Injuries from handcuffs either reflect relative movement between the cuff and wrist or are the result of direct pressure from the cuff to the tissues of the wrist. It is important to remember that injuries may be unilateral, especially where there has been resistance to their application.
The most common injuries found are erythema, abrasions, and bruising, particularly to the radial and ulna borders of the wrist (2). The erythema is often linear and orientated circumferentially around the wrist following the line of the handcuffs, reflecting direct pressure from the edge of the cuffs. Bruising is commonly seen on the radial and ulna borders, with tender swelling often associated with abrasions or superficial linear lacerations from the edge of the cuff. Abrasions reflect relative movement between the cuff and skin surface. However, it is not possible to determine whether this movement is from the cuff moving over the wrist or the wrist moving within the cuff, because either can produce the same skin abrasions. All of these soft tissue injuries will resolve uneventfully during the course of several days, and only symptomatic treatment with simple analgesia and possibly a cold compress is required. Although rare, it is possible to have wrist fractures from restraint using handcuffs. The styloid processes are the most vulnerable, but scaphoid fractures have been reported (3). Tenderness beyond that expected for minor injuries and especially tenderness in the anatomical snuffbox will need an X-ray assessment as soon as possible.
The earliest reports of sensory damage to the nerves of the wrist first appear in the 1920s, with sensory disturbance often restricted to a small patch of hyperesthesia and hyperalgesia on the extensor aspect of the hand between the thumb and index finger metacarpals (4). This area reflects damage to the superficial branch of the radial nerve and subsequent studies confirm that this nerve is most commonly affected by compression between handcuffs and the dorsal radius (5). However, injuries to the median and ulna nerves can also occur, and these may be isolated or in any combination. The superficial branch of the radial nerve may be spared with others being damaged (6). Resultant symptoms are reported as lasting up to 3 years in one case; pain may be severe and prolonged, although the most disturbing symptom to patients is paresthe-
sia (5). Nerve conduction studies may be used to distinguish between a compressive mononeuropathy and a radiculopathy. The majority of cases with significant nerve damage either involve detainees who are intoxicated or have a clear history of excessive pressure being applied by the officers (5). Intoxication may cause problems through a decreased awareness of local pain, marked uncooperativeness, or poor memory for the restraining episode when a significant struggle occurred. It is possible to have nerve damage with no skin breakage, reflecting undue pressure. Although some of the quoted studies predate the introduction of rigid handcuffs, because of the similar ratchet mechanism, direct pressure problems are still possible.
Sensory nerve damage causes loss of pain, touch, and temperature sensation over an area of skin that is smaller than the nerve's sensory supply because of the considerable overlap between the sensory territories of adjacent peripheral nerves. Lesser degrees of damage lead to tingling, pain, and numbness in the appropriate sensory distribution. In acute compression of the nerve, symptoms appear more or less abruptly, and relief of this acute compression should lead to resolution in the course of some weeks. Associated motor weakness can be demonstrated by the correct clinical test within the hand. It should be noted that compression of the radial nerve at the wrist does not result in weakness.
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