Dr. Ashok Kumar Banskota, Hospital and Rehabilitation Centre for Disabled Children, Nepal
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This study aims to describe the nature and incidence of hand injuries caused by corn-husker machines, as well as the accident conditions and treatment experiences.
This retrospective investigation included 34 patients treated at a single institution from August 2018 to August 2021 with postoperative follow-up of more than 12 months. The Hand Injury Severity Scoring System (HISS) was applied to identify the degree of hand injury. Depending on the type of damage, different surgical methods were used, including debridement and suturing, amputation, fracture fixation, negative pressure wound therapy (
The average age was 42.1 years, and 76.4% of the patients were male. 17.6% were classified as HISS I, 20.6% each as HISS II and HISS III, and 41.2% as HISS IV. Among the 83 injured fingers (6 thumbs, 13 index, 12 middle, 10 ring, and 7 little fingers), the finger amputation rate was 57.8%. The most common complication was infection, with 13 cases of postoperative infection, resulting in an infection rate of 38.2%. Although NPWT played an important role in treatment, there was no significant difference in infection rates between wounds treated with NPWT and those treated without. Median hospitalization duration was 35 days (IQR: 27–45); median treatment cost was $4740 (IQR: $3255–$6215). Infections significantly impacted both hospitalization duration and treatment costs.
Corn-husker machine-related hand injuries represent a new type of hand trauma and are often severely mutilating. The selection of appropriate surgical methods and the prevention of infection are crucial aspects in treating such injuries.
Among all economic sectors, agriculture is one of the most hazardous, with a high incidence of accidents, sometimes even fatal, and responsible for occupational diseases (
Corn-husker equipment is commonly used in corn-growing areas in northern China; its main structure is shown in
Agricultural machine.
Most accidents resulted from attempts to remove clogged corn by hand while the machines were still operating, leading to hands being caught in the gap between the two rollers.
Approval for this study was obtained from the institutional review board of our institution (W2021-051-1). Inclusion criteria: Acute corn-husker-related hand injuries requiring surgical intervention within 6 h post-injury. Exclusion criteria: Chronic wounds, prior hand surgeries, or incomplete records. Most hand injuries caused by corn-husker equipment are complex traumatic injuries, including metacarpal and phalangeal fractures accompanied by neurologic and vascular injuries. From August 2018 to August 2021, a total of 34 patients with corn-husker equipment-related hand injuries were treated. To evaluate the degree of hand injury, we used the Hand Injury Severity Scoring System (HISS) described by Campbell and Kay in 1996 (
In this group of cases, all patients' wounds were open and underwent emergency operations within 6 h after the accident. The basic surgical principles of preventing infection, achieving early healing, and providing optimal function as quickly as possible guided the surgical plan (
Debridement and irrigation: For open wounds, early adequate debridement was performed. The skin around the wound was washed with soapy water, and the wound was irrigated with 0.9% normal saline (NS), dilute iodine, and hydrogen peroxide repeatedly. All nonviable tissues and foreign debris were excised, leaving healthy, viable tissue and protecting vital structures (
Amputation: Primary amputation was performed when the surgeon believed that adequate wound excision would result in retention of little functional tissue or necessitate late amputation (
Fracture fixation: In major open injuries, K-wires were quickly placed by retrograde wiring through the fracture site (
Case 1: A 51-year-old man suffered a corn-husker machine injury to his left hand involving metacarpal fracture, phalangeal fracture, and neurovascular injury.
Negative pressure wound therapy (NPWT): For large soft tissue defects and infected wounds, NPWT provided temporary wound coverage. Before NPWT, foreign material, fatty tissues, and devitalized tissues in the wound were completely eliminated. Continuous negative pressure was set at 200 mmHg. The NPWT was removed 3–5 days after surgery. If necrotic tissue, infection, or inadequate growth of granulation tissue was present on the wound surface, NPWT was repeated until the wound was considered clean. The next stage of surgery involved skin flap repair or skin grafting.
Tendon repair: After restoration of reliable vascularity and reestablishment of skeletal stability, all injured tendons were repaired in the early stage. No tendon transplantation or functional reconstruction was performed at this stage.
Replantation: Blood vessel and nerve repair or replantation was performed within 6 h of warm ischemia (without cold ischemia), particularly for large segments. Replanted fingers included 2 thumbs, 1 middle finger, and 1 little finger. All patients were included in the following standardized pharmacological protocol: Fluids: 30–50 cc/kg/24 h; Dextran-40 (molecular weight, 40 kd): 500 cc/24 h; Heparin: 50–100 U/kg/24 h intravenous. This daily pharmacological protocol was carried out for 5 days postoperatively (
Skin flap and skin graft: If the damaged area exposed bare bone, tendon, or nerve, or if there was an open joint or bone, it was covered with different types of skin flaps (
In open skin injuries, symptoms typically manifest within 10 days after the injury (
Early administration of antibiotics is an important factor in reducing the infection rate. Antibiotics were administered 1–2 h prior to the surgical procedure in patients with open wounds, using a combination of cefazolin (2 g every 8 h) + gentamicin (5 mg/kg daily) for 2–3 days. If infection occurred in the wound, the regimen was adjusted based on the identification of specific pathogens. Tetanus prophylaxis followed the Department of Health guidelines (
Statistical analyses were performed using SPSS software (version 26.0, IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize patient demographics, injury characteristics, and treatment outcomes. Categorical variables were presented as frequencies and percentages, while continuous variables were expressed as means with ranges or standard deviations.
Fisher's exact test was used to assess differences in infection rates between wounds treated with and without NPWT and to compare hospitalization duration and treatment costs between infected and non-infected patients, as well as between patients with primary and secondary infections. Multivariate logistic regression adjusted for HISS classification was used to control confounding factors. A
Among the injured parts, there were 17 right hands and 17 left hands, involving 38 metacarpals and 83 phalanges. The 83 injured phalanges consisted of: 10 thumbs (12.0%), 22 index fingers (26.5%), 19 middle fingers (22.9%), 19 ring fingers (22.9%), and 13 little fingers (15.7%). The injured metacarpals included 3 first metacarpal bones (7.8%), 11 s metacarpal bones (28.9%), 9 third metacarpal bones (23.7%), 10 fourth metacarpal bones (26.3%), and 5 fifth metacarpal bones (13.1%). Of the 83 injured fingers, a total of 48 finger amputations were performed, including 6 thumbs, 13 index fingers, 12 middle fingers, 10 ring fingers, and 7 little fingers, resulting in an amputation rate of 57.8% (
Case 2. A 34-year-old man suffered corn-husker machine injury to his left hand involving multiple metacarpal fractures, neurovascular and tendon injuries.
Number of injured fingers, metacarpals, and amputated fingers. F (finger): F1: thumb; F2: index; F3: middle; F4: ring; F5: little finger.
According to the HISS classification, 14 patients (41.2%) suffered from HISS IV injury, 7 patients (20.6%) each had HISS II and HISS III injuries, and only 6 patients (17.6%) had HISS I injuries (
Demographic and clinical characteristics of patients with corn-husker equipment hand injuries.
| Variable | |
|---|---|
| 34 | |
| Gender | |
| Male | 26 (76.5%) |
| Female | 8 (23.5%) |
| Age (years) | |
| Mean (range) | 42 (16–61) |
| Injury side | |
| Right hand | 17 (50%) |
| Left hand | 17 (50%) |
| Number of injured fingers | 83 |
| Thumb | 10 (12.0%) |
| Index finger | 22 (26.5%) |
| Middle finger | 19 (22.9%) |
| Ring finger | 19 (22.9%) |
| Little finger | 13 (15.7%) |
| Number of injured metacarpals | 38 |
| 1st metacarpal | 3 (7.8%) |
| 2nd metacarpal | 11 (28.9%) |
| 3rd metacarpal | 9 (23.7%) |
| 4th metacarpal | 10 (26.3%) |
| 5th metacarpal | 5 (13.1%) |
| HISS classification | |
| Minor (HISS I) | 6 (17.6%) |
| Moderate (HISS II) | 7 (20.6%) |
| Severe (HISS III) | 7 (20.6%) |
| Major (HISS IV) | 14 (41.2%) |
According to HISS classification, the different proportion of using NPWT, flap repairment and skin graft.
| Treatment | I | II | III | IV |
|---|---|---|---|---|
| HISS (%) | 6 (17.6%) | 7 (20.6%) | 7 (20.6%) | 14 (41.2%) |
| NPWT (%) | 0 (0.0%) | 3 (17.6%) | 3 (17.6%) | 11 (64.7%) |
| Flap repairment (%) | 1 (10.0%) | 2 (20.0%) | 2 (20.0%) | 5 (50.0%) |
| Skin graft (%) | 0 (0.0%) | 3 (20.0%) | 3 (20.0%) | 9 (60.0%) |
Bacterial culture and antibiotic susceptibility tests were conducted on pus and wound secretions. Thirteen cases developed postoperative infections, including 6 cases of secondary infections (II: 1, III: 3, IV: 2), resulting in an overall infection rate of 38.2%. Most infected cases (61.5%) were HISS IV injuries, 23.1% were HISS III, 15.4% were HISS II, and no infections were found in HISS I injuries. Among NPWT patients, 8 (47.1%) had positive wound cultures. After adjusting for HISS severity via multivariate logistic regression, NPWT use showed no significant association with infection risk (adjusted OR = 1.4, 95% CI: 0.3–6.1,
Infection rate of wound infection in the NPWT and No NPWT groups.
| Treatment | Infection | No-infection |
|---|---|---|
| NPWT | 8 (47.1%) | 9 (52.9%) |
| No NPWT | 5 (29.4%) | 12 (70.6%) |
| Total | 13 (38.2%) | 21 (61.8%) |
Note: No significant difference between the NPWT group and no NPWT therapy group (
The isolated pathogenic bacteria in our research included Pseudomonas aeruginosa (5 cases) and Burkholderia cepacia (5 cases), followed by Citrobacter freundii (2 cases), Klebsiella pneumoniae (2 cases), and others including Proteus mirabilis, Staphylococcus saprophyticus, Acinetobacter baumannii, Staphylococcus aureus, and Escherichia coli (
Bacterial culture and drug susceptibility test results of the infected wound.
| Bacterial culture result | Cases | Drug susceptibility test results |
|---|---|---|
| Pseudomonas aeruginosa | 5 (35.7%) | Amikacin, Aztreonam, |
| Ciprofloxacin, Gentamycin | ||
| Burkholderia cepacia | 5 (35.7%) | Meropenem, Ciprofloxacin, Gentamicin |
| Citrobacter freundii | 2 (14.3%) | Amikacin, Ciprofloxacin, Gentamicin, Levofloxacin, Imipenem |
| Klebsiella pneumoniae | 2 (14.3%) | Amikacin |
| Proteus mirabilis | 1 (7.1%) | Ceftazidime, Cefoperazone, |
| Cefotaxime Oxime | ||
| Staphylococcus saprophyticus | 1 (7.1%) | Azithromycin and Doxycycline, co-trimoxazole, Gentamicin, Levofloxacin, Tetracycline, Vancomycin |
| Acinetobacter baumannii | 1 (7.1%) | Amikacin, Ciprofloxacin, |
| Ceftazidime, Cefoperazone | ||
| Staphylococcus aureus | 1 (7.1%) | Amikacin, Ceftazidime, Cciprofloxacin, Doxycycline, Gentamicin, Tetracycline, Vancomycin |
| Escherichia coli | 1 (7.1%) | co-trimoxazole, Imipenem, Cefoxitin |
Note: There were 5 cases had a bacterial mutation in the second bacterial culture.
Number of isolated pathogens and resistance according to HISS classification.
| HISS | Isolated pathogens | Distribution of pathogen drug resistance (n) | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| PIP | TZP | CAZ | CFP | IMP | AZT | LVX | MEC | GM | EM | CD | TC | CFX | CHL | TM | SXT | CX | AM | CFT | ||
| Ⅰ | No | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – |
| Ⅱ | Staphylococcus aureus | R | – | – | – | – | – | – | – | – | R | R | R | – | – | – | – | – | – | – |
| Pseudomonas aeruginosa | R | – | R | R | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | |
| Ⅲ | Proteus mirabilis | – | – | R | – | – | – | R | – | – | – | – | – | R | R | R | – | – | – | – |
| Pseudomonas aeruginosa | – | – | R | R | – | R | – | – | – | – | – | – | – | – | R | – | – | – | – | |
| Klebsiella pneumoniae | R | R | – | – | R | – | – | – | R | – | – | – | R | – | R | – | R | – | – | |
| Acinetobacter baumannii | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | R | – | – | – | |
| Ⅳ | Klebsiella pneumoniae | R | – | – | – | – | – | – | – | – | – | – | – | R | – | R | – | R | – | – |
| Escherichia coli | – | – | – | R | – | – | R | – | R | – | – | – | R | – | – | – | R | R | R | |
| Citrobacter freundii | – | – | – | – | – | – | – | – | R | – | – | – | R ( |
– | – | R | – | R ( |
R ( |
|
| Pseudomonas aeruginosa | – | – | R ( |
R ( |
– | – | R ( |
– | – | – | – | – | – | – | R | – | – | – | – | |
| Staphylococcus saprophyticus | R | – | R | R | – | – | – | – | – | – | R | – | – | – | – | – | – | – | R | |
| Burkholderia cepacia | – | – | R ( |
– | – | – | R ( |
R | – | – | – | – | – | R | – | R ( |
– | – | – | |
AM, ampicillin; AZT, aztreonam; CD, clindamycin; CFX, cefuroxime; CAZ, ceftazidime; CFP, cefepime; CFT, cefotaxime; CX, cefoxitin; CIP, ciprofloxacin; CHL, chloramphenicol; EM, Erythromycin; GM, gentamicin; LVX, levofloxacin; IMP, imipenem; PIP, piperacillin; SXT, co-trimoxazole; TZP, piperacillin-tazobactam; TC, tetracycline; TM, tobramycin; MEC, meropenem; R, resistant.
Median hospitalization duration was 35 days (IQR: 27–45); median treatment cost was $4740 (IQR: $3255–$6215). Infected patients had significantly longer stays (median 42 vs. 29 days,
To assess the long-term functional outcomes, we evaluated the Disability of the Arm, Shoulder, and Hand (DASH) scores and return-to-work rates during the 12-month follow-up. The mean DASH score was 30.2 (range: 14–41). Patients with HISS I and HISS II injuries exhibited lower DASH scores (mean: 16.7 and 24.8, respectively), reflecting better functional recovery. In contrast, patients with severe (HISS III) and major (HISS IV) injuries had higher DASH scores (mean: 32.5 and 37.3, respectively), indicating significant residual disability. Return-to-work rates were also correlated with injury severity. Overall, 85.3% (29/34) of patients resumed work within 12 months. All patients with HISS I and II injuries returned to work, while the return rate decreased to 78.6% (11/14) for HISS IV injuries.
In the last decade, corn-husker equipment-related hand injuries have been increasing gradually in China. Farm machinery is involved in a significant percentage of non-fatal injuries that can cause serious permanent disability (
Characteristic injuries include grossly contaminated lacerations, crush injuries with multiple fractures, severe soft-tissue tears, and primary digit amputation. In this retrospective study, we found that the index finger and the second metacarpal bone were the most commonly injured. Multiple injured fingers were observed in 18 cases (52.9%), multiple injured metacarpals in 10 cases (29.4%), and fingers accompanied by metacarpal injuries in 9 cases (26.5%) (
After debridement and irrigation, the surgeon must decide whether reconstruction of digits is viable or if function would be best improved with early amputation and possible future reconstruction (
The force of high-energy trauma acts on the incompressible blood in the vasculature, leading to a dramatic rise in tissue pressures and damage to multiple tissue types, including bones, blood vessels, nerves, and soft tissues (
NPWT may play a role in the initial management of high-energy, highly contaminated injuries caused by agricultural machinery (
Among our patients, flaps were chosen in 10 cases to cover the wound, with 50% being HISS IV injuries, according to the nature of the bed and future reconstructive needs. Five types of flaps were selected: rotation flap, abdominal wall flap, ALTP, peroneal artery perforator flap, and antidromic dorsal interosseous artery island flap. Free tissue transfers are relatively complex and time-consuming, requiring microsurgical expertise and often associated with donor-site morbidity (
Fifteen cases underwent split-thickness skin grafting after NPWT, with a 100% survival rate. Although split-thickness skin grafts offer poor color, contour, and texture match at the recipient site and are not as robust as full-thickness skin (potentially blistering or ulcerating more easily if subjected to wear and tear), their advantages include the availability of very large graft areas and improved graft take with thinner grafts (
Infection is relatively common in agricultural injuries, with deep wound infections or osteomyelitis occurring in 18% to 19% of these cases (
As indicated by previous studies, most open-fracture infections were caused by gram-negative rods and gram-positive staphylococci (
In our study, 8 patients (47.1%) who underwent NPWT had positive wound cultures. The NPWT group showed a higher infection rate, possibly because the negative pressure tightens wound contact, which could trap bacteria and hinder proper fluid drainage. The incidence of wound infection in the NPWT and No NPWT groups is shown in
The reasons for infection are as follows: (1) The main cause was the insertion of corn husks and soil, which carried numerous pathogens, between soft tissue and bone during the injury process. Debridement and irrigation were often insufficient to completely remove these microorganisms. (2) These injuries typically occurred in autumn, a season conducive to bacterial reproduction. (3) The mechanism of corn husker injury, including crushing, avulsion, or friction trauma, decreased the local soft tissue's ability to resist infection, greatly increasing infection rates after debridement. (4) The administration of broad-spectrum, empiric antibiotic therapy has limited effectiveness in treating wounds contaminated by multiple bacteria.
Infection is a significant factor in prolonged hospitalization, leading to increased treatment costs and poor patient outcomes. This suggests that reasonable and effective prevention and control of infection during treatment is key to shortening hospitalization time and reducing medical costs. During an average follow-up of 12 months, we found that postoperative outcomes were often unsatisfactory, frequently due to stiffness secondary to finger joint fractures and infections. Consequently, prevention of occupational injuries is of great importance. Most of these accidents could be prevented with the use of protective clothing, better education, and improved safety precautions (
Corn-husker hand injuries exhibit patterns similar to those caused by agricultural machinery across low- and middle-income countries (LMICs). The infection rate in corn-picker hand injuries has been reported to be 15%, which can vary based on crop types such as sugarcane or rice (
Future research should investigate the knowledge and awareness among farmers and their caregivers regarding safety precautions and the use of protective equipment. Machine design improvements should include emergency shutdown mechanisms operating within 0.15 s, physical barriers around snapping rollers, and two-hand operation controls. Retrofittable guards for existing equipment could improve safety without requiring full replacement. Personal protective equipment, including specialized cut-resistant gloves and forearm guards, should be standardized. Conducting relative surveys to evaluate their understanding of injury risks and safety practices can help develop the preventive measures. This baseline data would be benefit to minimize the risk of hand injuries and to improve safety in agriculture.
This study has several key limitations. The retrospective design introduces potential selection bias and limits causal inference. The small sample size significantly constrains statistical power, particularly for subgroup analyses. The single-center scope restricts generalizability to other regions with different agricultural practices. Future research requires multicenter, prospective designs with standardized outcome measures.
The current study reveals the characteristics of corn-husker equipment hand injuries, including epidemiology, injury mechanisms, surgical methods, and infections. This represents a new type of agriculture-related injury leading to multiple hand traumas, such as soft tissue defects, multiple fractures, and neurovascular injuries. Due to the complexity of these injuries, diverse surgical methods are employed, with NPWT playing an important role in treatment. Effective anti-infective treatment can reduce infection rates, shorten hospital stays, and decrease hospitalization costs, making it one of the most effective approaches. Given the high rate of disability associated with these injuries, prevention and proper use of this type of equipment are crucial in avoiding these serious accidents.
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethical approval was not required for the study involving humans in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was not required from the participants or the participants' legal guardians/next of kin in accordance with the national legislation and the institutional requirements.
C-JP: Conceptualization, Supervision, Writing – original draft, Writing – review & editing. X-YH: Conceptualization, Supervision, Writing – original draft, Writing – review & editing. YL: Conceptualization, Writing – original draft, Writing – review & editing. Z-YY: Conceptualization, Supervision, Writing – original draft, Writing – review & editing. LL: Data curation, Formal analysis, Writing – review & editing. X-BF: Data curation, Formal analysis, Writing – review & editing. S-WX: Data curation, Formal analysis, Writing – review & editing.
The author(s) declare that financial support was received for the research and/or publication of this article. Supported by the Key Medical Research Projects of Hebei Province (Grant No. 20210568); Special TCM Innovation Project of Hebei Provincial Department of Science and Technology, No. 223777130D; and Scientific Research Project of Hebei Province Administration of Traditional Chinese Medicine, No. 2024215.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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