Kite-string injuries: A case series.

Kites are very popular in India. Over the years, both kite-flying and kite-making skills have evolved. The conventional cotton threads that were used as kite string (manja) have been replaced by much cheaper and stronger Chinese manja, which is based on nonbiodegradable synthetic fibers. It is hard to break and has caused a sudden surge in dangerous kite string-related injuries. There are a lot of injuries usually sustained by kite-flyers, two-wheeler riders, and pedestrians. Very few case reports and case series have shown injuries related to flying a kite, which range from laceration of hand to fatal throat injuries. Secondary impact injuries attributed to kite string (manja) are rarely reported in the medical literature. We present a series of four cases with special emphasis on a patient, who sustained secondary impact injury with fatal outcome. Emergency physician should know that these trivial looking injuries can be associated with significant neck injuries. They can also cause significant secondary impact injuries. Copyright:

INTRODUCTION

Kites are popular in India. Kite flying is celebrated as a festival on the eve of Makar Sankranti and Basant Panchami in Indian states of Gujarat, Telangana, and Rajasthan and rest of North India in January and February. It is also a part of Independence Day celebration on August 15th. During this time in this part of India, kite-string injuries are commonly seen. Over the years, kite-flying and kite-making skills have evolved because of the increased competitiveness in this sport. To win or cut the kite of another person, people use dangerous methods to make their thread strong, like coating it with glass and glue; this will make the thread razor sharp and cut the other person's kite. These days people frequently use chemical or Chinese manja, which is based on nonbiodegradable synthetic fibers. It is hard to break and has caused a sudden surge in dangerous kite-string-related injuries. Razor sharp string can get entangled around a tree or a tall building. This entangled string serves as an obstacle for people going on the road. It can cause primary impact injuries such as entanglement of thread around the neck leading to minor laceration over face and neck, fatal neck injuries, or laceration of hand due to handling of manja.[1] Secondary impact injuries occur which manja gets wrapped around the feet of a person leading to fall on ground causing fracture of extremities or can cause pillion rider to fall from a moving two-wheeler leading to life-threatening injuries to head or torso.[2] Few case reports and case series have shown injuries related to flying a kite, which range from laceration of hand to fatal throat injuries. We were unable to find any case report of secondary impact injury. We present a series of four cases with special emphasis on a patient who sustained secondary impact injury with fatal outcome.

CASE REPORTS

Case 1

A 55-year-old lady was a pillion rider on a bike. Bike got obstructed by manja, and she fell from the bike. On arrival at the hospital, her airway was threatened, and she was immediately intubated. Her Glasgow coma scale (GCS) was E1VTM1; pupils were dilated and not reacting to light. Doll's eye and corneal reflex were absent. Noncontrast computerized tomography (NCCT) of the head and cervical spine was done. CT of the head showed right basifrontal/sphenoid and left temporal fracture. Fracture of skull bones were associated with bilateral fronto-temporoparietal acute subdural hematoma (right > left) with 8.5 mm of midline shift. It was also associated with diffuse subarachnoid and intraventricular hemorrhage. CT cervical spine did not show any abnormality [Figure 1]. A diagnosis of severe head injury was made, and due to GCS of E1VTM1 status with absent brainstem reflexes, the patient was managed conservatively on mechanical ventilation and vasopressor support. The patient went into cardiac arrest the next morning; cardiopulmonary resuscitation (CPR) was done for 30 min without return of spontaneous circulation. She was subsequently declared dead.

Figure 1

Noncontrast computerized tomography of the head showing bilateral fronto-temporo-parietal acute subdural hematoma right > left with 8.5 mm midline shift. Diffuse subarachnoid hemorrhage with gross intraventricular hemorrhage

Case 2

A 40-year-old male had an injury to the anterior aspect of his neck. It was a linear laceration which was 8 cm × 0.1 cm in dimension and extending to the right side of the neck [Figure 2]. NCCT of the head and cervical spine was within normal limits, and CT angiography of the neck was also done. It did not show any vascular compromise [Figure 3]. The patient was discharged after 6 h of emergency department (ED) observation.

Figure 2

A linear laceration of 8 cm × 0.1 cm in the Zone II of neck

Figure 3

Computerized tomography angiogram of neck vessels showing no vascular compromise (Zone II)

Case 3

Another 41-year-old male came with a similar history of injury to the anterior aspect of the neck. There was a laceration of 8 cm × 1 cm over the neck, breaching platysma muscle [Figure 4]. The patient was immediately shifted for CT angiography of the neck vessels which showed no injury to vessels [Figure 5]. After angiography, the patient was shifted to the operation theater (OT) for the repair of injury under general anesthesia. On exploration of the neck, it was found that right sternocleidomastoid and left strap muscles had a partial laceration. Muscles were repaired in layers. His stay in the hospital was uneventful and was discharged the next day.

Figure 4

A laceration of 8 cm × 1 cm over the Zone II of neck

Figure 5

Computerized tomography angiogram of the neck vessels showing no injury to the vessels (Zone II)

Case 4

A 28-year-old male had an injury to face by manja; it was over the cheek including the lower lip. This laceration was sutured under local anesthesia, and the aseptic dressing was applied over the wound. He was discharged from ED the same day after surgery review.

DISCUSSION

Kite flying in India is seen as a competitive sport. To win the competition, one tries to have a competitive edge by coating his/her kite's string with glass and starch known as manja. However, by doing so, they forget that this manja can injure both human and animals. The activities of kite flying and manja itself cause a lot of injuries. After reviewing literature, one can find injuries ranging from simple laceration injuries to hands and fingers to fatal cut throat with associated injuring to the neck vessels, leading to death. Another group of patients who suffers injuries due to kite string are two-wheeler riders and the pillion riders. Penetrating neck injury is defined as any breach to neck muscle platysma.[3] The common causes worldwide are stab wounds from violent assault, followed by gunshot wounds, self-harm, road traffic accidents, and other high-velocity objects.[4] Manja is not mentioned as a cause of penetrating neck injuries in the literature. In the Indian subcontinent, manja neck injury is not so uncommon. During the festival season, it becomes an important cause of penetrating neck injuries. Emergency physicians must be aware of neck zones and management of injuries to each neck zone. Neck is commonly divided into three distinct zones [Figure 6], which helps in initial assessment and management based on the limitations related with surgical exploration and hemorrhage control in each zone.[5] Zone I is the most caudal anatomic zone; it is defined inferiorly by the clavicle and superiorly by the horizontal plane passing through the cricoid cartilage. Vascular injury management is challenging in Zone 1, and mortality is high. Surgical access to Zone I may require sternotomy or thoracotomy to control the excessive bleeding. Zone II is between the horizontal plane passing through the cricoid cartilage and the horizontal plane passing through the angle of the mandible. The vessels in this zone are mobile and they can be approached easily and the mortality rate is low. Zone 3 lies between the horizontal plane passing through the angle of the mandible and the skull base. Surgical access to Zone 3 may require craniotomy, as well as mandibulotomy or maneuvers to anteriorly displace the mandible; due to difficulty in approach to Zone III, the mortality rate is high. In this type of trauma patients, initial assessment is done as per advanced trauma life support protocol developed by the American College of Surgeons. Few points are important and have been highlighted here [Figure 7]. Look for airway injuries as occult tracheal injuries can be missed. To avoid air embolism, the patient should be put in supine or in Trendelenburg position. Direct pressure should be applied over the wound to control the bleeding, and probing of wound should not be done in ED as this may lead to dislodgment of clot. Use two large bore intravenous cannulas for resuscitation and send blood for cross-matching. In case of injury to Zone I, one should suspect damage to subclavian vessels and avoid putting cannula on the same side to avoid extravasation of fluid. If during the primary survey the patient shows hard signs of neck injury such as active bleeding, shock, hematemesis, or massive subcutaneous emphysema, then the patient should be shifted immediately to OT. In a retrospective study by Gupta et al. which included 187 patients, the majority of the patients were male (n = 114). Patients aged 16–25 years formed the bulk of the population. Overall, the head and neck (59%) and upper extremities (28%) were the most frequently affected regions.[6] Kite-flyers are prone to injuries to their hands and face. Mir et al. presented a case of 11 patients who suffered injuries to the hand and their outcome. Seven patients had injuries in Zone II of the hand, while four patients presented with Zone III hand injuries. One of the patients had a nerve injury, and no patient had any major vessel injury.[7] Another case is reported in which a young adult who was riding a two-wheeler got the kite string entangled around his neck and had laceration over the neck. He had associated tracheal injury, leading to massive subcutaneous emphysema, and despite repair of the wound and tracheostomy and effective CPR, the patient could not survive.[8]

Figure 6

Classification of neck injuries on the basis of zones of the neck

Figure 7

Flowchart of emergency department assessment and management

CONCLUSION

Kite-flying and kite-string injuries can have severe consequences although kite flying cannot be banned in a country like India where it is seen as enjoyable leisure time and symbol of celebration. We can make common people aware of its sequel, through electronic media and also by information booklets and pamphlets. People should be encouraged to wear hand gloves and cover the exposed parts while flying a kite. There are some safety measures to be followed. Never fly a kite near power lines, which can be deadly. A blow of electrical current flowing through the body can be a life-threatening affliction and also never fly a kite near a road as it can cause a road traffic accident injuring both the kite-flyers and the vehicle riders.

Declaration of the patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient/relatives has/have given his/her/their consent for his/her/their image/images or the clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Applicable reporting guideline for case reports (CARE) was followed by the authors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.