s hospitals [15]. Sampling weights are provided with each case to estimate national incidence. Each case also contains a narrative of the event which can be used to elucidate data that would not otherwise be captured with coding provided by the NEI. As a review of de-identified, publicly available data, this study was exempt from our Institutional Review Board.

The NEISS was used to query all pumpkin-related knife injuries occurring from 2012 to 2021. Incident date, patient demographics, diag- nosis, injury location, narrative description of incident, and disposition data were collected from incident ED encounters. Product codes 464 (“Knives, Not Elsewhere Classified”), 218 (“Electric or Battery Powered Knives”), and 838 (“Knives with Replaceable Blades”) were utilized to capture all knife-related injuries in the database. The search term “pumpkin” and all common misspellings (“pumpin” and “pumpking”) were subsequently used to identify pumpkin-related knife injuries from the patient narrative. Narrative texts were manually reviewed to

further specify injury to the digits as well as laterality of injury. Provided weights were used to estimate national incidence of injuries. Descrip- tive analyses were then performed to evaluate patterns of presentation, patient demographics, and injury characteristics. All national incidence estimates were calculated with the Complex Samples function of SPSS to account for clustering and to produce 95% confidence intervals (CI) around estimates. Injury location data was queried from the patient nar- rative, and was not available for every patient. Linear regression analysis was performed to describe change in incidence over time. For national estimates, non-overlapping 95% CIs were used to determine signifi- cance.

  1. Results
    1. National estimates of pumpkin-related knife injuries and consumption

There were an estimated 20,579 (95% CI: 17,738-23,420) pumpkin- related knife injuries from 2012 to 2021. The incidence of these injuries has remained stable, with a trend toward decreasing incidence over time (R = -0.442, R2 = 0.195, P = 0.201; Fig. 1). Pumpkin-related knife injuries are more frequent on weekend days (Sunday [23.3%],

Saturday [16.5%]; Fig. 2) and in the fall months (October through De- cember [98.9%]; Fig. 3). October had the highest incidence of cases (83.5%). Nearly half of all cases (45.6%) occur in the last week of October, with the highest incidence of injuries occurring on October 30th.

    1. Patient characteristics associated with injury

Demographic characteristics of pumpkin-related knife injury pa- tients are described in Table 1. Women and men were injured at similar rates (51.6% vs 48.4%). The most common demographic injured were 10 to 19-year olds (31.5%) followed by children <10-years old (19.5%), while the least commonly injured group were ages 50 to 59-years old (4.9%) and those older than 60-years old (5.0%). Race was available for 55.7% of patients. 84.1% were white, 5.7% were black, 5.7% were His- panic, 1.9% were Asian, and 1.9% classified as ‘other’.

Fig. 1. Trends in pumpkin-related knife injuries presenting to emergency departments, 2012-2021.

Fig. 2. Estimated pumpkin-related knife injuries by day of the week, 2012-2021.

    1. Injury pattern and location

The vast majority of wounds were lacerations (97.2% of total). Punc- ture wounds occurred in 1.3% of the sample. The majority of cases were discharged from the ED (98.7%), with only 1.0% of patients were held for observation. Injuries to the hand comprised 87.6% of all cases, followed by forearm (5.3%) and wrist (2.9%) injuries (Table 2). Specific location of injury was available for 42.3% of hand injury patients on review of the narrative (7542/17,825). The most commonly injured digit was the thumb (33.5%), followed by the index (25.0%) and small fingers (17.6%). Injuries to the palm and web space occurred in 7.4% and 1.7% of all hand-related injuries, respectively (Table 2). Multiple digits were injured in 4.0% of all hand cases. Laterality of injury (left or right) was available for 21.2% of all patients (4371/20,579) with a slight predomi- nance of left versus right hand injuries (52.0% vs 48.0%) (Table 2). There

were an estimated 253 tendon injuries (95% CI: 69-490), 16 infections (95% CI: 1-243), and 20 arterial injuries (95% CI: 1-225).

  1. Discussion

The current study demonstrates that pumpkin-related knife injuries continue to result in significant injury and ED visits across the United States. We further characterize pumpkin-related knife injuries includ- ing national incidence, trends, and affected patient populations. Our data confirm the notion that pumpkin-carving injuries show seasonal variation and predictable high-incidence periods. These injuries occur primarily during fall months (98.9% of all injuries), with the highest in- cidence of cases in October (83.5%). The majority of injuries coincide with the days leading up to Halloween (October 31st), as nearly half of all cases (45.6%) occur in the final week of October with peak

Fig. 3. a. Estimated pumpkin-related knife injuries by month, 2012-2021.

b. Estimated pumpkin-related injuries by day of the month for October and November 2012-2021.

Fig. 3 (continued).

incidence of injuries occurring on October 30th. Furthermore, a greater proportion of pumpkin-related knife injury presentations occurred on the weekend. This is consistent with previous literature which has found increased weekend ED visits for all causes [15]. The reason for this is likely multifactorial, but likely due to increased participation in pumpkin-carving on weekends, thus increasing their risk of hand injury and presentation to the ED. Additionally, decreased access to walk-in clinics or urgent care may drive people to otherwise seek care in the ED. We additionally clarify which patient populations are most at risk for ED visits secondary to pumpkin-related knife injuries. Most injuries occurred in young children or adolescents, with young women aged 10 to 19-years old as the single most affected group. This is in contrast to previous knife injury literature, which has found the majority of knife injuries occur in males [9]. Adults over the age of 50 and 60- years old sustained the fewest pumpkin-related knife injuries, while most affected groups were below the age of 30 years old. These trends are consistent with the notion that pumpkin-carving is typically performed by children and young parents and less commonly in older individuals. The greatest incidence in older children and adolescents (ages 10 to 19) is notable and may occur as a result of increased auton-

omy and less parental supervision in these patients.

The majority of injuries occurred to the hand (87.6%), with the thumb and index fingers most commonly affected. There was a rela- tively equal distribution to the laterality of the injured hand with a slight predominance of left-sided injury. Prior literature has suggested higher incidence of left-sided (typically non-dominant) hand injury while cut- ting other household items such as avocados [16]. Most patients were

treated in the ED and discharged without admission, at a rate similar to other knife injuries [9]. Several patients in the study, however, were found to injure critical structures or develop an infection, emphasizing the importance of ED physicians to consider Vascular injury, nerve in- jury, tendon injury, and infection in any patient with a pumpkin- related knife injury to the hand.

    1. Safe cutting practices and future direction

Data from the study demands an increased focus on safe cutting practices in an effort to reduce pumpkin-related knife injuries in the fu- ture. Specifically, our data suggest that extra precautions should be taken in children and adolescents (19 and under) as they represent the majority of injuries (51%). Considering the relatively large propor- tion of injuries in this age group, we recommend that pumpkin carving be done exclusively by adults. In contrast to other knife related injuries, pumpkin-related injuries follow temporal trends related to fall festivi- ties, especially Halloween. Given the predictable yearly increase surrounding Halloween, these injuries would benefit from timely public safety initiatives regarding safe cutting practices in the preceding weeks to months. Best practices regarding safe pumpkin-carving have been described in the lay literature [8,17]. Ultimately, we recommend the following tips for safety tips and proper cutting techniques. 1) Leave pumpkin carving to adults and never let children do the carving (especially unsupervised. We suggest allowing children to be in charge of drawing pumpkin designs and cleaning the inside, while an adult is responsible for handling the knife. 2) Focus on safe non-cutting hand

Table 1

Incidence of pumpkin-related knife injury by sex and age groups.

Age groups

Male (48.4% of all injuries)

Female (51.6% of all injuries)

% of Total (Male and Female)

Estimate (95% CI)

Count

Estimate (95% CI)

Count

<10 yrs

2741 (2363-3120)

65

1278 (1102-1458)

35

19.5%

10-19 yrs

3135 (2702-3568)

73

3355 (2892-3825)

83

31.5%

20-29 yrs

1432 (1232-1633)

30

2065 (1776-2.355)

56

17.0%

30-39 yrs

1690 (1454-1927)

28

1332 (1145-1518)

34

14.7%

40-49 yrs

838 (721-955)

17

665 (572-758)

13

7.30%

50-59 yrs

328 (282-374)

7

686 (590-782)

13

4.90%

60+ yrs

481 (414-547)

10

551 (475-627)

11

5.0%

Total

10,647 (9177-12,117)

230

9932 (8561-11,304)

245

100%

Table 2

Location of injury.

Estimate (95% CI) Count Percentage (%)

hand injuries. Additionally, our data suggest that extra precautions should be taken when children take part in carving activities.

Location on person (reported for all patients)

Funding

Hand

17,825 (15,330-20,321)

416

87.6%

Wrist

600 (516-684)

14

2.9%

This research did not receive any specific grant from funding agen-

Forearm

1071 (921-1221)

25

5.3%

cies in the public, commercial, or not-for-profit sectors.

Upper Arm

86 (74-98)

2

0.4%

Trunk

Head/Face

87 (74-98)

214 (184-244)

2

5

0.4%

1.1%

CRediT authorship contribution statement

Lower Extremity

471 (405-537)

11

2.3%

Hand injury (reported for 7542 patients) Charles A. Johnson: Writing – review & editing, Writing – original

draft, Methodology, Formal analysis, Data curation, Conceptualization. Luke LaRochelle: Writing – original draft, Investigation, Data curation, Conceptualization. William N. Newton: Writing – review & editing, Software, Methodology, Data curation. Charles A. Daly: Writing – review & editing, Supervision, Methodology, Conceptualization.

Thumb

2528 (2174-2882)

59

33.5%

Index

1885 (1621-2149)

44

25.0%

Middle

300 (258-342)

7

4.0%

Ring

514 (442-586)

12

6.8%

Small

1328 (1142-1514)

31

17.6%

Web space (1st, 2nd)

129 (111-147)

3

1.7%

Multiple

300 (258-342)

7

4.0%

Palm

557 (479-635)

13

7.4%

Laterality of injury (reported for 4371 patients)

Declaration of Competing Interest

Left

2271 (1953-2589)

53

52.0%

The authors of this manuscript have no conflicts of interest to

Right

2100 (1806-2397)

49

48.0%

disclose.

References

placement. For instance, in a right-handed individual, the left hand may be used to support the pumpkin with the right hand carving in a down- ward motion in the opposite direction of the left hand. 3) Use pumpkin carving knives with small, serrated edge and avoid sharp kitchen knives. Pumpkin carving kits have shown to cause less severe injury when com- pared to kitchen knives in cadaveric studies [18]. 4) Perform all carving in a well-lit area. Failure to visualize cutting planes may lead to poor knife control and/or Hand placement, thus resulting in injury. 5) Finally, if an injury does occur during carving, parents should have a first-aid kit available to clean and dress the wound. For minor cuts and puncture wounds, application of pressure to the wound site should stop bleeding within minutes. If bleeding continues after applying pressure for 15 min, carvers should consider seeking care from a nearby ED [8].

    1. Limitations

This study likely underestimates the true national incidence of pumpkin-related knife injuries, as it only includes patients that present to the ED for their injury. It is possible that many patients self-treat or present to non-ED providers for their injuries, such as hand surgeons, urgent care clinic providers, or primary care physicians. Patients with minor injuries or poor access to care may not seek medical attention at all and therefore not captured in our dataset. Additionally, patient narra- tives within the NEISS database are limited to Initial ED encounters and the keywords entered into the patient narrative by NEISS coders. As a result, the search term “pumpkin” may be absent from our query of pumpkin-related knife injuries. Certain data points such as laterality of injury or precise digit location were not available in all patient narratives. Prior to 2018, only one body part was included in each encounter listed in the NEISS. The addition of a second body part variable after 2018 potentially increases the specificity of data regarding injury location for each encounter and could impact our results. The location of the hospi- tals sampled for the NEISS data could also influence our data, as certain areas of the country likely have higher rates of Halloween participation than others. Furthermore, tendon, nerve, vascular injury, or infection could not be reliably tracked, and thus are likely underestimated.

  1. Conclusions

Injuries to the hand sustained while pumpkin carving are a common and preventable cause of injury during fall months. Awareness and education regarding proper pumpkin carving techniques and tools could potentially reduce ED encounters for pumpkin carving-related

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