on our farms with a resultant increase in agricultural injuries. Injuries due to threshers are mostly of the upper limb and result in significant morbidity. In our setting, agriculture is largely family owned-family run activity, thereby involving a fairly large number of children in the farming activities. Children are particularly prone to severe hand and upper extremity injuries and machinery related limb amputations, which require multiple surgical procedures and weeks of hospital stay for limb-threatening injuries.[7]. If physical, psychological and economic fallout from agricultural injuries is to be reduced, we need to analyze agricultural injuries. This study has compiled and assessed information on agricultural Orthopaedic injuries in a tertiary care Centre in North India. We have also analyzed the injury trends, their severity and available preventive, curative and rehabilitative interventions.

A total of 106 patients with agricultural injuries (AI) who attended the Accident and Emergency department from February 2019 to March 2020 were enrolled in the study. Various parameters like socio-demographic data, injury-related characteristics, mode of injury, type of injury, body part injured, the time gap between injury and presentation, type of farmer, duration of work, intoxication and type of management were assessed in the study. Upper limb, lower limb, pelvic and spine injuries in subjects of all age groups involved in agricultural activities were included. Road traffic accidents, Suicide or parasuicide with agricultural equipment, Snakebites, and Physical assault were excluded from the study. The magnitude of agriculture injury was calculated concerning total acute trauma cases coming to accident and emergency in the Department of Orthopaedics, of a tertiary care centre in the state of Haryana in North India. The risk factors and their association with agricultural injury were identified. Analysis was also done to identify the correlation of different age groups, sex, agricultural activity, time and agricultural tool with agriculture injury. Patients included in the study were followed up at 2nd week, one month, 3 months and 6 months and wound status, fracture union, range of motion of injured body part, the effect of injury on daily household activity and performance after resuming work were recorded and outcome of the patient was noted. Pre-structured subjects proforma was used for data collection.

Table 2 shows the socio-demographic variables of the study population. Most of the patients (40; 37.74%) were illiterate (No formal education). Farmers made up 38 (35.84%), 26 (24.52%) were farm labourers and employees while the remaining 42 (39.62%) were housewives and children/students. Forty-five (42.46%) patients had no landholding and fifty-four (50.95%) patients were living in a Joint family. Table 3 shows the distribution of the patients in the study, according to etiology and different associated factors with the agricultural injuries. Machinery used in farming was the main etiological factor causing injury (60; 56.60%). Most patients sustained injury due to chaff/fodder cutting machine 40 (37.73%); and followed by thresher 11 (10.37%). Thirty-five (33.02%) patients were unskilled workers at the time of injury. Twenty-one (19.81%) patients were under the influence of alcohol/drugs while 29 (27.35%) patients were fatigued at the time of injury. Eighty-seven patients (82.07%) had worked for more than three hours before the injury. Sixty-nine (65.10%) patients presented in the winter season, Sixty-one (57.54%) patients reached hospital within 2 hours of injury, 28 (26.41%) reported in 2-3 hours, and 17 (16.03%) reached after 3 hours of injury.

Table 3: Distribution of the patients in the study, according to etiology and different associated factors with the agriculture injuries (N=106)

Shows picture after revision amputation and secondary wound closure.

Showing follow-up picture at 3 months postoperatively. Healing of the stump has occurred without any complication.

Figure 2.

a & b. Classical wheat thresher injury. It shows amputation at the level of proximal hand with grossly contaminated forearm and arm lacerated wounds.

1. Shows wound status after 14 days of daily debridement, EUSOL wash and daily antiseptic dressing.
2. Skin grafting was done once the wound was healthy. Shows picture of the wounds on 15^th postoperative day just before suture removal.

e & f: Show picture at 1-month post-op. Amputation stump appears healthy, skin graft was well taken up, but left a scar.

Figure 1

Figure 2

Table 5 shows the distribution of patients in the study, according to the different injury characteristics, management, and aftermath of agricultural injuries. The upper limb was involved most commonly and common injuries were amputations at different levels. The most common level of amputation was at fingers, which were present in 25 patients (23.58%). Ninety four (88.68%) patients required surgical intervention and 12 (11.32%) were managed conservatively. Conservative management was mainly done in form of crepe bandage, POP cast and medical therapy for back pain patients in the form of NSAIDs and muscle relaxants. Revision amputation was the most common (27 patients; 25.47%) surgical intervention required, K-wire fixation of fractures was done in 23 (21.69%) patients and wound debridement was done in 10 patients and 3 patients (2.83%) underwent skin grafting (Fig. 2). Household activities were decreased after injury in 52 (49.05%) patients. Agriculture injury has resulted in decreased work performance in 62 (58.49%) patients. Out of 42 patients with fractures, 2 were lost to follow-up while one patient expired. The union was achieved in 32 of the 39 remaining patients (82.05%). Thirty-four (32.07%) patients had decreased range of motion in the injured part. Wound healing without infection was observed in eighty-four patients (89.36%); whereas eight patients (8.52%) had chronic infections in their wounds. There was only one fatality (0.94%) in our study.

Agriculture has made great strides in moving India from chronic food deficits to food surpluses and net food exports since the early 1990s. Most people (49%) work in this sector. [8]. The accidents and injuries are natural hazards to everyone working in the farm environment and these happen as a culmination of multiple factors, e.g., man, machine, crop, toxic chemicals or environmental factors. Since the farming sector is unorganized, there is an absence of a nationwide repository on farm-related accidents and injuries, which could be useful to quantify the health and safety, and economic consequences. [9].

Mohan and Patel (1992) in a study conducted in nine contiguous villages in the Sonipat district of Haryana state reported that maximum injuries occurred while working with spades (24%), followed by sickles (23%), bullock carts and manually operated chaff cutters (6% each), and power–operated chaff cutters, tractors, and diesel engines (5% each).[12]. Tiwari et al (2001) have reported that of the total incidents, 77.6% were due to farm machinery, 9 (11.8%) were due to hand tools, and 8 (10.6%) were due to other sources like snakes, wells, agricultural chemicals, etc. Tractor–related incidents were most common (46.0%), followed by threshers (14.5%), sickles (10.5%), electric motors and pump sets (7.9%).[10]. Patel et al (2010) in a retrospective study (1996-2000) have reported that out of total injuries, 57 (53.77%) were farm machinery-related, 43 (40.56%) were due to hand tools and six (5.66%) were due to other sources.[13].

Das et al (2014) have reported from a study in Bengal that machine and hand tools were involved in the major number of farm injuries and among the farm machinery, overturn of a tractor with a heavy load causes a major number of accidents.[14]. Bhattarai et al (2016) reported farm injuries from a village in the Himalayan country of Nepal, where hand tool was a frequent mode of injury among the respondents.[15]. In our study the machinery used in farming was the main etiological factor causing injury (60; 56.60%). Most patients sustained injury due to chaff/fodder cutting machine 40 (37.73%) (Fig. 1) and followed by thresher 11 (10.37%) (Fig. 2). This is because with time there has been increased mechanization of farming as well as that due to the geographical and socio-economic advantage of northern Indian agrarian states there is a predilection towards the use of more mechanical aides in farming as compared to hand tools. Singh et al (2005) in a prospective study analyzing wheat thresher agricultural injuries during the wheat harvesting season of March to June, 2003, have reported that upper limb injuries were most commonly involved and a significant number resulted in the amputation of some parts. [11]. Grandizio et al have reported 35% upper extremity predominantly resulting in fractures of the phalanges and/or forearm bones. [16]. In the present study too, in most of the cases, the upper limb was involved in the form of amputations and fractures. In the cohort most common injury was upper limb injury (80 patients; 75.47%), followed by lower limb injury (19 patients; 17.93%).

1. Shows gross contamination of forearm lacerated wound with organic debris.

Ninety-four (88.68%) patients required surgical intervention and 12 (11.32%) were managed conservatively in the present study. Conservative management was mainly done in form of crepe bandage, POP cast and medical therapy for back pain patients in the form of NSAIDs and muscle relaxants. Revision amputation was the most common (27 patients; 25.47%) surgical intervention required and K-wire fixation of fractures was done in 23 (21.69%) patients. The surgery rate as well as the rates of readmission, revision surgery and the total length of hospital stay are dictated by the complexity of the injuries. As the farm machinery-related injuries involve dirt, grease, grime, organic material, etc. in combination with open injuries, the extent, duration, the number of surgical interventions and hospital stay are naturally increased.

Bhattarai et al (2016) reported that out of a total of 222, 64.3% of respondent injured workers took some time off work due to injury. [15]. In the present study, household activities were decreased after injury in 52 (49.05%) patients, whereas there was decreased work performance in 62 (58.49%) patients; all these have an impact on quality of life and income post-injury. Out of 42 patients with fractures, 2 were lost to follow-up while one patient expired. The union was achieved in 32 of the 39 remaining patients (82.05%). Thirty-four (32.07%) patients had decreased range of motion in the injured part. Wound healing without infection was observed in eighty-four patients (89.36%); whereas eight patients (8.52%) had chronic infections in their wounds.

Nag and Nag (2004) have reported that most of the fatal accidents resulted from machinery, with the annual fatality rate estimated at 22 per 100,000 farmers. [9]. Patel et al (2010) in a retrospective study (1996-2000) have reported a 9% fatality in a survey of six blocks Etawah district of Uttar Pradesh. [13]. This resulted in a substantial economic burden.[9,13]. Mohan and Patel (1992) estimated that agricultural activities caused about 5,000 to 10,000 deaths, 15,000 to 20,000 amputations, and 150,000 to 200,000 serious injuries every year in the three North Indian agrarian states of Haryana, Punjab, and Uttar Pradesh alone. [12].

In contrast, there was only one fatality (0.94%) in our study.

In addition, improvisation and modification in the machinery should be done as per the local requirements, for the safe use and prevention of AI. The present study highlights the need for a robust surveillance and data analysis leading to better design of farming machinery and equipment, more relevant education and training systems, stronger legislations as well as a comprehensive rehabilitative program aimed at reducing the socio-economic burden caused by agricultural injuries.