Why wrist cutting

Patients who met the criteria for two or more known psychiatric diseases were counted in each category. For patients who had cut their wrists multiple times and had been treated at the emergency department twice or more, only the last event was analyzed in this study, while earlier events were recorded as previous suicide attempts.

For those who consented, a psychiatric consultation and diagnosis were performed in the emergency room, after which outpatient care was recommended. If necessary, patients were hospitalized in a closed or general ward. As few patients had regularly received outpatient care, our institute planned and implemented a suicide prevention intervention SPI program starting on March 13, In the SPI program, we contacted and supported patients who had not received regular outpatient care.

In addition, we attempted to persuade patients to visit the hospital to receive appropriate treatment. Severity was classified according to the depth-dependent damage of the anatomical structure. In several previous studies examining wrist injury patterns, the three-layered taxonomy introduced by Lee et al.

These studies described the different patterns of damage and anatomical features of self-inflicted wrist injuries and wrist injuries caused by other reasons without suicidal intention e. We noted that deep layer injuries, the worst in the three-layered taxonomy, were significantly less common in self-cutting patients than in the other two groups. Therefore, in the current study, we classified anatomical injuries dichotomously.

We created a virtual line on the anatomy of the wrist, immediately above the median nerve, to examine the relationship between various patient-related factors and the severity of the wrist-cutting injury. If structures beneath this virtual line were damaged, the injury was classified as deep, while injuries to anatomical structures located above this virtual line were classified as superficial.

The rationale for this classification was that injury of neurovascular structures, including the ulnar artery and radial artery, can lead to critical self-harm. Skin-only injuries with subcutaneous fat exposure were considered to be the most minor. We simplified the anatomy of the wrist structures in a schematic manner and the relative location of each structure was drawn according to the study by Lee et al.

Injuries were dichotomized as deep or superficial based on their location relative to a virtual line running immediately above the median nerve. In accordance with the study by Lee et al. The deep layer comprised structures 8—16, which correspond to the radial artery, flexor pollicis longus, median nerve, second flexor digitorum profundus 2-FDP , 3-FDP, 4-FDP, 5-FDP, ulnar nerve, and ulnar artery, respectively.

As we categorized the severity of wrist injuries according to three levels skin only, superficial, and deep , the relationships of various factors with severity was evaluated using the linear-by-linear association test. The sex ratio was compared to the cumulative population of Seoul during the study period — [ 7 ].

The sex ratios for incidence and repeated wrist cutting were evaluated using the chi-square test. The mean ages of men and women were compared using the independent t-test. This study included patients who had cut their wrists for the purpose of self-harm, of whom 42 patients Women were significantly younger than men mean age, Alcohol consumption and drug abuse prior to wrist cutting were examined in all patients. Fifty-one patients In cases involving drug intoxication, the most common drugs used were prescription pills e.

In one case, a patient consumed a pesticide 50 mL of cypermethrin that was prepared in advance with the intention of committing suicide. Of the patients, 47 In total, 47 patients For patients who declined psychological counseling, we made several recommendations that they receive psychiatric care through the SPI.

The most adherent patient completed 10 SPI sessions. Twenty-six patients Of the 22 patients who had engaged in wrist cutting repeatedly, 19 The vast majority of patients patients; In addition, patients One patient performed amputation after cutting her wrist for 3 hours. In total, 82 patients None of the patients died. Thirty-three patients had injured at least one anatomical structure of the wrist. The number of patients who injured each anatomical structure of the wrist are listed in Table 3.

The patient who performed amputation was counted once in all cases. The most commonly injured structure was the PL, which was injured in 24 patients The most commonly injured structure in the deep layer was the median nerve, which was injured in 10 patients Previous studies have pointed out the protective role of some tendons against neurovascular injuries [ 5 , 6 ].

Specifically, those studies indicated that the FCR functions as an important protective barrier for the radial artery, and the PL exhibits a similar effect for the median nerve. In our study, all five patients with radial artery injuries had FCR injuries and all 10 patients with median nerve injuries had PL injuries; therefore, our findings validate the proposal that tendons are protective structures.

Of the patients, three refused treatment for the wound, while received skin repair. Tenorrhaphy was performed in 26 patients Neurorrhaphy, arteriorrhaphy, and venorrhaphy were performed in 13 Fascia reconstruction and nerve sheath reconstruction were performed in two patients each, with an acellular dermal matrix used to improve the prognosis.

Replantation surgery was conducted in the patient who performed amputation. Attempted suicide by wrist cutting is a major social problem, accounting for a large proportion of cases of upper extremity trauma presenting to the emergency room. Hence, many epidemiological studies have been conducted from a psychiatric perspective to examine the clinical features of self-inflicted wrist cutting [ 1 - 3 ].

Our results are consistent with those of previous studies on this topic. In addition, most patients who had engaged in wrist cutting repeatedly were women Table 1 [ 8 , 9 ]. Several studies have examined the relationship of suicide with substance use, one of which showed an association between alcohol consumption and suicide [ 10 ].

However, in the current study, alcohol consumption and substance abuse did not increase the severity of the injury or the risk of mortality in wrist-cutting patients. Among the 8 patients with deep injuries, 6 had a history of psychiatric disorders, whereas among the 9 superficially injured patients, only 3 had a previous psychiatric diagnosis.

When it comes to the long-term outcomes, 4 patients showed functional deficit in long-term follow-up period and all of these patients had nerve injuries including injuries of the median and the ulnar nerve. Patient no. Suicide is a global public health problem that impacts individuals and society.

Suicide rates have increased substantially over the past two decades. Suicide in Korea is the tenth highest in the world according to the World Health Organization, making it the fourth leading cause of death [ 3 ].

Due to increasing cases of self-inflicted wrist cutting and its low mortality rate, initial evaluation when facing this injury is the most important aspect to prevent long-term functional impairment. Thus, we suggest appropriate evaluation and aim to share the perspectives of a hand surgeon.

In this study, there were gender differences in self-inflicted wrist cutting 4 female and 13 male patients , as opposed to other studies which showed a higher proportion of women with self-cutting injuries [ 7 , 10 ].

This suggests that deep injuries involving deep flexor tendons, artery and nerve are more likely to occur in male patients. Male wrist-cutting patients showed more extensive injuries and all patients who had deep structural injuries were also male. Furthermore, as patients with psychiatric disorder have a higher rate of recurrent suicide attempts [ 11 ], multidisciplinary approach together with the Psychiatric Department is essential in order to effectively treat these patients.

Schizophrenic patients are more likely to get devastating injuries and other psychiatric disorders including depression and borderline personality disorder have a higher risk of attempted suicide [ 12 ].

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.

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Health Conditions Discover Plan Connect. Medically reviewed by Timothy J. Legg, Ph. Causes Is there a pattern? Is it an addiction?

History Media representation Cutting vs. Why do people cut themselves? Cutting does not have a profile or pattern. Cutting can become an addiction.

The history of cutting. The media misrepresents cutting.