Man With Patterned Cuts on Wrists, Hands, Arms

November 1, 2007

A 46-year-old man is seen by medical personnel with new skin injuries of the upper limbs as shown. States he has not had such injuries before. Denies altercations with knife wielders; also denies self-mutilation or any sexual practice involving bondage or injury.

 

HISTORY

A 46-year-old man is seen by medical personnel with new skin injuries of the upper limbs as shown. States he has not had such injuries before. Denies altercations with knife wielders; also denies self-mutilation or any sexual practice involving bondage or injury.

PHYSICAL EXAMINATION

Man who appears stated age, distressed and fatigued, "shaken up and dehydrated" but composed and not in shock. Systolic blood pressure, 102 mm Hg (normally 130); heart rate, 112/min and regular; respirations, 22/min; SaO2, 100% on ambient air. Random fingerstick glucose measurement, 190 mg/dL. No similar lesions on skin of face, trunk, or legs. Range of motion throughout both upper limbs normal.

The lesions run straight and shallow, without any dehiscence or exposure of subcutis and with sparse bleeding. Many are strictly parallel to one another or make a consistent angle of 120 degrees or so (Figures 1, 2, and 3). Most range from 1 to 6 cm in length. Small puncture wounds occur especially over the hypothenar eminence. There is almost no ecchymosis, nor any such deformity as might follow fracture or deeper extravasation of blood, nor edema. One wonders whether innumerable small cuts were deliberately inflicted with a sharp blade, either by an adversary or a sex partner, or by the patient himself.

The history proved crucial in illuminating these findings, as is so typically the case: The patient had gone off-path and gotten lost while bird-watching alone in a desolate area, in 100-degree heat with no water supply and no compass. He became disoriented amidst head-high reeds and thornbushes; could find no way out nor any means to get back on a track. Seeking to follow putative deer paths only led deeper into tangles. Attempts to press and push his way out, mostly by moving branches either by hand or the back sides of his bare arms, scratched them up thoroughly.

He was finally led out, shortly before dark, by police, after calling 911 on a cellular telephone and then listening for the shouts of officers sent in from the nearest open space. Emergency medical technicians obtained vital signs and oximetry readings, administered oral fluid repletion, and recommended routine evaluation in a hospital emergency department. This was refused and so recorded.

WHY KEEP KEY INFORMATION FROM THE READER?

Vital information was deliberately withheld to force consideration of the meaning of the pattern of injury, and to explore some key differential diagnoses. Patients often dissemble or mislead for diverse reasons, as discussed below. Others lack the capacity to tell us, eg, because of dementia, delirium, language barrier, or coma. So such omission, while harsh, more closely approximates the challenging end of the clinical spectrum of seeking to solve the puzzle of the scratches.

COULD THESE REPRESENT DEFENSIVE WOUNDS?

Ever since several fictional television programs with forensic themes have become popular, our entire society shows interest in interpreting crime residues, including on human beings. A forensic literature on wound pattern interpretation in the skin has long existed1,2 and includes use of ordinary and specialized photography3-6 and of computer-reconstruction techniques to comprehend both the injuring instrument, and the injured tissue, in 3 dimensions.7 Some such literature draws inferences from bite wounds.

Clinicians have, in addition to the generalized coexistent fascination and repulsion about these topics, a particular responsibility to recognize unreported violence and to alert law enforcement, as well as to document suspected or acknowledged violence for the benefit of the patient at hand and of society at large. This duty is more frequently articulated by pediatricians and gynecologists, but it extends to every physician and other clinician.

One could think, in this case, of innumerable small torture-cuts made with a short blade, or with a pointed tool held very steady and drawn across the skin. While the history clearly established another mechanism, the finding on the forearms raises the specter of defensive wounds in that arms are routinely raised to prevent graver injury to head, trunk, or the largest vessels, and thus often bear the brunt if their defensive function succeeds. However, it would be difficult to slash this many times, even with a tiny blade, without inducing more bleeding and some deeper cuts that should gape at least a bit; ecchymoses would also be expected. Hence we might think about controlled injury of a restrained person.

SEXUAL TORTURE WITH SADOMASOCHISM?

In addition to baseline prevalence of sadomasochism, our society includes persons so jaded by endless Internet pornography that they seek extreme images and, in some cases, practice of such behavior in real life. Although most such individuals behave responsibly and decently while acting out such preferences, always there is a fringe that oversteps boundaries--whether by design or by accident--and either inflicts substantial injury on a willing or paid partner, or receives it.

In encounters with a health care system that is perceived as judgmental and hostile, most persons who engage in the less-ordinary sexual practices do not volunteer such information. They usually won't admit it on direct questioning by a practitioner even if he or she is perceived as simpatico. So a negative history in this case must be regarded as inconclusive.

One could then try to make the case that shame and refusal of emergency department evaluation are consistent with sexual origin of the injuries. They are, but fall far short of being diagnostic: the history of having been retrieved, alone, from deep thorny areas by rescue personnel secured context and diagnosis. Deep personal embarrassment arose from having required and "bothered" police and rescue personnel due to "my own stupidity--and after a decade of bird-watching." One must not over-infer from mortification.

SELF-INFLICTED?

Finally, one could wonder, based on pattern, if this might be self-inflicted. The acts of repetitively cutting oneself or burning oneself with cigarettes are best recognized in relation to deeply psychiatrically troubled young persons, including women with anorexia nervosa, and have been reported in fiction8 (some likely incorporating personal painful reminiscence) as well as in clinical literature. With self-cutting, there might well be no deep cuts because of drawing back in pain--unless the psychopathology were very profound indeed, something the clinician would often infer readily. Bilaterality as seen here also makes the scenario of self-induced harm less likely, barring ambidexterity.

PREVENTION AND FOLLOW-UP

Fluids were provided by mouth. A restful next 24 hours was recommended. The patient was sternly counseled against going off-path; a supportive and frightened family underscored this message forcefully enough that recurrence of the dangerous behavior was considered unlikely.

"Preventive" oral antibiotics were not given because of concern that they would select for resistant organisms and almost surely would not be needed; the patient was regarded as reliable for follow-up by telephone call or in person. Topical bacitracin was applied just once, and patient and family watched out for any development of cellulitis, which never happened. The scratches healed quickly. As I contemplated the images, I realized that the parallel scratches reflected the stereotypic swinging of the arms to move thorny creepers out of the way: the angle was always the same, with one set of lines representing a straight lateral (external rotation) movement, and the other an up-and-out or down-and-out. The hands would move instantly on puncture by a thorn; the arms would not, they would keep sweeping, and hence bore linear remnants.

One colleague noted that the same look could follow a session planting rosebushes; another, a golfer, spoke of the appearance of arms after one tries to retrieve the ball deep in the rough when briars and bristles abound there. These comments underscore the limited number of patterns of injury that the skin can display, whether from deliberate violence or mere accident. *

Schneiderman H. Patterned scratches from thornbushes and the consideration of physical signs of deliberate violence. CONSULTANT. 2007;47:1163-1166.

References:

REFERENCES:


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I Never Promised You a Rose Garden.

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