Analysis of 41 suicide attempts by wrist cutting: a retrospective analysis

Abstract

Purpose
Self-cutting injuries have a low mortality rate, but this type of injuries has special clinical significance because they have the potential of leading to devastating disability and repeated suicide attempts. The purpose of this study is to analyze the nature and outcomes of wrist-cutting injuries.
Material and method
A retrospective study was designed in order to investigate 41 suicide attempts by wrist cutting attended to Uludag University Faculty of Medicine Emergency Department between June 2008 and December 2014. The patients were analyzed for age, gender, alcohol intake, psychological state, prior suicide attempts, and clinical features such as injury side, injury pattern, and used tool.
Results
It was seen that the severity of wrist-cutting injury variates between gender and age.
Conclusion
Alcohol or drug consumption and having a diagnosed psychiatric disorder create a higher risk for extensive wrist lacerations. It was seen that skin only lacerations were most likely to repeat the act and therefore are most in need of psychiatric intervention.
Level of evidence
Level III, retrospective study.

Full text

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DOI 10.1007/s00068-015-0599-4
Eur J Trauma Emerg Surg
ORIGINAL ARTICLE
Analysis of 41 suicide attempts by wrist cutting:
a retrospective analysis
B. Ersen1,4 · R. Kahveci2 · M. C. Saki3 · O. Tunali2 · I. Aksu2
Received: 2 June 2015 / Accepted: 16 November 2015
© Springer-Verlag Berlin Heidelberg 2015
Results It was seen that the severity of wrist-cutting
injury variates between gender and age.
Conclusion Alcohol or drug consumption and having
a diagnosed psychiatric disorder create a higher risk for
extensive wrist lacerations. It was seen that skin only lac-
erations were most likely to repeat the act and therefore are
most in need of psychiatric intervention.
Level of evidence Level III, retrospective study.
Keywords Wrist cutting · Median nerve · Ulnar nerve ·
Radial artery
Introduction
Hand and upper extremity injuries are among the most
commonly seen injury types in emergency departments.
Suicide attempt-related upper extremity injuries consti-
tute only a small percentage of these injuries. Even though
these types of injuries are not as common as other trauma
types, the increasing rate of suicide attempts is progressing
to become an important social problem due to its reasons
and results [1].
Several studies have demonstrated that the rate of sui-
cide attempts by sharp force injuries to total suicidal cases
is in the range of 2–3 %. However, most publications
regarding suicide attempts deal with single unusual cases,
while retrospective studies are relatively uncommon in the
literature due to its low mortality rate [2, 3]. Self cutting
injuries have a low mortality rate, but this type of inju-
ries has special clinical significance because they have the
potential of leading to devastating disability and repeated
suicide attempts [4]. At the palmar wrist, 16 structures,
including 12 tendons, two nerves, and two arteries, are
located just beneath the skin; therefore, these important
Abstract
Purpose Self-cutting injuries have a low mortality rate,
but this type of injuries has special clinical significance
because they have the potential of leading to devastating
disability and repeated suicide attempts. The purpose of
this study is to analyze the nature and outcomes of wrist-
cutting injuries.
Material and method A retrospective study was designed
in order to investigate 41 suicide attempts by wrist cutting
attended to Uludag University Faculty of Medicine Emer-
gency Department between June 2008 and December 2014.
The patients were analyzed for age, gender, alcohol intake,
psychological state, prior suicide attempts, and clinical fea-
tures such as injury side, injury pattern, and used tool.
* B. Ersen
drburakersen@gmail.com
R. Kahveci
drkahveci@uludag.edu.tr
M. C. Saki
mecasa90@gmail.com
O. Tunali
drorhantunalidr@gmail.com
I. Aksu
drismailaksu@gmail.com
1 Plastic Aesthetic and Reconstructive Surgery Department,
Dr. Munif Islamoglu Kastamonu State Hospital, Kastamonu,
Turkey
2 Plastic Aesthetic and Reconstructive Surgery Department,
Faculty of Medicine, Uludag University, Bursa, Turkey
3 Plastic Aesthetic and Reconstructive Surgery Department,
Bingol State Hospital, Bingöl, Turkey
4 UÜTF Plastik Cerrahi Polikliniği Görükle, Nilüfer,
16056 Bursa, Turkey

B. Ersen et al.
1 3
anatomical structures are highly vulnerable to injury. Apart
from the arm, hand or finger amputation, combined injury
of nerves, flexor tendons, and arteries at wrist level may be
the most traumatizing injury to the forearm. Nerve injury
causes loss of motor and sensory functions of the hand.
Diminished grip strength, imbalance of hand movements
due to loss of intrinsic muscle functions, and loss of sensa-
tion in some or all fingers leave the hand as a nonfunctional
tool. Laceration of several flexor tendons can lead to exten-
sive scar tissue formation, resulting in elimination of differ-
ential gliding of the tendons [5]. Suicide attempts by self-
cutting injuries may vary from simple skin lacerations to
extensive wrist laceration, affecting most of the anatomical
structured located in the wrist. Due to its clean cut nature,
suicide attempts by wrist cutting do not have the view of
spaghetti.
Several studies demonstrated that most of the wrist-cut-
ting suicide attempts, especially for women, are not “real”
suicide attempts. They are obsessive devices not to attempt
suicide but to reduce tension. This action could also be
called “antisuicide” to recover from a depersonalized state
[6–9]. In this patient group, there are usually numerous
lines of the scars often carved like pinstripe, although they
are superficial and delicate. This type of “wrist cutting”
does not appear to be a suicidal gesture, because it is less
likely to injure an artery and results in fatal bleeding than
extensive wrist cutting. These patients constitute nearly
half of the wrist-cutting suicide-attempt patients [10]. On
the other hand, same studies demonstrated that there are
also “real” or “lethal” suicide attempts. In these attempts,
the risk of fatal bleeding is higher due to laceration of
radial artery and ulnar artery. Moreover, diagnosed psychi-
atric disease history is higher in these patients [6–9]. Even
though these attempts are more dangerous, the mortality
rate is lower than 1 % in the literature [11].
In our study, we aimed to investigate suicide attempts
by wrist cutting and analyze their clinical and demographic
characteristics in relation to their mechanism of injury.
Material and method
A retrospective study was designed in order to investi-
gate 41 suicide-attempt patients attended to the Uludag
University Faculty of Medicine Emergency Department
between June 2008 and December 2014. The last physi-
cal examinations of the patients took place in Decem-
ber 2015. All patients attempted suicide by cutting their
wrists and all of them were evaluated and treated by the
Uludag University Faculty of Medicine, Plastic Recon-
structive and Aesthetic Surgery Department. During their
treatment, all patients underwent psychological evalua-
tion. The first psychological evaluation was performed
in the Emergency Department, and the second was per-
formed on the first postoperative day. All patients were
sent home after their postoperative psychological evalu-
ation and all patients were referred to Psychiatry clinic.
The data of the patients were collected from the comput-
erized file system of the hospital and analyzed for age,
gender, alcohol intake, psychological state, prior suicide
attempts, and clinical features such as injury side, injury
pattern, and used tool.
Postoperative hand therapy for a minimum 2-month
period was advised for all patients. The long-term out-
comes were assessed by using five criteria (tendon func-
tion, opposition of the thumb, intrinsic function, two-point
discrimination of the pulp, and additional surgery in the
postoperative period). Tendons function was evaluated and
addressed as excellent in case of individual tendon function
was evident with 85 % to a full range of motion (ROM)
or finger flexion to 1.0 cm or less from the distal palmer
crease, good (70–84 % total ROM or 2.0 cm from the dis-
tal palmer crease), fair (50–69 % ROM), or poor (limited
movement due to possible adhesion). To calculate the ROM
angle of each tendon, the possible flexion angle of the joint
was measured, and then the measured values were checked
with normal ROM values (Table 1).
The opposition of the thumb was evaluated with the use
of Kapandji index [12]. This evaluation was addressed as
good when the score was 7–10, fair (when the score was
3–6), and poor (when the score was 1 or 2).
Intrinsic functions were evaluated by using the Bun-
nell Littler test and addressed as good (in case of full PIP
flexion with MCP extension), fair (Limited PIP flexion and
Increased PIP flexion with MCP flexion), and poor (lim-
ited PIP flexion and no increase in PIP flexion with MCP
flexion).
Table 1 Normal range of motion reference values
Location Movement ROM angle
Wrist Extension 0
Flexion 145
Radial deviation 20
Ulnar deviation 35
Thumb ip joint Hyperextension 15
Flexion 80
Thumb MP joint Hyperextension 10
Flexion 55
Finger DIP joint Extension 0
Flexion 80
Finger PIP joint Extension 0
100
Finger MP joint Hyperextension 0–45
Flexion 90

Analysis of 41 suicide attempts by wrist cutting…
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The sensation was evaluated and addressed as normal
(when the two-point discrimination is less than 6 mm), fair
(when the two-point discrimination is 6–10 mm), and poor
(when the two-point discrimination is more than 10 mm
with light touch and pin prick sensation).
Results
A total of 41 patients attempted suicide by cutting their
wrists were included in our study. 53.6 % (22) of our
patients were women, and 46.4 % (19) of them were men.
The average age of the patient was 29.3 (15–81). The aver-
age age of male gender (31.4) was relatively higher than
female gender (27.4). The mean follow-up period was
20.8 months (12–65).
37 patients were using the right hand as the dominant
hand (90 %). 32 patients (78 %) cut their left wrists only
in order to attempt suicide. Three of them cut their right
wrists (7 %), whereas six patients (14 %) attempted suicide
by cutting their wrists bilaterally.
21 patients (51 %) did not damage any important ana-
tomical structures and only treated with skin suturation.
Remaining 20 patients (49 %) suffered from different
degrees of important anatomical structure damage. Out of
20 patients, eight patients (19 %) had nerve injuries con-
comitant with arterial injuries. Eight patients injured ulnar
or median nerve without arterial damage. Two patients cut
their median nerve partially. Only one patient had an exten-
sive wrist laceration. The list of demographic and clinical
features of our patients is shown in Table 2.
When the average age of patients who cut the important
anatomical structures was evaluated, the average age of our
study was 39.1. The average age of the female gender was
25.0 which was younger than the average age of all female
patients. The average age of male gender was 33.3 which
was older than the average age of all male patients.
When it was evaluated from the aspect of gender, inter-
estingly, female gender had a higher percentage of skin
only injuries (72 %). 16 of 22 female patients did not
damage any important anatomical structure. This rate was
(26 %) in the male gender. Out of 19 patients, only five
patients did not damage any important anatomical struc-
ture in the male gender. 74 % of male patients injured their
important anatomical structures, whereas this rate was only
28 % for the female gender.
Most commonly injured anatomical structures were wrist
flexor tendons with 15 tendon laceration. Median nerve
was the second structure commonly injured with 13 lacera-
tions. Ulnar artery and nerve were damaged together in five
patients. Three patients had radial artery injury, and two
patients suffered from extensor tendon injuries. The list of
injured important anatomical structures is shown in Table 3.
The tools used for suicide attempts were investigated.
We see that razor blade was the most common tool; 51 %
of the patients [21] attempted suicide by cutting their wrists
by razor blade. The second most common tool was a knife
with a rate of 36 %. The other two tools were glass frag-
ments (9 %) and scissors (4 %).
Alcohol or narcotic drug intake prior to suicide attempt
was investigated in all patients. In 12 patients (29 %), drug
or alcohol tests were positive. Nine of 12 of these patients
injured their important anatomical structures. Alcohol or
narcotic drug consumption before suicide attempt was
higher in male gender. Out of eight male patients who had
a positive drug or alcohol test, seven patients injured their
important anatomical structures in the wrist.
All patients who attempted suicide were evaluated for
acute onset or previously diagnosed Psychiatric diseases.
21 % (9) patients were under treatment for diagnosed psy-
chiatric diseases, and seven of them injured important ana-
tomical structures.
Patients who attempted suicide were also evaluated for
prior suicide-attempt histories. 11 patients were (six male/
five female) attempted suicide before, interestingly eight of
them (72 %) only lacerated their skins without any impor-
tant anatomical structure injury.
The long-term outcomes of wrist lacerations were also
evaluated and are shown in Table 4. Out of 21 patients,
the outcomes of 18 patients were considered as satisfac-
tory. Three patients had poor or fair results. Two of these
patients received additional surgeries in the postoperative
period. Five patients received additional surgeries during
follow-up period, two were scar revisions, one was tenoly-
sis due to tendon adhesions, and two were tendon transfers
due to ulnar nerve palsy. A tenolysis and tendon transfer
procedure was offered to one patient, but the patient was
not suitable due to psychiatric state. The same patient did
not attend to the hand therapy sessions due to the same
reason.
Discussion
Suicide attempt-related upper extremity injuries are not
common compared to other types of upper extremity trau-
mas admitting to the ER, but the increasing rate of suicide
attempts is progressing to become an important social
problem due to its reasons and results.
In the case of self-inflicted wrist cutting, injury to ten-
dons, nerves, and arteries can result in a reduced or loss of
sensory and motor capacity. Thus, such injuries are prob-
lematic in terms of both wound treatment and mental care
[13].
The suicide attempts in Europe are most commonly
seen in adolescence and young adulthood, usually

B. Ersen et al.
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between the ages of 14 and 24 [14]. In our study, our aver-
age age was 29.3 which was apparently older compared
to the literature. Also, when we investigate the average
age of patients who cut their wrists and damage impor-
tant anatomical structures. The average age of this patient
group was 39.1 which is apparently older than the study`s
average age.
In our study, 32 patients (78 %) cut their left wrists only
in order to attempt suicide (Fig. 1). It considered as nor-
mal because the right hand is usually the dominant hand in
Table 2 Clinical and demographic features of the patients
No Age Gender Alcohol/drug intake Known psychiatric
disease
Prior suicide attempt Number of injured ana-
tomical structure
Tool used for suicide
attempt
1 30 F − + − Skin only Razor blade
2 15 F − + + Skin only Scissors
3 81 F − − − Skin only Kitchen knife
4 16 F − − − Skin only Razor blade
5 20 F + − − Skin only Razor blade
6 28 F − − − Skin only Glass fragment
7 28 F − − − Skin only Razor blade
8 29 F − − + Skin only Razor blade
9 25 F + − + 6 Glass fragment
10 23 F + + − Skin only Kitchen knife
11 18 F − − + Skin only Razor blade
12 22 F − + − 2 Razor blade
13 19 F + − − 2 Kitchen knife
14 21 F − − + Skin only Razor blade
15 28 F − − − Skin only Razor blade
16 42 F − − − 2 Kitchen knife
17 24 F − − − 1 Kitchen knife
18 25 F − − − Skin only Razor blade
19 50 F − + − Skin only Razor blade
20 16 F − − − Skin only Razor blade
21 30 F − − − Skin only Kitchen knife
22 18 F − − − 4 Kitchen knife
23 32 M + − + Skin only Razor blade
24 27 M − + + Skin only Kitchen knife
25 40 M − + − 4 Glass fragment
26 23 M + − − 4/4 Kitchen knife
27 44 M − − − 3 Kitchen knife
28 49 M − − − 2 Kitchen knife
29 61 M − − − 1 Kitchen knife
30 25 M − − − 10 Glass fragment
31 38 M − − − 1 Kitchen knife
32 60 M + − − 3 Kitchen knife
33 19 M + − + 2 Razor blade
34 21 M − − + Skin only Razor blade
35 21 M − − − Skin only Razor blade
36 23 M + + − 5 Razor blade
37 30 M − − + Skin only Razor blade
38 23 M + + + 2 Razor blade
39 24 M + − + 5 Kitchen knife
40 18 M + − + 5 Razor blade
41 20 M − − − 6 Razor blade

Analysis of 41 suicide attempts by wrist cutting…
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Table 3 List of injured important anatomical structures
R Right wrist, L Left wrist, PL Palmaris longus, FCR Flexor carpi radialis, FCU Flexor carpi ulnaris, FDS Flexor digitorum superficialis, FDP
Flexor digitorum profundus, FPL Flexor pollicis longus
Patient number Age Gender Side Injured structure
9 25 F L PL, FCR, FCU, median nerve, ulnar nerve, ulnar artery
12 22 F R/L R: skin only L: ulnar artery, ulnar nerve
13 19 F L Median nerve (partial), PL
16 42 F L Median nerve (partial), PL
17 24 F R/L R:skin only L: FCR
22 18 F L Median nerve, ulnar artery, ulnar nerve, FCU
25 40 M L Median nerve, radial artery, PL, FCR
26 23 M R/L R:median nerve,PL, FCR, FCU L: median nerve, PL, FCR, 3rd finger FDS
27 44 M L Ulnar artery, ulnar nerve, FCU
28 49 M L 2nd finger extensor tendon, indicis proprius
29 61 M R/L R: skin only L: median nerve
30 25 M R Ulnar artery, ulnar nerve, FCU, PL, 3rd-4th-5th FDS and FDP
31 38 M L 3rd extensor tendon
32 60 M L Median nerve, radial artery, FCR
33 19 M L Median nerve, PL
36 23 M L Median nerve, FCR, FPL, 2nd FDS and FDP
38 23 M L Median nerve (partial), PL
39 24 M L Median nerve, 2nd-3rd-4th-5th FDS
40 18 M L PL, FCU, FCR, 3rd-4th FDS
41 20 M L Median nerve, radial artery, PL, FPL, 2nd FDS and FDP
Table 4 The long-term outcomes of wrist lacerations
Patient no Tendon function Opposition Intrinsics Sensation median nerve Sensation ulnar nerve Additional surgery
9 Fair Fair Fair Fair Fair +
12 − − Normal −Good −
13 −Good −Good − −
16 −Good −Good − −
17 Excellent − − − − −
22 Excellent Fair Poor Fair Poor −
25 Excellent Good −Good − −
26 Excellent Good/Good −Good/Fair − −
27 Excellent −Normal −Good −
28 Dorsal wrist injury −
29 −Good −Good − −
30 Fair −Poor −Poor +
31 Dorsal wrist injury −
32 Excellent Good −Good − −
33 −Good −Good − −
36 Good Good −Good − −
38 −Good −Good − −
39 Fair Good −Good − +
40 Good − − − +
41 Excellent Good −Good − +

B. Ersen et al.
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the overall population. In our study, 37 patients were using
their right hand as the dominant hand.
Out of 41 patients, 21 of them were only able to cut their
skin and did not damage any important anatomical struc-
tures. 16 of these 21 patients were female. While attempt-
ing suicide by wrist cutting, female patients tend to cut
their wrists superficially, whereas male patients tend to
have more extensive wrist lacerations (Figs. 2, 3). Out of
19 male patients, 14 patients injured important anatomical
structures in the wrist. Our results were similar to previous
publications in the literature [8, 10]. The patients who were
only able to cut their skin closely resembled those with
wrist-cutting syndrome: most were female, their wounds
were not severe, and they were nonsuicidal.
Self-cutters have a high baseline of pain threshold,
which elevates higher with distress, and self-cutting has
the function to terminate the dissociation precipitated by a
strong emotion, such as anger. In other words, the intensity
of depersonalized symptoms is at a maximum just before
self-cutting, and this is why patients do not feel pain during
injury and why they feel release after depersonalized symp-
toms decrease immediately [15, 16].
39 patients had flexor side injuries, and two patients cut
their wrists dorsally. Wrist flexor tendons were the most
commonly injured anatomical structures, but specifically,
the median nerve is the most frequently injured anatomical
structure [17].
Several studies demonstrated that some serious hand
injuries result following alcohol intake [18, 19]. Our study
demonstrated similar results as well. Alcohol or narcotic
drug intake prior to suicide attempt was investigated in all
patients. In 12 patients (29 %), drug or alcohol tests were
positive. The rate of injuring important anatomical struc-
tures in the wrist was 75 % in our study.
All patients in our study were also evaluated for psychi-
atric disorders. Nine patients were under treatment for pre-
viously diagnosed psychiatric disorder. Seven of these nine
patients had extensive wrist laceration and injured some
important anatomical structures in the wrist. Remaining 32
patients attempted suicide impulsively and were not diag-
nosed for any psychiatric disorders.
Self-harm is listed in the diagnostic and statistical man-
ual of mental disorders as a symptom of borderline person-
ality disorder. However, patients with other diagnoses may
also self-harm, including those with depression, anxiety,
substance abuse, eating disorders, posttraumatic stress dis-
order, schizophrenia, and severe personality disorder [20].
In our study, there were nine patients with a psychiatric
disorder history. One patient had the diagnosis of schizo-
phrenia, one with post traumatic stress disorder, and the
remaining seven patients were under treatment for major
depression.
Our results agree with previous findings that most wrist-
cutting patients cut themselves impulsively and wrist cut-
ting usually reflects poor emotional regulation [21].
Our patients were also investigated if they attempted
suicide before. It was seen that 11 patients were (six male/
five female) attempted suicide before, interestingly eight of
them (72 %) only had skin only injuries and did not dam-
age any important anatomical structures.
Fig. 1 Patient No. 7, a “skin only” laceration cut by a razor blade
Fig. 2 Patient No. 30, a transection view of a glass fragment cut. Ten
important anatomical structures were cut
Fig. 3 Patient No. 30, Green arrow: ulnar artery and nerve, blue
arrow: deep flexor tendons

Analysis of 41 suicide attempts by wrist cutting…
1 3
The long-term results of our study were generally satis-
factory. The attendance rate of the patients to the hand ther-
apy sessions were high, and also the lacerations were rather
distally located. We consider these two features were the
main factors for satisfactory clinical outcomes. Out of 21
patients, the long-term results of 18 patients were satisfac-
tory. Only three patients’ results were poor or fair. Two of
them received additional surgeries, and the remaining one
was not suitable for surgery.
During the follow-up period, two patients did not attend
to the hand therapy sessions. One of them received a ten-
olysis procedure due to tendon adhesions. A tenolysis and
tendon transfer procedure was offered to the other patient
who did not attend to the session, but the patient was not
appropriate due to psychiatric state. The remaining patients
attended to the hand therapy sessions for two or more
months.
Conclusion
In our study, we investigated the demographic and clinical
features of 41 suicide attempts by wrist cutting. It was seen
that the severity of wrist laceration differs between gender
and age. Alcohol or drug consumption and having a diag-
nosed psychiatric disorder create a higher risk for exten-
sive wrist lacerations. It was seen that skin only lacerations
were more likely to repeat the act and therefore are most in
need of psychiatric intervention. All patients were referred
to psychiatry clinic postoperatively, and it was seen that
none of the patients were committed suicide during the fol-
low-up period. We believe that psychiatric intervention is
a crucial postoperative step in case of wrist-cutting suicide
attempts.
Compliance with ethical standards
Conflict of interest Burak Ersen, Orhan Tunali, Ramazan Kahveci,
Ismail Aksu, and Mehmet Can Saki declare that they have no conflict
of interests.
Funding None.
Consent For this type of study, formal consent is not required. Only
written informed consent was obtained from the patient for publication
of this accompanying image.
Ethical standards This study has been approved by the appropriate
ethics committee and has therefore been performed in accordance with
the ethical standards set forth in the 1964 Declaration of Helsinki and
its later amendments.
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