Treating and Preventing Injuries from Fireworks

The Fourth of July can be devastating for those who sustain firework injuries

The Fourth of July: a day of celebration, American pride and, of course, fireworks. Fireworks are a widely loved and practically unavoidable part of summer in the United States – but that doesn’t mean that they come risk-free.

According to the U.S. Consumer Product Safety Commission, there were an estimated 10,500 injuries involving fireworks – including not only the large-scale fireworks seen over rivers and amusement parks, but also firecrackers, bottle rockets, sparklers and other small displays – treated in emergency rooms in 2014. Of those injuries, 67% occurred in the month between June 20 and July 20.1

Perhaps unsurprisingly, the largest percentage (36%) of these injuries affected the victims’ hands, either from misuse of the firework or from a manufacturing error. These accidental, preventable wounds can be life-changing: A person’s thumb and palm control approximately 50% of hand function, and that same area is the most frequently damaged in firework injuries.

These injuries are very different from typical burns, which only affect skin and tissue and can usually be treated in a relatively short period of time. “Simple burns can just be evaluated and treated in the emergency department by ways of wound care and medication ointment,” explained Jennifer Oakley, FNP, MSN, BSN, trauma nurse at the Hospital of the University of Pennsylvania. “But with firework injuries, there’s the risk of extensive limb damage, soft-tissue concern or, in some cases, amputation, so they need to be trauma-evaluated.”

Injuries caused by fireworks can include first-, second- or even third-degree burns. After the wound and extremity are evaluated in the trauma unit, the patient is often referred to a specialized burn unit, which Oakley said rarely occurs with an “everyday mild” burn.

Beyond the initial trip to the trauma unit, there can be a necessity for specialized treatment for these patients. “Because the hand is so specific and has so many ligaments, tendons and nerve endings, a specialized hand or plastic surgeon often needs to perform the evaluation and treatment,” Oakley said. “Afterward, because the injury can be so severe, patients might require physical therapy, occupational therapy or inpatient rehabilitation.”

Truly, for hand injuries as drastic and potentially life-changing as those caused by fireworks, it can be crucial for victims to continue their treatment after leaving the hospital – and it must be just as specialized as the initial treatment. “Every single firework injury is different,” said MaryLynn Jacobs, MS, OTR/L, CHT, vice president of operations for ATI Physical Therapy and practice management chair of the American Society of Hand Therapists. Because of the variation in types of injuries that can be caused by fireworks, there is a wide range of rehabilitation techniques that can be used. Jacobs recommended the following considerations to ADVANCE readers:


  • What bony structures were injured and repaired? How stable are the structures post-repair?
  • What protection or splinting and orthosis management are needed for healing?


  • Were venous, arterial or both injured, and to what extent was vascularity repaired?
  • Are structures at risk due to poor or insufficient vascularity?


  • What tendons were injured and/or repaired?
  • What is the integrity of the repaired tendon(s)/pulley(s)?


  • What motor or sensory nerves were injured? Were they repaired and, if so, what was the type and integrity of the repair?


  • How much skin loss occurred?
  • Is it appropriate to apply compression dressings or garments? Will they compromise vascularity?
  • Is debridement necessary?

In addition to developing a therapy plan that is tailored to the patient’s specific injury, it’s important for the therapist to form a personal relationship with the patient – and in a very short period of time. “You have to very quickly develop a rapport with the patient and the patient’s family because you’re probably the first one who’s going to be exposing them to what they’ve lost,” Jacobs explained. “They have to look at their hand. They eventually have to use their hand. You really have to develop a warm, empathetic approach with them.”

Just because rehabilitation can be crucial for the patient does not necessarily mean that all victims of these injuries will get the treatment they need. In 2016, Tasha Pilling and Pragashie Govender conducted a study for South African Family Practice examining 65 patients who had sustained hand injuries caused by fireworks. In their study, the researchers found that only 63.1% of patients were referred for any kind of hand rehabilitation at some stage of their surgical and orthopedic management. Of that percentage, 31.7% never attended rehabilitation, and another 31.7% only attended one or two sessions.2

“It’s really important that patients come to therapy,” Jacobs stressed, “especially people who have sustained partial or complete amputation of a finger or palm. These injuries will forever change the way they use their hand. Chronic pain, alterations in sensation and functional use need to be addressed.”

Although they can be devastating, these injuries are entirely preventable. Jacobs emphasized the importance of educating patients about how dangerous these celebratory items – even those as seemingly harmless as sparklers – can be. “A sparkler can melt metal,” she said. “What parents would give that to their children if they knew that much heat was generated? Getting that message out to the consumer – or even to other healthcare professionals – is crucial.”


  1. Tu Y, et al. Firework-related deaths, emergency department-treated injuries, and enforcement activities during 2014. U.S. Consumer Product Safety Commission. 2014: 1-44.
  2. Pilling T, et al. Profile and management of the firework-injured hand. South African Family Practice. 2016;58(2):48-53. doi: 10.1080/20786190.2015.1125167.

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