Self–Wrist Cutting Injury

Abstract

Sir:FigureSelf–wrist cutting injuries include all volar wrist lacerations from superficial to extensive deep injury caused by self-cutting associated with or without suicidal intent. This injury has special clinical significance because it has the potential to lead to devastating disability and repeated suicide attempts.1 To achieve optimum treatment outcomes, this injury should be evaluated and managed by considering simultaneous traumatologic and psychological aspects. In the present report, we review aspects of self–wrist cutting injury and describe treatment principles for balanced care. A retrospective review of 72 patients who underwent treatment for self–wrist cutting injury at the Korea University Medical Center between July of 2001 and June of 2010 was performed. Traumatologic data including wound features and injured structures and psychological data related to behavior characteristics and mental status were collected. The patients were divided into three groups based on the severity of the injury (Fig. 1). Functional restoration of the hands was assessed using a hand functional grading system based on intrinsic muscle and sensory tests2 and tendon functional grading system.3 Each grade was translated into a numerical score, and the two grading system scores were added together to obtain a total score. Lastly, comparative analysis of various psychological parameters was conducted.Fig. 1: Preoperative view of severe self–wrist cutting injury that is defined as an extensive deep injury involving complete transection of at least three major structures, including at least one nerve or a vessel. In contrast, an injury involving skin and subcutaneous fat layer is defined as mild injury and the remainder except mild and severe injury is defined as moderate injury.Unlike previous studies,1,2,4 the laceration wounds were predominantly located on the radial side of the wrist, and central tendons such as the palmaris longus and the flexor carpi radialis were frequently injured. This may be because most patients supinate their wrists to cut their volar wrists. The number of patients in each severity group was as follows: 16 patients (22.2 percent) in the mild group, 37 patients (51.4 percent) in the moderate group, and 19 patients (26.4 percent) in the severe group. Functional outcomes are summarized in Table 1. Most patients (72.2 percent) obtained excellent or good functional recovery. Only five patients (6.9 percent) obtained poor results, but all of them suffered from severe functional loss. In particular, three of four patients who committed additional fatal suicide attempts obtained poor outcomes because the wrist treatment was delayed as a result of emergency care of associated injuries (Fig. 2). These findings show that rapid initial assessment and well-organized collaborative care with other specialists are crucial for preventing tremendous disability. Fourteen patients (19.44 percent) cut their wrists with suicidal intent, and three of them reattempted wrist cutting during follow-up. However, most patients cut impulsively without suicidal intent. Our results agree with previous findings that wrist cutting usually represents a low intention of suicide but instead reflects poor emotional regulation.5 Presence of suicidal intent was irrelevant to injury severity and functional recovery. This finding implies that all patients who cut their wrists need to be evaluated by a psychiatrist to uncover suicidal intent even though the injuries seem trivial.Table 1: Summary of Functional OutcomesFig. 2: Four-month postoperative view shows ischemic contracture of intrinsic muscles and ischemic necrosis of proximal palmar skin. There was intrinsic-plus deformity with metacarpophalangeal joint flexion contracture, and the intrinsic-plus test was positive. At the end of the follow-up period (18 months later), permanent deformity remained in this patient.The overall prognosis of self–wrist cutting injuries was favorable. However, to minimize catastrophic disability and repeated suicide attempts, a balanced approach considering traumatologic and psychological aspects of these injuries is essential. Ja Hea Gu, M.D., Ph.D. Seong-Ho Jeong, M.D., Ph.D. Department of Plastic Surgery, Korea University Guro Hospital, Seoul, Korea DISCLOSURE No authors involved in the production of this communication have any commercial associations that might pose or create a conflict of interest with the information presented herein. No intramural or extramural funding supported any aspect of this article.