Kite String Injury to the Head-and-Neck Region

A Review

Abstract

Flying kite is a popular sport among children although many adults also fly kites in festive seasons. People frequently fly kites to celebrate the arrival of spring. These kite festivals feature a sport called kite fighting, in which competitors attempt to sever the string of a rival kite with their own kite. The majority of injuries are sustained at the time of flying kites due to falls, cuts, neck injuries, or even death. Injury to the head-and neck region by kite string is often fatal. These injuries can range from a superficial laceration to profound muscle, tendon, artery, or nerve injury. Flying kite is associated with simple injury to grievous trauma. The severity of the injury is determined by the abrasive materials used on the kite's string to improve its cutting capabilities. Injuries caused by flying kites are usually avoidable. Because the neck is frequently exposed while riding a motorcycle, this is likely the source of the high number of injuries in this area. Injuries caused by kite string can be avoided. The preventive methods include choosing a safe site and improving knowledge of the kite string's potential threats. There are not many research articles concerning kite string injury in head-and-neck area. This review article seeks to provide a complete overview of head-and-neck kite string injuries.

INTRODUCTION

Flying a kite is a popular pastime for people of all ages in several Asian countries.[¹] Any frame wrapped in cloth or plastic and attached to a long string that is flown in the air is referred to as a kite.[¹] Kite flying is a popular sport in many nations, particularly in the Indian subcontinent and South America.[²] In India, during the Makar Sankranti festival, kite flying and kite battles are popular among almost everyone in the neighborhood.[¹] The nature and types of kites vary from region to region. Currently, keeping competition in mind, players are using dangerous sharp strings to the kite. Hence, incidences of injuries are happening by kite string, not only among flyers but also passers-by, particularly when kites are flown in populated locations. Kite string injuries range from abrasions to full-thickness lacerations that harm the deeper structures. Face and hand injuries are common among kite flyers.[³] They are also prone to falling from roof-tops and suffer more grievous injuries.[⁴] The common areas of the body injured by kite string are the head-and-neck area (59%) and upper limbs (28%).[⁵] Kite flyers frequently sustain facial and hand injuries. Others should be aware of the process of kite string injury and several safety precautions to avoid deadly accidents while kiting. Neck injuries caused by kite flying are occasionally recorded in medical journals. Here, this review article is focused on the mechanisms of injury, implications of kite string injury, and management along with safety measures.

METHODS OF LITERATURE SEARCH

Current research publications on kite string injury in the head-and-neck region were found using a variety of methodical methodologies. We began by conducting an online search of the Scopus, PubMed, Medline, and Google Scholar databases. Preferred Reporting Items for Systematic Reviews and Meta-Analysis standards were used to create a search strategy. Other research articles were discovered manually from the citations using this search approach, which recognized the abstracts of published works. Eligible studies included randomized controlled trials, observational studies, comparative studies, case series, and case reports. The total number of articles was 54 (26 case reports; 10 cases series; and 18 original articles) [Figure 1]. This paper focuses solely on head-and-neck kite string injuries. This research looks at the history, epidemiology, mechanism, management, and prevention of neck injuries, as well as kite string injuries. This research lays the groundwork for future prospective trials on kite string injuries in the head-and-neck region. It will also serve as a springboard for further research on kite string injuries in the head and neck.

Figure 1: Methods for literature search

HISTORY

Kites are said to have originated in China and have since spread to other regions of the globe.[⁶] Kites have been used for a variety of purposes throughout history, from battle in ancient China to a belief that it brings good fortune in Japan; from capturing fish in New Zealand to preventing birds from damaging crops.[⁷] Flying kites, on the other hand, is now considered a celebratory activity. In the Indian subcontinent, kite flying competitions and festivals are prominent. Makar Sankranti, also known as Uttarayan, is a prominent festival in India, especially in the central, northern, and western regions.[⁸] During a thunderstorm, Benjamin Franklin experimented with electricity by flying a kite with a silk thread.[⁸]

EPIDEMIOLOGY

Flying kites are a more than 2000-year-old celebratory sport that originated in China and Malaysia.[⁸] Kite flying is a popular springtime pastime in various Asian nations, including India, China, and Pakistan.[²] Kites were frequently employed by the Chinese to lift spies into the air to locate enemy sites. People in Japan often wear colorful wind socks shaped like carp fish in the hopes of attracting good luck. Kites are used by fisherman in New Zealand to catch fish. Kites are used by farmers in various Asian countries to drive away birds that eat their crops.[⁹] Some individuals in Pakistan fly kites at night with the use of strong searchlights. The kite is known in Afghanistan as Gudiparan, which means “flying doll.” Several South American countries celebrate the winter season by flying kites, which can result in serious or even life-threatening injuries from a kite string. Most of the neck injuries due to the kite string can occur during peak seasons which often hit the headline in local newspapers.[¹⁰¹¹] Many cases of kite string injuries were reported in the newspaper. One news from China showed that five persons faced throat injuries where one of them suffered from a cut injury to artery and a vein.[⁹] Multiple deaths and injuries were reported from Pakistan in February 2006, according to another account published in The New York Times, and over 600 kite fliers were jailed for inappropriate kite string use. An individual from Mumbai suffered a voice box rupture, according to an Indian news report owing to a kite string injury to the neck and another individual from Chennai. They were both on motorcycles.[¹²]

RELEVANT NECK ANATOMY

The penetrating neck injury has been classified as per Roon and Christensen's classification.[¹³] The classification has three zones [Figure 2] such as Zone 1: The area between the clavicle and the cricoid cartilage contains key circulatory structures such as the subclavian artery and vein, the jugular vein, the common carotid artery, and the esophagus; Zone 2: The common carotid artery, internal and external carotid arteries, jugular vein, pharynx, larynx, and cranial nerves X, XI, and XII are all found in this area, which runs from the cricoid cartilage to the angle of the jaw.; and Zone 3: It ranges from the mandible's angle to the base of the skull.

Figure 2: Different zones of the neck

MECHANISM OF NECK INJURY

Kite flying requires two people: One to fly the kite and the other to hold the wooden drum with a string wrapped around it (Charkha). For strength and sharpness, the kite is frequently flown on a strong processed thread or, on rare occasions, a thin metallic wire. The kite's string is typically covered with “manja,” a mixture of pulverized glass and water-soluble paper glue.[¹⁴] The sharp, cutting action of “manja” causes many people to suffer severe to life-threatening injuries every year.[¹⁵] Along the kite's string, a coating adhesive containing finely granulated glass powder formed from fused bulbs and fluorescent glass tubes creates the “manja.” This string covering is known as “cerol” in Brazil. There are several coatings that may be applied for making extra sharpness of the string of a kite. The goal of sharpening the string's edge is to allow a kite-flying enthusiast to knock a competitor's kite out of the sky or make it fly. This glass spiked string not only cut the competitor's kite string but also make deadly injury to the body part if a person faces such string. This string is so deadly that it can cause injury to the important vessels in a way like cut by a sharpened cutting knife. The person flying the kite has the potential to injure their palm. If injury is severe, can cause total transaction of tendons and result in cutthroat-like injury in the neck. In the neck, it can cause deadly injury by cutting the airway and major blood vessels of the neck [Figure 3]. Falling from a height can potentially cause injury to someone flying a kite from a rooftop. This causes polytrauma since the person may move around while staring at the sky. The individual who is not flying the kite is more likely to get injuries to the head-and-neck region above the collar bone [Figure 4].[¹⁶] Riding a motorcycle can result in serious and occasionally deadly injuries.[¹⁶] It can cause an imbalance in addition to string cause harm to the biker and result in a major road accident. Sometimes, death may happen when the copper material is made for string touching the high voltage power lines and cause an electric burn or electrocution.[¹⁵]

Figure 3: A fatal injury of the neck and airway by kite string

Figure 4: Injury of the neck by kite string

KITE STRING INJURY AND ITS IMPLICATIONS

Kite flying is a popular celebration among kids and teenagers. They often ignore hazards of the kite string injury. There are several types of injures during flying kites. While preparing the string, injuries to the fingers and hand are common. The sharp string may inflict figure injuries while flying the kite. Other forms of injuries are caused by kite fliers falling from rooftops while flying the kite or attempting to grasp free-drifting kites while staring up at the sky. Riders on motorcycles and bicycles may have their necks and limbs dragged by wayward kites, resulting in serious and fatal injuries, including injuries to the nasofacial area and airway.[¹⁷¹⁸] Injuries sustained by two-wheeler riders are more severe than those sustained by pedestrians, as the severity of the injury is determined by both the vehicle's speed and the movement of the kite string. Electrical injuries have been reported in certain occasions while flying the kite in the rain. Due to kite string injury, a rare and dangerous complication called pseudoaneurysm of the wounded vessel might develop.[¹⁹] There may be electrical injuries are associated with kite string which results in significant morbidity and mortality. Electrical injuries have a severe impact on children and may cause permanent deformities. Electrical injuries have long-term hazards on the central nervous system, ophthalmic and skeletal complications, and make life miserable.[²⁰] Electric wires usually pass in residential areas are prone to electrical injuries during flying the kite. Because the victim is typically unaware of the presence of “manja” string in the nearby environment, the depth of the kite string injury is usually larger in patients driving than in patients strolling. Due to the fact that boys are more typically active in kite flying and related activities than girls, males have a higher frequency of kite string injuries than ladies.[²¹] Kite string can sometimes cause ocular injuries including globe penetration or lid damage.[²²] If injuries result from falling from a height while flying the kite, or when the string is wrapped around an individual's lower limbs, causing them to fall from a height, or when moving two-wheelers become entangled by kite strings, causing injuries to the eye or head.[²²]

MANAGEMENT

Treatment for neck injuries should begin in the emergency room. Patients with skin injury, subcutaneous tissues, and platysma are managed in trauma bay. Cleaning the wound with saline and betadine should be done aseptically as possible. Wounds are sutured in layers after appropriate hemostasis. The contaminated wound is addressed like a postprocedure infection with systemic broad-spectrum antibiotics. If there is respiratory difficulties or massive bleeding from the wound site, resuscitation should be done immediately for securing the airway by intubation or performing emergency tracheostomy and stop bleeding from local site.[²³] Tetanus vaccine, a thorough cleansing of the wound region, and surgical repair as needed are all part of the kite string injury treatment regimen. In the vast majority of situations, the basic wound closure in layers is required. After the patient has been stabilized, immediate imaging such as a computed tomography scan of the neck or a portable chest X-ray may be used to determine the extent of the damage.[²⁴] Imaging is also helpful to check any compression or shifting of the trachea, larynx or pharyngeal/esophageal trauma, vessel injuries, or development of subcutaneous emphysema.[²⁵] Barium swallow can be performed to rule out any tear in esophagus. The timing of exploration of the neck is critical in the treatment of such an injury. If the patient presents with increasing respiratory distress by tension hematoma or if there is any evidence of uncontrolled hemorrhage then emergency exploration of the neck must be required. Temporary tracheostomy can be done in case of airway injury to overcome the extensive laryngeal edema.[²⁶] When a tracheostomy is performed, it is usual practice to investigate the neck and do endoscopy. Intraoperative management of wounds is similar to other traumatic injuries. Optimum care must be taken to remove any residual foreign objectives in the wound. Antibiotic solution must be applied to the wound completely. The hematoma must be removed, and the incision should be examined for vascular damage. Any major vessel near the wound should be dissected and ligated if it is found to be damaged. If there is any injury to the pharynx, esophagus, or larynx should be repaired. If there is tracheal injury by kite string, it should be managed with end-to-end anastomosis.[²⁷] It is recommended to keep a drain in the neck for at least 48–72 h and such patients should be actively treated with broad-spectrum antibiotics and analgesics. A check fiberoptic endoscopy should be performed in the postoperative phase to verify vocal fold mobility and rule out any visceral injury. Long-term complications such as nerve damage, swallowing issues, fistulas, and unsuccessful decannulation should be monitored.

PREVENTIVE MEASURES

Injuries associated with a flying kite are preventable. Appropriate preventive measures include a selection of safe locations for flying kites (like open beaches or fields) and keeping a safe distance from electricity cables, telephone lines, trees, people, and animals. Sometimes, kite flying should be banned by authorities during festive seasons.[²⁸] To keep wayward kite strings from sliding over their necks, many bikers employ bent long rods in the front and rear of their motorcycles. To avert such deadly casualties, government officials should prohibit kite flying near highways and major roadways. Kite merchants should be prohibited from selling coated thread, and only cotton, linen, or nylon should be allowed. Flying a kite in open fields, away from power lines, and in dry weather is recommended.[²⁹] Wet kite string is an excellent conductor of electricity and can result in electrocution. If the kite's string becomes entangled in electrical cables, the kite or its string should not be disturbed. Kite flying is difficult to prohibit in India because it is seen as a fun festival sport during the festive season. In terms of public sentiment and interest, however, cautious offseason bans can be encouraged.

CONCLUSION

In many cultures around the world, kite flying is a popular sport for youngsters. Kite flying may appear to be like blossoms floating in the breeze, yet it is one of the most dangerous hobbies in the world. Kite flying is linked to everything from minor cuts to serious lacerations or brain damage. The severity of the injury is determined by the abrasive substance that is frequently used on the kite's string. The possible dangers of kite flying should be taken seriously and addressed appropriately to avoid life-threatening accidents. There is a need of increasing awareness of the possible hazards of kite flying and also social counseling should be offered to families which can be helpful to decrease the incidence of injuries. Injuries associated with kite string are preventable.

Declaration of patient consent

The authors declare that they have obtained consent from patients. Patients have given their consent for their images and other clinical information to be reported in the journal. Patients understand that their names will not be published and due efforts will be made to conceal their identity but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.