AN EPIDEMIOLOGIC STUDY OF GUNPOWDER WOUNDS

Tejerina C., Reig A., Codina J., Herrero J., Mirabet V.

Pepartment of Plastic Surgery and Burn Centre, Hospital La Fe, Valencia,1Spain

SUMMARY. A retrospective epidemiologic study was made of patients with gunpowder bums admitted to our Bum Centre between I January 1988 and I January 199 1. During this three-year period 5679 patients were treated; of these, 443 (7.8%) required hospitalization. Gunpowder was the cause of the burns in 39 cases (8.8%). Mean patient age was 21.6 years (range, 8-54); 64. 1 % were aged between I I and 20. Mean bum extent involved 13.8% of the total body surface, predominantly second-degree deep and third-degree burns being the most common association. The hands were the region most commonly affected (82%), either isolatedly or in association with wounds elsewhere. The months of March, August and September are the times of year of greatest folklore activity in our region, and lead to the highest incidence of gunpowder bums. Three patients (7.7%) died as a result of their bums.

Bums continue to pose a considerable problem in plastic surgery. Within the context of bum wounds, lesions caused by gunpowder are of particular importance in regions such as our own, where fireworks are profusely (and sometimes. negligently) employed in folklore activities during certain key months of the year.
The fact that most victims of gunpowder burns are young individuals (aged 11 to 20) accentuates the problem. Lesions most commonly affect body areas such as the hands, face and genitals, which leads to severe physical and psychological problems in these patients.
In the present study we have attempted to identify the epidemiologic factors involved in gunpowder bums, with the aim of favouring the reinforcement of appropriate preventive measures.

A retrospective epiderniologic study was carried out on patients with gunpowder burns; the patients studied were admitted to our Burn Centre between I January 1988 and I January 1991.
During this three-year period a total of 5679 burn cases were treated; 443 (7.8%) required hospitalization. 39 (8.8%) of the hospitalized patients presented gunpowder bums.

Mean patient age was 21.6 (range 8-54), Fig. I shows the age distribution of the 39 patients studied. 64.1% were aged 11-20, 5.1% were over 50 years of age, and no case was under age

Thirty-five (89.7%) patients were males, and only four (10.2%) females. Fig. 2 shows patient distribution according to both age and sex. The four women were aged 11-30.

Fig. I Distribution of patients by age Fig. 2 Distribution by age and sex

Mean burn area involved 13.8% of the total body surface (range 1-70%). In most cases (64. 1 %) the burns affected less than 11% of total body surface. In almost all patients (87. 1 %) less than 2 1 % was affected. Patient distribution according to bum extent is shown in Fig. 3.

Fig. 4 shows patient distribution according to the degree of burn depth.

Fig. 3 Distribution of patient by BSA Fig. 4 Distribution by burn depth

Thus, 25.6% of patients with gunpowder bums presented second-degree superficial wounds associated with second-degree deep burns; 23% presented isolated third-degree burns. The most common association was second-degree deep lesions with third-degree bums (48.7%), whereas only one patient (2.5%) suffered first-degree wounds associated with superficial second-degree burns. 25% of patients with third-degree burns suffered tissue loss; in three cases the first and second fingers had to be partially amputated.
Two cases suffered eye loss as a result of gunpowder burns.

Burn location

Burn location is indicated in Fig. 5.
The most commonly affected locations were the hands (82%) - either isolatedly or in association with burns elsewhere. The head and neck were involved in 16 patients (41%), in 10 of whom associated with upper limb burns (the hands being involved in each case).
The trunk was affected in 43% of cases - always in association with other locations. 53.8% of patients had lower limb lesions, with genital involvement in 25.6%.

Fig. 6 shows patient distribution according to the time of year when the bums occurred. Thus, 30.7% of accidents took place in March, during the yearly Fallas folklore festivities in our region, and 46.1% in August and September, when the villages and towns surrounding metropolitan Valencia celebrate their local fiestas.

Fig. 5 Location of bums Fig. 6 Monthly incidence

Mean hospital stay was 20 days (range 2-47 days).
74% of patients underwent at least one surgical operation during their hospital stay; reintervention was required in 35%.

Of the 39 patients with gunpowder wounds, three (7.7%) died. These clearly corresponded to the most extensive and deepest bums affecting more vital regions.

In regions such as ours, where gunpowder is so profusely employed in local festivities by non -professionals, bums and their resulting mutilating effects pose considerable problems for plastic surgeons and for society as a whole.
During the key festivity months of March, August and September, the purchasing of fireworks is legal and open to all in public establishments. Evidently, the young (aged 11-20), often under the effects of alcohol, are most prone to accidents involving gunpowder burns.
The literature is very poor in studies of such lesions. However, we have reviewed works published on terrorist bombings (Brismar and Bergenwald, 1982; Cooper et al., 1982; Hadden and Rutherford, 1975) where the wounds inflicted - albeit more severe -possess similar characteristics to those reported in our study. Such bums may severely affect the physical and psychological conditions of their young victims.
We are of the opinion that the work of the plastic surgeon is important but not sufficient in patients of this type. Preventive measures are required, at two levels in particular:

• government control should be exerted in the sale and indiscriminate use of explosive materials
• the general population, and the young in particular, should be made more aware of the risks involved in the negligent handling of these materials.

RESUME On prtsente une étude épidémiologique rétrospective des patients atteints de brfilure par explosion de poudre hospitalisés dans un centre de brfilés dans la période I janvier 1988-1 janvier 199 1. Pendant ces trois ans un nombre total de 5é79 patients ont W hospitalisés. En 39 (8,8%) de ces cas la cause des brfilures était la poudre. Udge moyen de ces patients était 21,é ans (variation 8-54 ans); é4,1% kait dgé de I I A 20 ans. La surface brfilée était en moyerme 13,8% de la surface corporelle totale; I'association la plus commune était entre les brOlures profondes du deuxiéme degré et les brélures du troisi&me degré. Les mains étaient la partic du corps la plus atteinte (82%), ou isolément ou en association avec d'autres blessures. Les mois de mars, aoét et septembre sont les périodes de I'an oé il y a la plus grande activité folklorique dans notre région, et cc sont les mois avec la plus haute fréquence de brélure par explosion de poudre. Trois patients (7,7%) sont morts A cause de leurs brCilures.

BIBLIOGRAPHY

1. Brismar B., Bergenwald L.: The terrorist bomb explosion in Bologna, Italy (1980): an analysis of the etlects and injuries sustained. J. Trauma, 22: 216, 1982.
2. Cooper G., Pearce B., Stainer M. et al.: Casualties from terrorist bombings. J. Trauma, 23: 955, 1982
3. Hadden W., Rutherford W.: The injuries of terrorist bombing: a study of 1532 consecutive patients. Br. J. Surg., 65: 525, 1975.