Spectrum of Tendon Injuries Caused by Kite String (Manjha) during a Kite Flying Season

Kite flying is a common recreational activity in Indian subcontinent during the months of July to September.[1] It takes a competitive turn in the form of “kite fighting” which involves “taking down” the rivals' kite by cutting its string. The kite string is “enhanced” (commonly known as “manjha” in India) to give a competitive advantage and powdered glass is used for the purpose to give it a cutting edge.[2] [3] [4] [5] This makes kite strings dangerous with potential to cause severe injuries. Head and neck injuries caused by such kite strings are commonly reported, but the literature on tendon injuries remains sparse.

We wish to bring the spectrum of tendon injuries to your kind attention that are caused by kite string as we did retrospective review of prospectively collected data of all the patients who suffered tendon injuries caused by kite string from July 2016 to September 2016 and were treated in the Orthopedic Department of our tertiary level teaching referral hospital ([Table 1]). Out of the seven patients included in the study, six had injury to the upper limb ([Fig. 1]), whereas one patient had a tendoachilles tear ([Fig. 2]). Only three patients presented to us on the day of injury and hence underwent primary repair. The rest underwent delayed primary or secondary repair due to delayed presentation. Three of the injured were pedestrians, two were riding cycles, and two while flying kites. Six patients had injury to tendons of the hand (four on dominant side and two on nondominant side) and one sustained injury to the tendoachilles tendon. None of the cases had associated bony injuries. All injuries were sustained in urban areas. Three of the injured were pedestrians, two were riding cycles, and two while flying kites. All injuries were sustained in the evening when kite flying is most prevalent. All patients had good clinical results at 12-month follow-up.

Table 1 Details of cases of kite string related tendon injuries included in the series

Age/sex	Tendon injured	Delay in presentation	Mode of injury	Treatment	12 months outcome
10/M	Tendoachilles	<24 hours	Ankle got entangled in kite string while running	Primary repair by Krackow's stitch	Returned to sports
15/M	EDC 3rd digit	6 weeks	While trying to unentangle herself from kite string while walking on street	Secondary repair by modified Kessler's technique	Full range of flexion and extension without any lag
23/M	FPL	2 days	Kite string got entangled around hand while flying kite	Delayed primary repair by modified Kessler's technique	Full range of flexion and extension without any lag
18/M	EDC 5th digit and EDM	<24 hours	Kite string got entangled around hand while flying kite	Primary repair of EDC 5th digit and EDM	Full range of flexion and extension without any lag
42/M	FPL	<24 hours	Patient was riding cycle when he raised his hand to protect his face and neck from kite string injury	Primary repair by modified Kessler's technique	Full range of motion, grip strength 81% of contralateral side
55/M	FDP 3rd digit	2 days	Patient was riding cycle when he raised his hand to protect his face and neck from kite string injury	Delayed primary repair by modified Kessler's suture	Full range of motion, grip strength 89% of contralateral side
20/M	FDP 2nd digit	3 weeks	While trying to unentangle herself from kite string while walking on street	Secondary repair by modified Kessler's technique	Full range of motion, grip strength 94% of contralateral side

Abbreviations: EDC, extensor digitorum communis; EDM, extensor digiti minimi; EPL, extensor pollicis longus; FPL, flexor pollicis longus; FDP, flexor digitorum profundus; M, male.

Fig. 1 (A) Healed scar mark just proximal to the knuckle of the 3rd digit. (B) Lag of terminal 30 degrees of extension at metacarpophalyngeal joint due to the tendon injury. (C) On exploration of wound, cut ends of the middle finger extensor digitorum tendon found. (D) Tendon repair done by the modified Kessler technique using 5–0 prolene suture. (E) Complete extension and (F) flexion of middle finger, with no extensor lag at 3 months of postrepair.

Fig. 2 (A) Wound over the posterior aspect of ankle. (B) Exploration of the wound revealed cut ends of tendoachilles. (C) Repair done by the Krackow technique. (D) Heel push off at 3 months of postrepair.

The origin of kite flying can be traced back to China, as far as 3,000 years ago. Kite flying becomes a popular activity among children and young adults in North India, Pakistan, China, and Brazil during the months of June to September.[1] [2] [3] [4] [5] Kite string injuries can be sustained by kite flyers, two-wheeler riders, and pedestrians. These injuries may be broadly classified into two groups as follows: (1) primary impact injuries: for example, 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 manjha; and (2) secondary impact injuries: for example, manjha gets wrapped around the feet of a person leading to fall on ground and subsequent fractures or it can cause pillion rider to fall from a moving two-wheeler leading to life-threatening injuries to head or torso.

Although there are occasional case reports and a few case series on kite string–related injuries in literature, but the true extent of the hazard posed by this has never truly been uncovered. This is perhaps due to the wide spectrum of injuries getting distributed across various departments and also since simple lacerations seldom come under the scrutiny of researchers and seasonal nature of these injuries. Shahid Mahmood et al studied 170 patients of kite string–related injuries those were treated by neurosurgeons, orthopaedic surgeons, trauma surgeons, burns and plastics department, or emergency department only.[1] The authors also raised the concerns about the as yet unreported aspect of psychological trauma caused by such injuries.

Kite strings were made with cotton thread before nylon cord was introduced.[1] [2] [3] [4] [5] Competitive kite fighters, who while flying kites try to cut the kite string of other kite flyers using their own, use processed thick thread or occasionally a thin metal wire. Metallic powder, chemicals, and glass powder (from fused bulbs and fluorescent glass tubes) have been used to coat kite string to enhance its cutting effect. The coating on the wire is the reason behind severity and potentially fatality of kite string injuries. Polypropylene has become a popular material for making kite strings, since it has higher strength as compared with traditional materials.[2] This kite string, popularly known as “Chinese manjha” continue to pose risks to humans and birds

To conclude, kite string–related tendon injuries may be encountered in crowded urban areas and it usually involves upper extremities. The impact of such injuries is under appreciated and serious administrative steps (effective ban on “Chinese manjha”) need to be taken to nip the problem in the bud.

Publication History

Article published online:
29 October 2020

• References

• 1 Shahid Mahmood NA, Maqbool N, Nadeem IB. Kite related injuries during Basant season. Rawal Med J 2011; 36 (03) 218-221
• 2 Bagaria V, Nemande A, Joshi N. Achilles tendon rupture secondary to kite string (manja) injury: a rare etiology seen in two cases. J Foot Ankle Surg 2015; 2 (02) 90-93
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• 4 Gupta P, Jain A, Patil NA, Thakor R, Kumar S. Kite string injuries: a thin line between a harmless sport and grievous injury. Int J Community Med Public Health. 2018; 5: 2782-2785
• 5 Mir MA, Ali AM, Yaseen M, Khan AH. Hand injuries by the killer kite manja and their management. World J Plast Surg 2017; 6 (02) 225-229