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Articles on Clinical Spectrum & Management Outcomes of Firecracker Injuries

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1. Epidemiology & Pediatric Populations

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Billock RM, Chounthirath T, Smith GA (2017)

• 25-year analysis of ~136,991 pediatric injuries (ages <20) from National Electronic Injury Surveillance System (NEISS)
• Annual injury rate fell by 30.4% over the study period; 7.6% required hospital admission
• Most injured body region: Hands (30.0%), followed by head/neck (22.2%) and eyes (21.5%)
• 60% of all injuries were burns; firecrackers were the most implicated device (26.2%)
• Most patients were male (75.7%), mean age 10.6 years

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Tandon R, Agrawal K, Narayan RP et al. (2012)

• 1,373 patients over 2002-2010 at a government burn center in Delhi during Diwali
• 73% of victims aged 5-30 years; majority (90.87%) sustained <5% TBSA burns
• Despite legislation and court orders, patient numbers continued to rise each year
• Highlights the failure of existing regulatory measures and need for public education via digital platforms

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Smith GA et al. (1996)

• One of the landmark early epidemiological studies on pediatric firework injuries in the US
• Established that children are disproportionately represented among firework injury victims

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2. Hand & Upper Extremity Injuries

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Cardenas D, Harirah M, Dogaroiu A et al. (2025)

• 74 surgically treated patients at a level-1 trauma center (2009-2023)
• 80% had thumb injuries; 88% involved both thumb and first web space
• Surgical procedures: amputation (60%), skin grafting (36%), primary closure (32%), local/free flaps (35%)
• Proposes a treatment algorithm for thumb/first web space blast injuries based on injury level
• Key principle: preserve/restore thumb length, sensation, mobility, and a supple first web space

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Sandvall BK, Keys KA, Friedrich JB (2017)

• Retrospective cohort of 105 operative hand injury patients at a trauma center (2005-2015)
• 84% had thumb and/or first web space injuries; 87% had thumb fractures/dislocations
• 52 thumb carpometacarpal (CMC) joint dislocations; 23 hands (25%) required thumb revision amputation
• Up to 7 surgeries for acute reconstruction; 17% required 3+ operations
• Shells/mortars were the most common device type (59%)
• First web space adduction contracture is a key long-term complication requiring secondary reconstruction

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Saucedo JM, Vedder NB (2015)

• Comprehensive review of hand injury patterns: burns, traumatic amputation, blast injuries
• Covers principles of debridement, flap reconstruction, and amputation revision
• MeSH terms include: blast injuries, burns, traumatic amputation, emergency department management

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3. Ocular Injuries

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Kurien NA, Peter J, Jacob P (2020)

• 96 patients (122 eyes) over 2 years; 53.8% were bystanders; median age 14 years
• Spectrum of injuries: lid burns (57.3%), corneal epithelial defects (51.6%), hyphema (20.5%), open-globe injury (8 eyes), commotio retinae (13.1%), posterior segment injuries
• 88% managed conservatively; 15 eyes required surgery
• Predictors of poor visual outcome: open-globe injury (p<0.001) and poor initial visual acuity (p=0.05)
• 7 patients developed monocular blindness; Diwali (59.4%) was the predominant context

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Shiuey EJ, Kolomeyer AM, Kolomeyer NN (2020)

• 34,548 estimated firework-related ocular injuries in US EDs from 1999 to 2017
• Injury types: ocular burns (62.9%), foreign bodies (11.7%), ruptured globe (2.8%)
• Bottle rockets were the most severe, with ruptured globe OR 5.82 (95% CI 2.72-12.46)
• Firecrackers (19.2%) and bottle rockets (17.6%) were the leading specific devices
• 65.9% of patients aged ≤18 years; 71.9% male; 90.5% treated and released from ED
• Temporal clustering around Independence Day (July) and New Year's Day

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Patel R, Mukherjee B (2016)

• 49 patients at a tertiary eye center in South India (Diwali period)
• 26.5% open-globe injuries, 67.3% closed-globe injuries
• 44.8% underwent surgical intervention
• 36.7% had final vision <20/40; 8 patients had no perception of light
• Bystanders and device handlers were equally represented (49% each)

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Qi Y, Zhu Y (2013)

• 48 patients (54 eyes) with mean follow-up 18.5 months; 85.4% male, 62.5% under 15 years
• Most common injury: penetrating/perforating ocular injury
• The Ocular Trauma Score (OTS) showed 100% sensitivity and specificity for predicting NLP, LP/HM, and 1/200-19/200 visual acuity outcomes
• Useful clinical scoring tool for prognosis counseling in firecracker ocular trauma

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Kumar R, Puttanna M, Sriprakash KS et al. (2010)

• 51 patients classified using the Birmingham Eye Trauma Terminology (BETT) system
• Records visual outcomes before and after intervention; 10 patients required admission
• Emphasizes public education for prevention of Diwali-associated ocular morbidity

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Jeyabal P, Davies L, Rousselot A, Agrawal R (2019)

• Global literature review on firework-related eye injuries across multiple countries
• Examines the role of legislation in mitigating injuries and associated morbidity
• Notes that annual injury numbers have remained stable globally despite prevention efforts

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4. Multi-Region & General Trauma Reviews

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Read DJ, Bradbury R, Yeboah E (2017)

• 55 patients (17 children) over 16 years at Royal Darwin Hospital (Australia)
• 67 injuries resulting in 68 operating theatre visits, 322 hospital days, 380 outpatient appointments
• Burns, hand, and eye injuries predominated
• Women and children more likely to be bystander victims (p<0.05); alcohol involved in non-Territory Day injuries
• Advocates expanding prevention campaigns to include bystander and child safety

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Nunziato CA, Riley CJ, Johnson AE (2021)

• National Trauma Databank analysis of civilian blast injuries including fireworks
• Characterizes injury mechanisms, associated injuries, and demographics at a national scale

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Summary Table

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• Firecracker injuries follow a distinct seasonal pattern (festivals/holidays) and affect predominantly young males
• The hand (especially thumb and first web space) and eye are the most severely and permanently damaged structures
• Open-globe injury and poor presenting visual acuity are the strongest predictors of permanent blindness
• Management ranges from conservative wound care to complex multi-stage reconstructive surgery and amputation
• Prevention through legislation and public education remains the most effective long-term strategy, though compliance is inconsistent globally