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ORIGINAL ARTICLE
Year : 2022 | Volume
: 9
| Issue : 5 | Page : 381-384
Kite string vascular injuries: Management of uncommon vascular injuries with common suggestions
Devender Singh, Aruna Sree Kottilliyil, Basavarajendra Anurshetru
Department of Vascular and Endovascular Surgery, Yashoda Hospitals, Hyderabad, Telangana, India
Correspondence Address:
Dr. Devender Singh
Department of Vascular and Endovascular Surgery, Yashoda Hospitals, Hyderabad, Telangana
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijves.ijves_66_22
Introduction and Objectives: Vascular injuries due to kite string are uncommon but are associated with significant morbidities and mortality. With the increase in the sharpness of the string, the incidence of these injuries is on the rise not only to flyer but also to the innocent other people. We present our experience as there is a relative paucity of data and literature on this subject and suggest measures to control. Methods: Between January 2016 and January 2022, six patients suffered vascular injuries due to kite string (manja) and were admitted to the vascular unit of tertiary care center. The medical histories of the patients were reviewed retrospectively and analyzed. Initial treatment included hemorrhage control by direct pressure or packing and fluid resuscitation and airway establishment by intubation (if required). Neck injuries were divided into three zones. All patients were subjected to computed tomography angiography followed by emergency exploration and repair. Results: Males are most commonly affected. The most common age group affected was 3050 years. Majority of these patients were travelling on a two wheeler. The neck was most commonly involved with primarily venous injuries. Four patients had injuries in Zone II and one patient in Zone I. One patient had a deep laceration around the ankle with vascular and significant soft-tissue injuries. The injuries were of the jugular veins, external carotid artery, trachea and tibial artery, nerve, and tendoachilles (complete tear). All the major vascular injuries were either repaired or ligated. There was no major morbidity or mortality. Conclusion: Kite flying is a popular sport in the Indian subcontinent. Vascular injuries due to sharp string can lead to grievous injuries or may be fatal. This study attempted to enlighten these dangers and emphasize that potential threats have to be understood and addressed adequately.
Keywords: Kite string, manja, slit neck, vascular injury
Kite string leading to vascular injuries is an uncommon cause and only seen in limited parts of the world. Kite flying is a popular sport in the Indian subcontinent and is celebrated on the eve of winter festivals in January and on August 15 in India. Over the years, these celebrations have now turned into competitions. Children and young adults compete against each other with an objective of bringing down kites of their competitors and be the last kite flying. To win or cut the kite of another person, people use dangerous methods to make their string strong, like coating it with glass and glue (also known as manja); this will make the string 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. As a result, the incidence of injuries resulting from kite strings is on the rise, not only among flyers but also among unsuspecting passerby, especially when flown in populated areas. Deep injuries to the major vessels can lead to grievous injuries and sometimes fatal. We retrospectively reviewed a series of patients who presented with vascular injuries due to kite string at a tertiary care hospital in Southern India. We present our experience as there is a relative paucity of data and literature on vascular injuries due to kite string and also suggest measures for its prevention.
MethodsBetween January 2016 and January 2022, six patients suffered vascular injuries due to kite string (manja) and were admitted to the vascular unit of tertiary care center. The medical histories of the patients were reviewed retrospectively and analyzed.
Initial treatment included hemorrhage control by direct pressure or packing, and fluid resuscitation and airway establishment by intubation (if required) by the emergency departments (ED). Advanced trauma life support protocol was followed for all patients. The oral pharynx was carefully examined, and any internal wound or blood was noted. Respiratory distress, hoarseness, subcutaneous emphysema, and associated injuries were also evaluated. The neck was divided into three zones: I, below the cricoid cartilage; II, between the angle of the mandible and the bottom of the cricoid cartilage; and III, above the angle of the mandible. A proper neurovascular and soft-tissue injuries examination was done for limb injuries. All patients were subjected to computed tomography (CT) angiography followed by emergency exploration and repair.
The demographics of the patient (gender and age), mechanism of injury, time spent at the scene and in transit to the hospital, vital signs on admission, time interval between the initial injury and required operation, injuries to organs, type of surgical procedure required by the patient, presence of postoperative complications, length of stay (LOS, measured in days), and mortality were recorded.
ResultsIn total, six patients (four men and two women) were evaluated in the present study. The mean age of the patients was 40 years (range: 3050 years), and all of the injuries were caused by kite strings coated with manja. Four of the victims were riding a motorcycle, one victim was riding a bicycle, and one was walking.
The mean average time spent by the prehospital team transporting patients to the hospital and assisting victims at the scene was 5 min ± 30 min; however, the total time varied from 5 to 8 h. In two cases, the patients were transferred from other hospitals after a few hours in their ED. Except for two patients who were brought by those who witnessed the incident nearby hospital, others were transported to the ED by the emergency team.
Three patients were hemodynamically unstable due to deep neck wounds with profuse bleeding and were resuscitated with fluids and blood products [Figure 1] and [Figure 2]. One patient presented in shock with a tear in the trachea and was intubated on arrival. The other two patients were hemodynamically stable on admission; one of them had deep laceration of the leg around the ankle. Except for the patient who was intubated on admission, the evidence of respiratory distress was not observed. All the patients were subjected to CT angiography for the proper evaluation before shifting to the operation theater.
All patients were found to have neck injuries in Zone II [Figure 3], except one who sustained injury to the leg and ankle [Figure 4]. The pharynx and esophagus were intact in all the patients. None of the patients had serious head injuries. In all of the cases, penetrating neck injuries were immediately explored because the wounds were deep and had transected the platysma. All of the injuries were confirmed during the operative exploration. In five of the patients, the surgical team used the cervical wound to access the injury.
Most patients had injury to the skin, subcutaneous tissues, platysma, strap muscles, and sternocleidomastoid. The external jugular vein was injured in five patients. In a patient who was bleeding profusely, he was found to have injuries to the branches of the external carotid artery. None of the patient was found to have injury to the major vessels in the neck. All the neck vascular injuries were treated with ligation.
A tracheostomy was placed in one patient and removed after 4 weeks. Posterior tibial artery and nerve were repaired primarily after the repair of tendoachilles [Figure 5]. Peri- or postoperative complications did not occur in the patients who underwent operations, and the mean average LOS was 3 days. The follow-up period ranged from 1 month to 2 months [Figure 6].
DiscussionKite flying in India is seen as a competitive sport and most commonly seen in January around the festival of makar sankranti. 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. Recently, manja made of polypropylene thread (nylon) called “Chinese manja” (because it was imported from China) became very popular due to its increased strength, which provided an edge to kite-flying competitors.
Various types of injuries occur while flying kites. 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] The secondary impact injuries occur when manja gets wrapped around the feet of a person leading to fall on ground causing fracture of extremities or can cause a pillion rider to fall from a moving two-wheeler leading to life-threatening injuries to the head or torso.[2]
Vascular trauma due to kite string can be lethal and often associated with devastating injuries to the neck and extremities. In the neck, they are divided into three zones, which helps in initial assessment and management based on the limitations related with surgical exploration and hemorrhage control in each zone. 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 I, 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 III lies between the horizontal plane passing through the angle of the mandible and the skull base. Surgical access to Zone III 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. We had five patients with Zone II injuries.
Only a few cases of ankle injuries with transaction of tendoachilles are reported in the literature due to kite string.[3] Ankle injuries with the total transection of posterior tibial artery, nerve, and tendoachilles are not reported so far.
The management of neck injuries should begin in the ED. If there is respiratory distress or profuse hemorrhage, resuscitation should be immediately done to secure the airway with intubation or tracheostomy and stop the hemorrhage. Once the patient is stabilized, an urgent CT scan of the neck or portable chest X-ray may demonstrate further injuries, namely, shift or compression of trachea, laryngeal or pharyngoesophageal injury, vascular injuries, or subcutaneous emphysema.[4],[5] A contrast swallow can be done to rule out the esophageal perforation. The timing of the neck exploration is very important. If there is increasing respiratory distress due to a tension hematoma or if there is any clinical evidence of uncontrolled hemorrhage, then urgent neck exploration should be done.
Intraoperative wound management is the same as most other traumatic wounds. Care should be taken to remove any residual foreign body. A careful neurovascular examination is warranted because the depth and damage are maximum at the center and deeper injuries may be missed by an unsuspecting eye, which may see the wound as just a clean superficial laceration. Thorough and gentle lavage with a normal saline is a must because the wound often contains fine glass particles that stick to the tissues as the thread sinks deeper while cutting.[6],[7] Hematoma should be evacuated and wound should be explored for vascular injuries. All the major vessels in the vicinity of the wound should be dissected, and if found to be injured, then it should be ligated or repaired. Usually, the neurovascular structures and tendoachilles are repaired end to end due to a sharp cut by the string. Any injury to the pharynx, esophagus, or larynx should be anticipated depending on the zone of injury and if found should be repaired. Tracheal injury should be managed with an end-to-end anastomosis.
ConclusionKite flying demands caution and responsible action on the part of the people and the local government authorities. Prevention should be advocated among both groups at risk. Pamphlets and information booklets should be distributed to everyone. Awareness programs and announcements can also be made over the television, radio, and print media to make people aware of the potential tragedies of a fun sport. Wearing gloves and head gear and covering exposed extremities should be encouraged for kite flyers. The local government authorities could organize formal kite competitions to discourage unwarranted kite flying from rooftops. Designating open spaces for kite flying cannot be emphasized more. Such spaces should be away from roads, power lines, or grids, airports, bird sanctuaries, and other such hazardous areas. Medical facilities for immediate care and transport should be made available during such events.
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Conflicts of interest
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