Introduction
On September 17, 2024, following the explosion of approximately 5,000 pagers in an organized attack in Lebanon, around 3,000 people were injured, and 37 victims were killed instantly.Reference El Sayed1 The explosive devices, disguised as regular pagers, contained pentaerythritol tetranitrate (PETN), a high-powered plastic explosive embedded between 2 battery cells.Reference Gebeily, Pearson and Gauthier-Villars2 The resulting trauma predominantly affected the hands, face, and eyes due to the close contact with the device at the moment of detonation.Reference Helou, Weinstein and Kalaji3 Due to the large number of injured individuals, some were sent to other countries for treatment, including Iran.Reference Daryabari, Hosseini Imeni and Hassanpour4 Among the 123 injured admitted to Baqiyatallah Hospital, 5 children under the age of 12 were treated. This paper presents a brief report of 5 pediatric patients treated at Baqiyatallah Hospital, describing the characteristic injury patterns and management challenges.
Methods
This is a retrospective, descriptive brief report of 5 pediatric patients (<12 years old) who sustained injuries in the September 17, 2024, pager detonations and were referred to Baqiyatallah Hospital for tertiary management. Institutional ethics committee approval and written informed consent from legal guardians were obtained. Data abstracted from electronic records included demographics, mechanism/timing of referral, clinical presentation, imaging, operative interventions, and outcomes for 3 months. Imaging included CT of face/orbits and hand radiographs as indicated. Management was multidisciplinary; surgical approaches were tailored to injuries and contamination status.
Results
Five children (mean age 9.2 years, range 5-11) were treated; 4 were male and 1 female. Most had initially received care at local centers and were transferred 2-7 days after injury. All 5 sustained complex injuries involving the eyes, face, and at least 1 upper extremity; details are summarized in Table 1.
Table 1. Injury pattern, interventions, and early outcomes for each patient
Case Series Reports (Injury Details per Patient)
Case 1—11-year-old male: The right globe was auto-eviscerated and could not be salvaged; Tenon’s capsule and conjunctiva were approximated, and a conformer was placed. The left eye retained limited vision (counting fingers at 4 m) after removal of corneal and subconjunctival foreign bodies. Extensive facial lacerations, burns, and tattoos required repeated layered repair. The left hand sustained a crush injury with multiple finger amputations; tendon rupture and nerve damage resulted in permanent loss of sensation and flexion in the fifth digit (Figure 1).
Figure 1. Multidisciplinary Treatment of a Male Patient Age 11 with Complex Blast Injuries(Case 1) (A) Intraoperative photo demonstrating significant trauma to the right face, including full-thickness soft tissue avulsion, loss of nasal bone and cartilage, and blast injury-induced right globe auto-evisceration. (B) Despite severe tissue loss and digital amputations of the left hand, the postoperative image demonstrates good skin healing and facial regeneration. (C) An X-ray of the left hand shows a high-energy crush injury consistent with traumatic amputation of digits I–IV and related bone distortion. (D) Coronal CT image showing soft tissue disruption, globe evisceration, nasal fractures, and severe facial skeletal trauma, and involvement of the right orbit.
Case 2—9-year-old male: The right eye had corneal lacerations with an intraocular foreign body requiring vitrectomy and keratoprosthesis; vision remained at hand motion. The left eye was auto-eviscerated. Multiple facial lacerations required staged debridement and layered closure. The left hand sustained amputations, tendon rupture, and a fifth metacarpal fracture stabilized with Kirschner wires. Despite fracture union, a flexion contracture persisted.
Case 3—11-year-old male: The right eye underwent corneal repair, lensectomy, and vitrectomy, later receiving a secondary intraocular lens with vision improving to 20/35. The left eye was auto-eviscerated and reconstructed as a socket. Facial wounds healed after staged debridement, but left tattoos and scars. The left hand had total finger amputations; revision and flap coverage were performed, with reconstruction planned.
Case 4—5-year-old female: The right eye was intact; the left eye required lensectomy, vitrectomy, foreign body removal, and silicone oil tamponade. Facial soft tissue avulsion and burns necessitated repeated debridement, leaving significant scarring. The right hand sustained fractures and crush injury; fixation and tendon preservation allowed near full thumb motion by 2 months.
Case 5—10-year-old female: Both globes remained anatomically intact with superficial injuries; vision was preserved. Facial lacerations and tattoos were repaired, with a secondary eyelid scar correction. The right hand had crush and open fractures with amputations; Kirschner wire fixation and flap coverage achieved fracture healing and good thumb motion.
Key Findings Based on Site of Complication
Ocular: Three patients presented with globe auto-evisceration. The remaining eyes exhibited severe open-globe injuries with intraocular foreign bodies in several cases. Urgent ocular procedures performed included primary repair, pars plana lensectomy, deep vitrectomy, IOFB removal, keratoprosthesis (case-dependent), conformer placement, and temporary blepharorrhaphy. Visual outcomes at short follow-up ranged from no-light-perception to 20/35 in the best eye.
Hand/extremity: Four patients required partial finger amputations (levels variable from metacarpal to phalanx). Management included debridement, stump revision, Kirschner-wire fixation for fractures, local flap coverage, and tendon/nerve exploration when feasible. Functional deficits and contractures were common at early follow-up.
Facial/soft tissue: All patients had multiple facial lacerations, traumatic tattoos from particulate contamination, and, in some cases, partial loss of nasal cartilage or soft tissue requiring staged reconstruction. No immediately life-threatening intracranial injuries were observed among these 5 patients.
All patients underwent multiple operations across specialties, including early socket formation and wound control.
Discussion
The damage pattern in the “Pager Explosion Trauma” was unique compared to similar attacks. The cause of the explosion was 6 grams of white pentaerythritol tetranitrate (PETN) plastic explosive squeezed between 2 battery cells in pagers.Reference Gebeily, Pearson and Gauthier-Villars2 The explosion of the pagers created a strong blast wave that impacted the hands, eyes, and faces of the victims. The blast wave, shrapnel, and heat were the 3 primary factors responsible for the harmful injuries in this tragic incident.Reference Ramzi, Baha’ and Ahmad5, Reference Antoine, Elie and Tarek6 A specific pattern of injury was observed in the affected organs. The damaging factors from the explosion first injured the hands and then traveled in a linear path, reaching the upper part of the face, particularly the eyes. In contrast, the lower third of the face experienced far less severe damage, and the neck and chest tissues were less affected due to their relative distance from the explosion.Reference Helou, Weinstein and Kalaji3 Additionally, due to the unique pattern and proximity of the explosion, life-threatening injuries were less common,Reference Helou, Weinstein and Kalaji3 despite causing severe mutilating injuries to the hands and eyes. In most cases, the injuries involved critical organs essential for an individual’s functioning, such as both hands and eyes. Consequently, the injured, while surviving, were unable to perform meaningful tasks and became permanently disabled. This distinct injury pattern allowed a significant number of injured individuals to be transferred to other countries for advanced treatment. The rate of severe ocular injuries and finger amputations among these patients was considerably higher compared to similar studies. In comparable studies, the rate of ocular injuries has been reported to range between 2.13% and 28%.Reference Jiang, Xue, Gao and Wang7–Reference Odhiambo, Guthua and Macigo10 However, based on our observations, over 90% of the patients injured in the “Pager Explosion Trauma” who were referred to our hospital exhibited ocular involvement.Reference Daryabari, Hosseini Imeni and Hassanpour4 Among the 5 cases described in this manuscript, 100% of the patients sustained ocular injuries. This rate is significantly higher than that observed in the 2020 Beirut explosion, considered one of the largest non-nuclear explosions in history.Reference Daryabari, Hosseini Imeni and Hassanpour4, Reference Odhiambo, Guthua and Macigo10, Reference Carley and Mackway-Jones11 The severity of ocular injuries in our patients was also notably high, with 30% of eyes (3 eyes) being auto-eviscerated, and most of the other eyes failing to achieve favorable outcomes.
In addition, injuries to the hands and face of these patients were notably high. Our observations indicated that hand injuries in most wounded adults were on both sides because the explosion of the pagers occurred after the ring of an arriving message, necessitating the use of both hands to respond.Reference Gebeily, Pearson and Gauthier-Villars2 However, in children, since most were merely taking the ringing pagers to deliver to their parents, they were injured in only one hand. Conversely, the rate and severity of facial and ocular injuries in children were much higher than in adults, possibly due to children using pagers very close to their faces.
Conclusion
The “Pager Explosion Trauma” in Lebanon resulted in a significant number of innocent children being accidentally injured while carrying or playing with pagers. This tragic pager explosion led to devastating pediatric injuries characterized by severe ocular, facial, and hand trauma. The extent of their injuries was much more severe than that of adults due to the short distance at which they were holding the pagers. All 5 children in this case series experienced disabling injuries, profoundly impacting their quality of life and functionality, with little hope for recovery.
Acknowledgments
The authors would like to thank the staff and medical team at Baqiyatallah Hospital for their support and dedication in the care of the patients involved in this study, and the patients for their high level of patience and tolerance for pain and treatment procedures, despite their young age and the severity of their injuries.
Author contribution
All authors contributed to conceptualization, data collection, surgical management, manuscript writing, and final revision. All authors reviewed and approved the final manuscript.
Funding Statement
No funding was received for this work.
Competing interests
None.
Ethics standard
This brief report was reviewed and approved by the Baqiyatallah Hospital Ethics Committee. Written informed consent was obtained from the parents or legal guardians of all patients.
Open access
