|Year : 2014 | Volume
| Issue : 1 | Page : 30-34
Hand injuries from cassava milling machine in sub-urban Nigeria
Emmanuel E Esezobor1, Oluwafemi O Awe1, John E Onuminya2, Andrew E Dongo1, Osita C Nwokike2, Folake O Abikoye3, Edwin O Edonmwonyi2, Quincy O Aigbonoga1
1 Department of Surgery, Irrua Specialist Teaching Hospital, Irrua Edo State, Nigeria
2 Department of Orthopaedics, Irrua Specialist Teaching Hospital, Irrua Edo State, Nigeria
3 Department of Burns and Plastic Surgery, National Orthopaedic Hospital, Lagos, Nigeria
|Date of Web Publication||26-Aug-2014|
Emmanuel E Esezobor
Department of Surgery, Irrua Specialist Teaching Hospital, Irrua Edo State
Source of Support: None, Conflict of Interest: None
Background: Nigeria is the highest cassava producer in the world. The processing of cassava tubers into a valuable product involves grinding in locally fabricated machines. This process exposes the hand to injuries.
Aim: The aim of this study is to investigate the pattern of presentation and outcome of hand injury from locally fabricated cassava milling machines in our rural plastic surgery practice.
Materials and Methods: This is a prospective clinical audit of patients with hand injuries from cassava milling machines managed in Irrua Specialist Teaching Hospital from January 2010 to December 2011. Demographic data, type of injury and outcome were documented and analyzed.
Result: There were 33 patients who had injuries from locally fabricated cassava milling machines. Females in the second decade of life were mostly affected. Mutilating injury involving digits 2, 3, 4 and 5 of the dominant hand was the main finding. Although, no amputation was recorded, stiffness was a major complication.
Conclusion: We observed that the dominant hand of female teenagers is mostly at risk in locally fabricated cassava milling machine hand injuries. This injury is preventable.
Keywords: cassava milling machine, female, hand injury, teenagers
|How to cite this article:|
Esezobor EE, Awe OO, Onuminya JE, Dongo AE, Nwokike OC, Abikoye FO, Edonmwonyi EO, Aigbonoga QO. Hand injuries from cassava milling machine in sub-urban Nigeria. Afr J Trauma 2014;3:30-4
|How to cite this URL:|
Esezobor EE, Awe OO, Onuminya JE, Dongo AE, Nwokike OC, Abikoye FO, Edonmwonyi EO, Aigbonoga QO. Hand injuries from cassava milling machine in sub-urban Nigeria. Afr J Trauma [serial online] 2014 [cited 2019 Jun 19];3:30-4. Available from: http://www.afrjtrauma.com/text.asp?2014/3/1/30/139455
| Introduction|| |
The hand is the chief tactile organ of humans. Its grasping mechanism combined with great strength and finely controlled accuracy makes the human hand different from that of other mammals.  Since the hand plays this vital function, it is usually exposed to risk at home, in transit, at work and at play. , Injury to the hand can affect the physical and socio-economic status of an individual, family and society. The hand is a great asset for survival and its use in subsistence farming cannot be overemphasized. Nigeria is the highest cassava producer in the world, producing a third more than Brazil and almost double the production capacity of Thailand and Indonesia. Her current capacity is about 38 million metric tons per annum. Most of her production is from subsistence farming and is mostly for human consumption as against those produced from South America and Asia, which is mostly for industrial use from mechanized farming.  Whereas cassava processing in South America and Asia is done using advanced technology, a low cost cassava milling machine is used in Nigeria. This is a diesel powered machine which has a processing area made of a roller with a grating surface that presses against a firm smooth surface. This area of the machine is encased in wood with an opening at the upper and the lower part for loading of the tubers and retrieval of the milled product respectively [Figure 1]. Hand injuries from this machine are becoming common in our emergency room. With Nigeria aiming to double her current cassava production by the year 2020,  the impact of this goal on the health of the rural farmers will require some assessment. This study attempts to highlights the pattern of presentation and outcome of hand injuries from cassava milling machine in our suburban practice.
|Figure 1: Operator scooping cassava product from the locally fabricated cassava milling machine|
Click here to view
| Materials and Methods|| |
This is a prospective study of patients seen with hand injuries from cassava milling machine in Irrua Specialist Teaching Hospital from January 2010 to December 2011. Ethical approval was received from the institution's research and ethics committee. Demographic information, records of pre-hospital care, duration from time of injury to presentation and side affected were recorded. Injury description was also recorded using the Tic-tac-toe classification zones and system for mutilating hand injuries.  This classification divides the hand into 9 numerical zones with two imaginary vertical lines through the first and the third web space and two imaginary transverse lines through the metacarpophalangeal (MCPJ) and carpometacarpal (CMCJ) joints. Distal to the line through the MCPJ are zones 1, 2 and 3 which contains the phalanges while distal to the line through CMCJ are zones 4, 5 and 6 which contains the metacarpals. Between the line through the CMCJ and the crease of the wrist are zones 7, 8 and 9 which contains the carpal bones [Table 1]a. The injuries were further classified based on the injured tissue and vascular status. Roman numeral I-VII represents the orientation of the injury as follows; dorsal, palmar, ulnar, radial, transverse, degloving and combined while the alphabets A, B and C represents soft-tissue, bony and combined tissue loss respectively. The Arabic numerals 1 and 2 written in subscript represents vascularized and devascularized respectively [Table 1]b. The eventual outcome of treatment was also recorded. Data were presented in tabular and descriptive forms and analysis completed using SPSS for windows (version 16.0 SPSS Inc., Chicago, IL, USA).
| Result|| |
A total of 33 patients who had hand injuries from cassava processing machines were seen within the period. The Female: Male ratio was 2.7:1. The mean age was 28.2 (°16.2) years. The age group 10-20 years was the most affected constituting 33.3% (n = 11), followed by that between 31 and 40 years of age constituting 24.2% (n = 6) as shown in [Figure 2]. The right hand was more commonly affected by this injury (90.9% [n = 30]) and 72.72% (n = 24) of those who presented had their dominant hand injured [Table 2] and [Figure 3]. The mean duration from the time of injury to presentation to our accident and emergency department was 2.09 ° 1.28 h. Combined zones 2, 3, 5 and 6 injury was the most common presentation constituting about 72.7% (n = 24) of the patients seen [Figure 4]. All the studied patients had type 1C 0 injury [Figure 5], [Figure 6], [Figure 7], [Figure 8]. Most of the patients (69.7% [n = 23]) had no pre-hospital care and none had visited the traditional bone setter (TBS) before presenting to our center. None of the patients had any part of their fingers amputated. Apart from two patients 6.1% (n = 2) who had a full recovery of hand function, the rest developed stiff hands.
|Figure 2: Age distribution of patients injured by cassava milling machine|
Click here to view
|Figure 8: Antero - posterior view of the crushed fingers showing multiple fractures and dislocation of bones and joints|
Click here to view
| Discussion|| |
Hand injuries can occur from accidents at home during domestic chores, at play, in transit and at work. , Depending on the severity, they could be disabling affecting the social, economic and psychological state of patient.  The locally fabricated cassava milling machines are designed with little concern for safety. These machines are owned by small scale entrepreneurs who make them available for rent by people in the community to mill their cassava into flour. Although the miller loads the machine with the cassava tubers, the cassava owner tries to scoop the product from a reservoir [Figure 1]. Sometimes, they are tempted to push their hand further into the grinder in an attempt to evacuate their entire product leading to the hand being trapped. A recent literature review indicates that the average age of patients presenting with hand injuries is <30 years, , but others identified children to be a special age group at risk for injuries due to agricultural machines.  Hartling et al. in their study have reported that 60% of this patients were aged 15 years or younger.  This is in line with our finding that cassava milling machine hand injuries are commoner among teenagers. It is not surprising to see another peak among the working class group whose primary profession is cassava milling. In contrast to the findings of Trybus et al. where males are commonly affected in occupational hand injuries,  our study revealed a female predominance. Our interaction with the local communities revealed that the processing of cassava is considered a female chore.
This study showed that the right hand which in most cases is also the dominant hand is the most vulnerable in the case of cassava hand injury. This is in keeping with the observation of many other studies. ,,, This can perhaps be explained by the fact that most intentional actions are carried out with the dominant hand. Scooping the cassava mill product from the reservoir with the hand is an intentional act. Unfortunately, this act continues to occur due to ignorance of the risk and fear of parental repercussions for loss of milled product. Health education of mill owners and the use of a wooden spoon may reduce this risk.
The short duration of presentation is in keeping with the study by Ihekire et al.  which noted that patients with machine hand injuries present earlier to the hospital when compared with hand injuries from other causes. Those who sought pre-hospital care consulted orthodox medical practitioners who are quick to refer them to the plastic surgery unit. In contrast to other studies, which observed a high patronage of TBSs for fractures, , our observation was that the fractures from cassava hand injuries are not taken to the TBS. All the injuries seen in our study were open. The thumb is spared in most instances because it is not usually required in the initial mechanism of scooping the milled product from the grinding area of the machines.
Using the Tic-tac-toe classification system, the commonest injury type is type 1C 0 (dorsal mutilation with combined bone/soft-tissue loss and intact vascularity). The explanation to this may be due to the mechanism of injury. The rotatory force and grating surface on the roller crushes the cassava against a smooth surface below. When the hand is trapped, this causes the crushing of the dorsal skin, tendons, bones and joints while the glabrous skin on the volar aspect of the hand is spared [Figure 4].
The digital arteries were usually spared as evidenced by the bleeding to the tip of the fingers. Furthermore, none of the patients had amputation. The major challenge while treating this injury is the destroyed joints which contributed immensely to stiffness. This made it difficult to rehabilitate the hand to the premorbid state.
From our observation, this injury is preventable by proper education and modification of this cassava milling machines. The fact that it affects more of the rural vulnerable age and gender group makes it a serious condition that will require attention. If Nigeria is to achieve her goal of producing over 76 million metric tons of cassava per annum without increasing her health bill and the numbers of physically challenged population, mechanisms should be put in place to properly educate the cassava farmers about the dos and don'ts of these machines.  The use of warning and danger signs which can be understood by the user can also go a long way to help in this regard. The Ministry of Agriculture in collaboration with the ministry of health and other safety standard agencies should collaborate with the manufacturers of these machines so as to see to the redesigning of a modified version that will meet the desired safety standard and still be affordable. Encasing the grinding area so as to make it unreachable to the hand is a possible option. 
| Conclusions|| |
Hand injury from cassava milling machine is a challenge to the rural medical practitioners in Nigeria. It majorly affects the dominant hand of the female teenager. The outcome of the injury can pose a significant challenge to the physical and psychological state of a growing child. Prevention seems to be the key solution to reducing or eradicating the injury.
| References|| |
|1.||McMinn RM. Upper limb. In: Last's Anatomy Regional and Applied. 9 th ed. Edinburgh: Churchill Livingstone; 1997. p. 53-143. |
|2.||Rosberg HE, Dahlin LB. Epidemiology of hand injuries in a middle-sized city in southern Sweden: A retrospective comparison of 1989 and 1997. Scand J Plast Reconstr Surg Hand Surg 2004;38:347-55. |
|3.||Ahmed E, Chaka T. Prospective study of patients with hand injury: Tikur Anbessa University Teaching Hospital, Addis Ababa. Ethiop Med J 2006;44:175-81. |
|4.||UNIDO. Executive Summary. Cassava Master Plan: A Strategic Action Plan for the Development of The Nigeria Cassava Industry. UNIDO; 2006. p. 8-9. |
|5.||Weinzweig J, Weinzweig N. The "Tic-Tac-Toe" classification system for mutilating injuries of the hand. Plast Reconstr Surg 1997;100:1200-11. |
|6.||Trybus M, Lorkowski J, Brongel L, Hladki W. Causes and consequences of hand injuries. Am J Surg 2006;192:52-7. |
|7.||Trybus M, Guzik P. Occupational hand injuries. Med Pr 2004;55:341-4. |
|8.||Angoules AG, Lindner T, Vrentzos G, Papakostidis C, Giannoudis PV. Prevalence and current concepts of management of farmyard injuries. Injury 2007;38 Suppl 5:S27-34. |
|9.||Hartling L, Brison RJ, Crumley ET, Klassen TP, Pickett W. A systematic review of interventions to prevent childhood farm injuries. Pediatrics 2004;114:e483-96. |
|10.||Ihekire O, Salawu SA, Opadele T. International surgery: Causes of hand injuries in a developing country. Can J Surg 2010;53:161-6. |
|11.||Beaton AA, Williams L, Moseley LG. Handedness and hand injuries. J Hand Surg Br 1994;19:158-61. |
|12.||Thanni LO. Factors influencing patronage of traditional bone setters. West Afr J Med 2000;19:220-4. |
|13.||Oginni LM. The use of traditional fracture splint for bone setting. Niger Med Pract 1992;24:49-51. |
|14.||Ozgenel GY, Akin S, Ozbek S, Kahveci R, Ozcan M. Severe hand injuries in children related to farm tractors: A report of 70 cases. Ulus Travma Acil Cerrahi Derg 2008;14:299-302. |
|15.||Grogono BJ. Auger injuries. Injury 1973;4:247-57. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]