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ORIGINAL ARTICLE
Year : 2022 | Volume
: 21
| Issue : 3 | Page : 237-243
Incidental blast injuries to the hands of hunters in suburban Africa
Olakunle Fatai Babalola1, Adedayo Idris Salawu1, Adeniyi Steven Hassan2, Abiodun Idowu Okunlola1, Omotola Oluseyi Banjo1, Richard Oluyemi Fadairo2
1 Department of Surgery, Federal Teaching Hospital, Ido-Ekiti; Department of Surgery, Afe Babalola University, Ado-Ekiti, Nigeria
2 Department of Surgery, Federal Teaching Hospital, Ido-Ekiti, Nigeria
Correspondence Address:
Olakunle Fatai Babalola
Department of Surgery, Federal Teaching Hospital, PMB 201, Ido - Ekiti /Afe Babalola University, Ado -Ekiti, Ekiti State
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_113_20
Abstract
Background: Civilian blast injuries are common during celebrations and festivities. In the intervening times, civilian nonterrorist blast events are rare. The aim of this report is to highlight the increasing occurrence of blast injuries to the dominant right hand of hunters and the ensuing crippling consequences. Methodology: A review of incidental blast injuries to the hand among hunters was conducted. The case files, clinical photographs, and radiographs of consecutive cases of blast injuries presenting to our unit over 3½ years were studied. Result: Six patients had incidental blast injuries to the hand within the period. All the patients were males and hunters by profession. The age range was 30–49 years. The dominant right hand was involved in all the six cases with high-energy soft tissue and bony injuries. Five patients had staged soft tissue coverage while the sixth patient, after initial resuscitation, discharged against medical advice due to economic constraints. Multiple joint stiffness and significant disability occurred in all the affected hands. None of the patients represented for secondary procedures. Conclusion: Incidental blast injuries to the hands of local hunters are lifestyle threatening. The dominant right hand is invariably involved with attendant crippling socioeconomic consequences. Meticulous clinical care and methodical operative intervention are primal to hand salvage.
Abstract in French Résumé
Contexte: Les blessures civiles dues à des explosions sont fréquentes lors des célébrations et des festivités. Dans l'intervalle, les explosions civiles non terroristes sont rares. sont rares. L'objectif de ce rapport est de mettre en évidence la fréquence croissante des blessures par explosion de la main droite dominante des chasseurs et les conséquences invalidantes qui en découlent. conséquences invalidantes. Méthodologie: Une revue des blessures accidentelles par explosion à la main chez les chasseurs a été menée. Les dossiers, les photographies cliniques Les dossiers, les photographies cliniques et les radiographies des cas consécutifs de blessures par explosion qui se sont présentés à notre unité pendant 3½ ans ont été étudiés. Résultat: Six patients ont eu blessures accidentelles par explosion à la main au cours de cette période. Tous les patients étaient des hommes et des chasseurs de profession. La tranche d'âge était de 30 à 49 ans. La main droite dominante était impliquée dans les six cas avec des lésions osseuses et des tissus mous à haute énergie. Pour cinq patients, la couverture des tissus mous s'est faite par étapes. tandis que le sixième patient, après une réanimation initiale, a quitté l'hôpital contre avis médical en raison de contraintes économiques. Raideur articulaire multiple et un handicap significatif sont apparus dans toutes les mains affectées. Aucun des patients ne s'est représenté pour des procédures secondaires. Conclusion: Les blessures accidentelles dues à l'explosion de Les blessures accidentelles aux mains des chasseurs locaux menacent leur mode de vie. La main droite dominante est invariablement touchée avec des conséquences socio-économiques invalidantes. conséquences socio-économiques. Des soins cliniques méticuleux et une intervention chirurgicale méthodique sont essentiels pour sauver la main.
Mots-clés: Poudre noire, blessure par explosion, mains de chasseurs, accidentelle, banlieue.
Keywords: Black powder, blast injury, hands of hunters, incidental, suburban
Introduction 
Hunting expeditions in suburban Africa mainly rely on the use of shotgun firearms, especially the Dane gun variety known as muzzleloader.[1] These firearms though classified as low-energy weapons can cause high-energy injuries at close range.[2] Hunters readily acquire these firearms for their peculiar characteristics of aiming a wider arc of coverage by their scatter effect. Therefore, games are readily apprehended even at long range without extensive tissue damage. The preparation for hunting requires putting these firearms in accurate shooting condition; ensuring appropriate pellets containing fixed shells or cartridges are stuffed in the respective barrel with the right constitution and amount of gunpowder as propellant. This process, though relatively innocuous when rightly done, can become a hunter's nightmare. The occurrence of 12/20 burst,[3] inappropriate constitution or amount of gunpowder, or defective firearm barrels can lead to sudden high-energy explosion with the inadvertent target of the hands or face in the secondary and miscellaneous blast injuries.[4] In this report, we present our early experience with shotgun blast injuries to the hands of hunters during preparation for hunting expedition. Our aim is to highlight the variable patterns of hand injuries, their pathomechanism, and the possible operative intervention in our resource-limited environment.
Methodology The study location is a tertiary health institution. This is a case series study in which a review of incidental blast injuries to the hand among hunters was conducted. The case files, clinical photographs, and radiographs of consecutive cases of blast injuries presenting to our unit over 3½ years were studied. The biodata, pathomechanism, patterns of hand injury, operative procedures, and clinical outcomes were collated and reviewed.
Ethical approval
Ethical approval was obtained from our institution's Human Research and Ethics' Committee with reference number ERC/2020/08/04/396A.
Result Six patients had incidental blast injuries to the hand within the period [Table 1]. All the patients were males and hunters by profession. The age range was 30–49 years. The dominant right hand was involved in all the six cases with high-energy soft tissue and bony injuries. Concurrence of flammable explosive with charged environment was adduced for the incidental events in all cases. Five patients had staged soft tissue coverage while the sixth patient, after initial resuscitation, discharged against medical advice due to economic constraints. Multiple joint stiffness and significant disability occurred in all the affected hands. None of the patients represented for secondary procedures.
Case 1
The first case is 44-year-old right-handed male hunter, who had accidental gunshot injury to the right hand. He was attempting to load his Dane gun to shoot a game when he had accidental discharge to the right hand.
Clinical review showed entry and exit wounds on the volar and dorsal surfaces of the right hand, respectively, with gunpowder black residue discoloration. The hand was swollen and held in position of ease. Dorsal wound was 8 cm × 6 cm with exposed tendons and bone fragments. On the volar aspect, there was a laceration from the wrist through the third web space [Figure 1]. There was difficulty with flexion/extension movement with crude touch preservation. Plain radiograph revealed fracture of the third and fourth metacarpal, with loss of part of the third metacarpal.
Figure 1: Clinical photograph of Case 1 (a) preoperative dorsal view (b) preoperative volar view (c) immediate postoperative view (d) late postoperative viewHe had operative surgical debridement, intravenous broad-spectrum antibiotics and commenced daily wound dressing with physiotherapy while awaiting definitive wound cover.
He subsequently had radial artery perforator flap cover for the dorsal wound, split-thickness skin grafting of the secondary defect, and direct closure of the volar wound. He will still require bone and tendon reconstructions.
Case 2
The second case is 32-year-old right-handed male hunter, who had accidental blast injury to the right hand. The incident occurred 2 h before presentation to the hospital. He was attempting to lift his gun from the resting place during a hunting expedition when it suddenly discharged. There was no injury to any other part of the body.
Clinical review revealed a swollen hand, with an entry wound (4 cm × 2 cm) on the volar aspect, and an exit wound (10 cm × 8 cm), on the dorsum of the right hand. There was a segmental loss of the third metacarpal with gunpowder staining of the exposed tendons and wound edges. There were multiple bony fragments on the floor of the wound, with exposed distal ends of extensor tendons.
Plain radiograph revealed fractured ends of the 1st to 4th metacarpals with comminution of the proximal two-thirds of the third metacarpal [Figure 2]. He had initial bedside serial debridement and dressings, followed by operative debridement and pedicled groin flap wound coverage a week later. Flap division was at 3 weeks and was discharged home 48 h after.
Figure 2: Clinical and radiological photograph of Case 2 (a) first-stage preoperative dorsal view (b) first-stage preoperative volar view (c) 3-week post groin flap (d) Radiographs with arrow pointing at third metacarpal segmental lossThe patient did not return for secondary procedures.
Case 3
The third case is 49-year-old right-handed male hunter and farmer, who had blast injuries to both hands. He presented to the hospital 12 h later. He was transferring the match head of the strike anywhere matchstick brand and match paper (side of safety matchboxes) mixed inside a glass bottle onto the lid to prime the gunpowder of his loaded Dane gun when a spark generated an explosion that resulted into injuries to both hands.
On the right hand, there was an extensive soft tissue injury from the radial border of the hand through the thenar eminence with near-total disarticulation of the thumb at the level of the basal joint and amputation of the tips of the thumb, index, middle, and ring fingers. There were exposed tendons and carbonaceous substances in the floor of the wound.
On the left hand, there was also a near-total disarticulation of the thumb through a ragged avulsion wound at the level of the basal joint extending distally through the thenar eminence to the dorsum of the hand. Plain radiograph confirmed dislocation of the thumbs of both hands and amputation of the tips of the distal phalanges of the right index, middle, and ring fingers [Figure 3].
Figure 3: Clinical and radiological photograph of Case 3 (a) Preoperative dorsal view left hand (b) Preoperative volar view of right hand (c) Postoperative volar view of both hands (d) Postoperative dorsal view of both hands (e) Radiograph with arrow showing dislocation at the first carpometacarpal joints of both handsHe had wound exploration, debridement, and Kirschner wire fixation of the nearly disarticulated thumbs. The amputated tips of the fingers were equally refashioned. Postoperatively, wound care continued with resultant significant contraction. He subsequently had split-thickness skin grafting of the residual wound before being discharged to out-patient care. There was residual multiple joint stiffness and was referred to physiotherapy.
Case 4
The fourth case is 45-year-old right-handed male hunter, with accidental shotgun blast injury to the right hand. He was attempting to load his Dane gun when accidental discharge occurred, affecting the right hand. He presented with a ragged avulsion injury to the dorsum of the hand, 8 cm × 7 cm in dimension, with floor stained with carbonaceous materials, and exposing devitalized tendons. At the volar aspect, there was a laceration from the wrist through the fourth web space [Figure 4]. The ring finger appeared dusky. Plain radiograph showed fracture of the fourth metacarpal bone. He had wound exploration and debridement and continued postoperative wound care. There was progressive dry gangrene of the ring finger. Definitive surgery was delayed by financial constraints with patient opting for outpatient wound care. The patient later had ray amputation of the ring finger and direct closure of the markedly contracted residual wound. There was significant stiffness of all the hand joints for which he was counseled on physiotherapy and secondary procedures. He was, however, lost to follow-up.
Figure 4: Clinical and radiological photograph of Case 4 (a) Preoperative dorsal view (b) Preoperative volar view (c) Preoperative volar view with established index finger gangrene (d) Postoperative volar viewCase 5
The fifth case is 41-year-old right-handed male hunter and police officer who sustained accidental blast injury to the right hand 7 h before presentation. He was trying to load his Dane gun when it suddenly discharged, resulting in an open injury to his right hand. There was no injury to any other part of the body. At presentation, right hand was swollen with an 8 cm × 6 cm avulsion wound on the dorsum, with dark staining of the wound, exposed tendons, and bones [Figure 5]. There was also a 2 cm × 3 cm stellate entry wound at the thenar eminence, with restricted ability to extend the fingers. All fingers were pink, with preserved crude sensation.
Figure 5: Clinical photograph of Case 5 who discharged against medical adviceHe had immediate wound debridement, and postoperatively daily wound dressing instituted. He was scheduled to have groin flap coverage but the patient declined on account of financial constraints. He was discharged to outpatient clinic but defaulted.
Case 6
The sixth case is 30-year-old male farmer and hunter who sustained shotgun blast injury to the right hand 4 h before presentation. He was loading his Dane gun, with his palm in the proximity of the muzzle, when it accidentally discharged. There was a penetrating injury through the right hand but no injury to any other parts of the body.
Wound review showed an exit wound at the dorsum, measuring about 10 cm × 8 cm with proximal and distal extensions, and exposed tendons/metacarpal. At the volar aspect, there was a laceration from 3 cm proximal to the wrist to the ulnar border of the index finger at the second web space. There were exposed muscle bellies, transected tendons, and gun powder residue in the wound bed [Figure 6].
Figure 6: Clinical and radiological photograph of Case 6: (a) Preoperative volar view (b) Preoperative dorsal view (c) Postoperative volar view (d) Postoperative dorsal view (e) Radiograph with arrow showing multiple metacarpal fracturesPlain radiograph showed fracture dislocation of the third and fourth metacarpals at the carpometacarpal joints.
He had initial wound debridement, postoperative wound care, and definitive posterior interosseous flap dorsal wound coverage with direct closure of the volar wound. He was referred to physiotherapy while awaiting secondary procedures.
Discussion The study evaluated the blast injuries sustained to the dominant hands of hunters during preparation for and performance of the hunting exercise in our suburban African environment. Typically, black powder was involved in all the six cases reviewed and crippling injuries resulted to the dominant right hand. The wide spread use of low-energy gunpowder explosives as propellant in firearms dated back to the medieval times with general consensus of origin in ancient China.[5] Before the middle of the 19th century, the only known chemical explosive was the black gunpowder, aptly called black powder. It derived this eponym from the formation of black soot on deflagration[5] as opposed to the newer smokeless gunpowder. Characteristically, black powder gives itself away with this appearance and stains biological tissues that suffer from its destructive effect. All the patients reported in this series had their wounds discolored by the signature appearance of the carbonaceous soot.
Black powder typically comprises 75% potassium nitrate (KNO3, saltpeter), 15% charcoal, and 10% of sulfur. The relative proportion of these three constituents may, however, change depending on the purpose of preparation. In the aforesaid standard composition, saltpeter which provides the needed oxygen for the rapid combustion process forms the bulk and the most important ingredient. Charcoal made up of pyrolyzed cellulose provides carbon and other substances as fuel while sulfur increases the rate of combustion by lowering the ignition temperature.[5] The combustion process generates 60% solid particle and 40% gas under pressure to propel the pellet missiles of shotgun. The knowledge of the effectiveness and the indigenous manual preparation of black powder are well entrenched within the circle of local hunters who deploy it for their regular hunting expedition. Conversely, ignorance prevails on the dynamics of the electrostatic ignition potential of the highly sensitive gunpowder. Although static electricity phenomenon has been variably utilized to the bewilderment and amusement of participants in social circles, its relevance and hazardous implications regarding handling of black powder are often underestimated by the locals. Brush discharges and spark generation are known to occur during filling of highly insulated containers with hydrocarbons, transportation, and storage of organic and polymeric powders. In the presence of a flammable atmosphere such as the gunpowder dust, sudden blast of explosion may result.[6],[7] One of the hunter patients reported in this series experienced a shattering blast injury of both hands during the pouring out of highly flammable strike anywhere match head brand already separated and packed inside a small container. He had transported it turbulently on a motorcycle before reaching his destination. This substance composed of intensely flammable potassium chlorate and phosphorus sulfide constituents is usually used by the hunters as primer for the loaded Dane guns. The electrostatic charges built up during the turbulent transportation must have generated a spark that ignited the explosive as the hunter attempted pouring the match head granules out from the container onto the lid.
All the other patients experienced the blast during the loading of the shotguns with black powder [Figure 7]. High separation velocity is known to build up charges dense enough to propagate brush discharges. Continuous impact of powder particles during stacking of gun barrel can inadvertently propagate brush discharges capable of igniting explosives. Complex and diverse are the varied mechanisms that can interplay to bring about a concurrence of a flammable environment with highly charged surfaces.[6]
Figure 7: (a) Photograph showing typical local Dane gun and (b) the locally prepared black powderThe hand was the only body organ affected in all the cases studied confirming the proximity of the hand to the gun muzzle during the ammunition loading process. The pattern of hand injury resulting from the explosion is similar to those reported for high-energy gunshot injuries even though low-energy shotguns were involved.[2] Proximity of missiles to target converts a supposedly low-energy to high-energy impact. The characteristic intense soft tissue crush avulsion, web space hyperabduction, and other related tendon and nerve injuries described by various authors were evident in our patients.[8],[9],[10] Expectedly, neither feature of primary nor tertiary blast injuries were observed. Unlike low-energy shotgun black powder explosion, powerful military or terrorist associated explosions have recognizable five patterns of blast injuries.[11] Shock waves from heated and expanding gases are capable of injuring hollow and air containing organs such as the auditory canal and the respiratory tract (primary blast injury).[4],[12]
The economic and psychosocial burdens of accidental explosion on these low-income hunters are also troubling. One of the patients could not afford surgical treatment and discharged against medical advice. Others managed to have a two-staged surgical intervention to ensure soft tissue coverage. None represented for bony or tendon reconstruction. It is pertinent to note, however, that while all the hunters that received care were glad to avert a complete hand amputation, long term disability was engendered by the residual joint stiffness and digital losses. Crude functions of the hand continue to subsist.
Presumably, accidental explosions from shotguns may not be completely prevented; its incidence can be significantly reduced to halt the currently disturbing trend in the suburban communities. Although the series presented in this report affirm the recognized pattern of relatively few numbers of firearm deaths from accidental blast or gunshot events, the ensuing disability is lifestyle threatening. Maintenance of shotgun device integrity, screening, and counseling on firearm safety by clinicians, control of static electricity through bonding and grounding as well as employment of antistatic devices are some of the established safety procedures.[13],[14],[15] Graphite coating of modern gunpowder granules is now known to reduce the incidence of accidental ignition by static electricity.[5] Addition of water during preparation reduces the risk of explosion. In general, countermeasures passively deployed in product designs and engineering exert a more positive effect at reduction of incidental events than measures requiring cooperation of the human element.[13] Nonetheless, establishment of safe hunter program course and certification before licensing, periodic updating, and recertification may contribute in no small measure to the safety of both casual and professional hunters.[13]
Conclusion This study brings to the fore a disturbing trend of incidental blast injuries to the hand among local hunters in suburban communities. High-energy impact injuries were recorded in all the patients with resultant long-term disability. Methodical operative intervention averted amputation in all the cases that allowed meticulous clinical care.
Limitations
This study did not evaluate the knowledge base of the local hunters regarding firearm handling and the consequent implications on the clinical scenarios enacted. Furthermore, this is a preliminary report with few cases reported but pertinent enough to draw attention to emerging trend. Future studies will take cognizance of these limitations.
Acknowledgment
We acknowledge the cooperation of the patients included in this study and the access granted us by one of them to examine the Dane gun and the black powder explosive.
Declaration of patient consent
The authors certify that appropriate consent was obtained from the patients for this publication.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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