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Medical Staff Services. Even though some patients have not been previously diagnosed with psychiatric disorders, it is likely that they have an underlying mental problem [ 13 ]. In this study, two patients with the deepest injuries Patient no. Therefore, in case of male patient who have attempted suicide by wrist cutting and who have been diagnosed with a psychiatric disorder such as schizophrenia, the high possibility of deeper injury should be considered.
Ironically, this unpredictable trauma can be one of the most predictable injuries to a hand surgeon in three ways. First of all, as there are more right-handed people who hold implements with their right hands, there is higher probability of injury to the left wrist [ 7 ], as confirmed in our study, which showed injuries to the left wrist in Secondly, almost all patients have flexor side injuries 16 patients with injuries of the flexor side and one with injury of the radial side.
Wrist flexor tendons were the most frequently injured anatomical structures because they are located close to the skin surface and therefore more likely injured. As can be seen through the results of this study, The author drew an axial anatomy of the left wrist focusing on the most common injury site Fig. Arterial bleeding from both the radial and the ulnar side on the wrist indicates the high probability of structural injuries in intentional self-cutting [ 15 ].
Similarly, injury of the radial artery is often accompanied by an associated injury of the flexor carpi radialis tendon Patient no. Thus, we should keep in mind the possibility of accompanying structural injuries if arterial bleeding is suspected in the patient.
Axial anatomy of left wrist of the most commonly injured level. When we consider the type of implements used and mechanism of injuries, they can be classified into cutting wounds and stabbing wounds [ 9 ]. From an anatomical perspective, cutting wounds can be considered as horizontal injuries and stabbing wounds as vertical injuries. In terms of the implements used, Knife was the most common tool for suicide attempts, followed by glass.
In cases of injuries caused by cutter and razor, they were all horizontal injuries, whereas in case of injuries caused by glass or scissors, vertical injuries were observed.
Injuries by knife could be of both injury types, but cutting wounds were more common 8 cases of horizontal injuries and 1 case of vertical injury. Especially, if the patient has vertical injury on their wrists, more attention should be paid to the motor and sensory evaluation.
In case of Patient No. At initial examination, no specific functional deficits were detected and the patient was treated with primary wound closure in the emergency department. At further examination in our outpatient clinic, indication to surgical exploration was given: intraoperatively injuries to the 4th flexor digitorum superficialis and profundus tendons were detected and repaired. Since this kind of injury is often inconspicuous, proper evaluation is necessary depending on the mechanism of injury and implements used.
Especially, when vertical injury is suspected, it is important to check the injured area through proper exploration. As mentioned above, initial evaluation and proper treatment are the most important in the prevention of long-term functional impairment. Accordingly, it would be helpful to undertake a proper evaluation in order to understand the axial anatomy schematically at the level where wrist cutting injury occurs most commonly.
From the point of view of an initial examiner, not a hand surgeon, it is one of the best ways to estimate the possibility of structural injury by using the palmaris longus tendon, which is the most prominent structure on the flexor side, as an anatomical landmark Fig. The median nerve is located in the relatively shallow depth directly below the palmaris longus tendon.
From a total of 17 patients in this study, there were 4 patients who inflicted damage on the median nerve, which was most commonly damaged nerve, and injury of the palmaris longus tendon was accompanied in all these cases. Of the 4 cases resulting in long-term disabilities, 3 of those cases were patients with median nerve damage which was the most likely structural injury to cause motor or sensory impairment Patient No. Regarding the palmaris longus tendon as the central structure, the flexor side of the wrist can be divided into the radial and the ulnar sides.
FCR flexor carpi radialis tendon and FCU flexor carpi ulnaris tendon can be regarded as tendon group of superficial layer and it is relatively simple to detect the presence of injuries. Furthermore, as mentioned above in case of arterial bleeding, we should also consider injuries of the adjacent structure such as the accompanying damage to both ulnar artery and nerve Patient no.
This study has several limitations. First, there is a possibility of selection bias because this was a retrospective study and only patients who underwent operation at the Plastic and Reconstructive Department were included.
Second, a sample size was small for statistical analysis because this was a preliminary study before we started prospective cohort study. In the future, a prospective studies using larger number of patients will be required. Despite these limitations, this study is meaningful in that it allows all stakeholders to understand the clinical characteristics of self wrist-cutting injuries and evaluate properly.
A further prospective study will analyze the results of long-term follow-up and rehabilitation program of these patients, which could be more helpful for those who treat these patients primarily. In this study, we investigated 17 patients who had structural injury due to self-inflicted wrist-cutting as a pilot study. This demonstrated a different tendency in comparison with those with deep injuries. Male patients with a psychiatric disorder had a higher risk of more extensive wrist lacerations.
In terms of implements used when inflicted injury, we can predict the type of damage to some degree depending on the type of implement used. In view of these characteristics, more appropriate evaluation can be possible in the emergency room. In conclusion, through sharing our perspectives as hand surgeons, we can aid those who face these patients primarily, allowing them to cope more effectively for better long-term results.
Varnik P. Suicide in the world. Risk factors for suicide ideation among adolescents: five-year National Data Analysis. Arch Psychiatr Nurs.
Article PubMed Google Scholar. Analysis of deliberate self-wrist-cutting episodes presenting to the emergency department. The reason matters: deep wrist injury patterns differ with intentionality accident versus suicide attempt. Plast Reconstr Surg Glob Open. Trends in US emergency department visits for attempted suicide and self-inflicted injury, Gen Hosp Psychiatry. Trends in US emergency department visits for suicide attempts, Analysis of 41 suicide attempts by wrist cutting: a retrospective analysis.
Eur J Trauma Emerg Surg. Analysis of self-inflicted lacerations to the wrist: a multi-disciplinary approach to treating. Retrospective study on suicidal cases by sharp force injuries. J Forensic Legal Med. Article Google Scholar. Self-cutting and risk of subsequent suicide. J Affect Disord.
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