Change in spectrum of hand injuries during COVID-19 lockdown period: Increase in mixer grinder and domestic violence related injuries in lieu of trauma sustained in outdoor activities

INTRODUCTION

At 2000 h on March 24, 2020, a nationwide lockdown was announced by Indian government, beginning 0000Hrs on March 25, limiting the outdoor movements of one-sixth of humanity (1.3 billion Indians). The aim was to limit the community transmission of the SARS-CoV-2 virus and flatten the curve in ongoing pandemic of COVID-19 disease.^[1-3] It was preceded by a 14 h voluntary public curfew on March 22 (Sunday).^[4] It is a fact that India is a developing country and does not have the health-care infrastructure to deal with a large number of patients requiring hospitalization, intensive care, and ventilatory support as a result of anticipated sudden surge in COVID-19 affected individuals in the absence of preventive and social containment measures, unlike in the developed countries, namely, USA, UK, etc.^[4] Therefore, prevention rather than cure, was the only possible solution for India. The nationwide lockdown restricted people from stepping out of their homes. All transport services were suspended with the exceptions for transportation of essential goods, fire, police, and emergency services. The ongoing school board examinations were postponed. Educational institutions and offices shifted to online mode and availed services such as Zoom, GoToWebinar, FreeconferenceCall for classes, and Livestorm for meetings. All physical conferences were postponed, and many shifted to online mode. Health care and other essential services and their manufacturing were exempted. Anyone who failed to follow the restrictions could expect to be prosecuted under appropriate laws.

All the residents of India were advised to stay at home. Those could start to work from home. India is a developing country, where most of the families in metropolitan cities have both husband and wife working to earn the livelihood. Some are nuclear, but most families have elderly parents staying with them. During daytime, nearly, all children are at school. Most such middle-class families stay in group housing societies, gated complexes and flats. Household work in these families is carried out mainly by part-time general duty workers, who visit a few hours in morning and/or evening to do dusting and cleaning, laundry, and cooking. Most such part-time workers stay within walking distance in low-income housing societies/shanties/huts/jhuggis in crowded areas with low sanitation.

The initiation of nationwide lockdown also restricted the movement of these household workers, as even those who stayed near the housing societies were barred entry into these complexes for the dual purpose of honoring the social distancing guidelines and avoiding the transmission of respiratory infections from crowded low sanitation areas to these societies. However, they were taken care of economically, because as per government directive, they were to be paid their salaries, irrespective of work. As a result, the burden of household work in the middle-class Indian families fell on those, who were unaccustomed to it, namely, the husband and wife, and as far as, cooking was concerned, mainly the wife.

This sudden change in lifestyle of families took its toll mainly on the working adults. Not only did they had to carry out their office work online from home, they also had to deal with constant demands from children, who were now “always at home,” carry out the various household chores to which they were unaccustomed, as well as meet the needs of aged parents. Many ordinary tasks were made more cumbersome by epidemiological needs such as wearing masks and going out to buy groceries, standing in lines for essentials, stoppage of e-commerce and e-deliveries of routine household needs, sanitizing of all purchase with the help of isopropyl alcohol, rigorous washing of all fruits and vegetables, painstaking cleaning of all frequently touched surfaces, and the house with sodium hypochlorite-based solutions.

All this pressure combined with unfamiliarity with the kitchen gadgets and relentless unaccustomed work translated to injuries, especially those of the hand in these working adults.

MATERIAL AND METHODS

The data were recorded from the emergency department and the department of plastic surgery of a tertiary care hospital in New Delhi. The study was approved by the hospital local ethics committee. In our hospital, the department of plastic surgery witnessed a sudden increase in finger/hand injuries due to mixer grinder during the nationwide lockdown.^[5,6]

Case records of all upper limb injuries including hand injuries in the lockdown period from March 25, 2020, to May 17, 2020, a period of 54 days were examined. There were a total of 32 cases of hand injuries due to mixer grinder, 7 cases of self-inflicted and intended wounds on upper limb, 4 door closing injuries of the hand, 2 cases of scald burns to hand, and 2 cases of upper limb injuries sustained accidentally at home. On the other hand, hand injuries related to road side accident and industrial accidents were conspicuous by their absence.

RESULTS

There were 32 (68.08% of total hand injuries) cases of mixer grinder injuries to the hand. All patients were females of age group 25–35. All patients were right handed with injuries in the dominant hand. There was no case of hand injuries due to road side accident or industrial trauma in this period.

The records of emergency department also showed 7 cases (14.89% of total hand injuries) of domestic violence related hand injuries. Five of these were self-inflicted in a fit of rage when the patient smashed his dominant right hand over a glass table or door. All five were males. The remaining two were female patients, when they incised the skin on volar aspect of their non-dominant wrist or forearm. The main wound was surrounded by parallel superficial incised wounds, typical of hesitation wounds. Both these patients were females. All these seven patients were in the age group of 35–45 years.

In addition, four cases of door closing injuries to digits (all children below 10 years), two cases of scald burns to hand, and two cases of accidental injuries to upper limb sustained at home also came during this period. These have been included in miscellaneous injuries.

Detailed history revealed that all the female patients with mixer grinder injuries were infrequent users of the machine, though they had some familiarity with the machine. While 12 patients got injured when they were cleaning the machine without unplugging it, 18 patients were injured as a result of error of judgment/precision while multitasking. Two patients were distracted as they were talking on phone held in other hand.

All these patients underwent thermal screening and quick evaluation for COVID-19 disease. However, as these were emergency cases, there was no time to wait for RT PCR test. They were presumed COVID-19 positive and taken up for surgery in operative room (OR) under monitored anesthesia care. PPE kits were worn by the surgeon and the staff and all universal precautions were taken. All injuries were at the level of finger PIP joint, thumb IP joint, or distal. After debridement, the cases in which there was exposed bone with insufficient soft-tissue coverage were treated with local, regional, adjacent flap (Atasoy/thenar/cross finger), or distant flap (groin) coverage. In cases without tissue loss, wound repair, reconstruction of fingertip, nail apparatus, and revascularization or replantation were done as per the need. The fractures were fixed with K wires. In case of severe/ multiple wounds with devitalization, shortening and closure of stump was done. The aim of the treatment was coverage of wounds with provision of painless and sensate fingertip with good IP and MP joint motion [Tables 1 and 1a].

In cases, five male patients, who sustained wounds by smashing their dominant right hand against glass table or doors, all patients had multiple lacerations in hand and forearm. Three patients had additional tendon injuries, which were repaired. Two of the five patients also sustained injuries to elbow and upper arm region with brachial artery injury. The median nerve was also injured in one patient. All these injuries were repaired primarily and the upper limbs were dressed and splinted in position of elbow flexion. The two female patients with injuries to non-dominant wrist and forearm had multiple parallel lacerations. In one of these, the palmaris longus tendon was found divided. All injuries and the tendon were repaired. The miscellaneous injuries were also dealt with as per protocol.

DISCUSSION

This is the first case series reporting the impact of lockdown on pattern of hand injuries coming to a tertiary care hospital in a third world country. The data were analyzed using SPSS software version 25.0.

CONCLUSION

During part of the lockdown period from March 25, 2020, to May 17, 2020, there was a spike in domestic mixer grinder injuries sustained while doing unaccustomed cooking work. Injuries were due to unfamiliarity with machine and task, lack of concentration, complacency, distraction by mobile device, and multitasking. Such injuries with associated morbidity are easily avoidable if due precautions are taken.

Second pattern change in lockdown period was a demographic change in suicidal attempt injuries sustained on non-dominant wrist. While earlier, these injuries were a result of anxiety due to poor performance in examinations in school-going students (age group 16–19 years), during the lockdown period, similar injuries occurred as a result of rage and frustration and conflict with the spouse in older age group (35–45 years) due to confinement at home and constant friction for long periods as a result of lockdown. The clinicians should be aware of these patterns as these could well be the new normal in the coming months. There was a decrease in injuries sustained due to assaults and conflicts, sports, school, and work activities, and this was along expected lines. In addition, no patients with hand injuries due to road traffic accidents or industrial accidents presented at our center during the lockdown period. This could be due to the preventive/protective effects of lockdown. This study is limited by the small number of patients. The psychological impact of lockdown and related mental health issues will need to be evaluated on a larger database.