Complaints of pain after use of handcuffs should not be dismissed

Editor—Handcuffs are commonly used to restrain prisoners. It is not unusual for them to be applied in violent circumstances and for the prisoner to struggle. This can lead to overtightening of the handcuffs and considerable trauma to the structures around the wrist. We have recently seen fractures, lacerations, and injuries to the radial, ulnar, and median nerves (table). This is probably the tip of the iceberg, as many people with such injuries fail to attend for assessment, follow up, or investigation.

Superficial radial handcuff neuropathy is the most common injury,^1–3 although injuries to the median, ulnar, and multiple nerves have all been described.⁴,⁵ Nerve conduction studies both confirm the organic basis of the patient’s complaint and help to define the prognosis. Fortunately most lesions are not degenerative.

Kwik-cuffs, the most commonly used handcuffs in the United Kingdom, are applied by allowing the cuffs to spring shut on a ratchet. This can lead to direct trauma and allows overtightening to occur. We postulate that bony injuries are caused at the time the cuff is applied or by levering on the cuffs afterwards, which causes a considerable torque at the wrist joint. While a double locking mechanism exists to limit further tightening of the handcuff, this may be omitted when the prisoner is violent or aggressive, or time is lacking.

Police officers are aware of the potential dangers. Kwik-cuffs are used only by those who have received the relevant training. Officers are nevertheless encouraged to use them to maintain control and for self protection. Moreover, they are instructed not to remove or adjust handcuffs until a safe controlled environment is reached. This may mean that detainees’ complaints of overtight handcuffs are addressed only after a considerable time.

It is probably inevitable that any restraint procedure offering reasonable safety for the police force entails a potential risk for those who lash out against the restraining structures applied to the wrist. It would be difficult to implement other ways of detaining them, although greater awareness of the possibility of handcuff related lesions may lead to an earlier reappraisal once events are proceeding in a controlled manner.

Complaints of pain, sensory symptoms, or weakness after use of handcuffs should not be dismissed. While neuropraxia of the radial nerve may not lead to motor dysfunction, it can none the less be persistent and severe. Damage to the ulnar or median nerve and fractures can be extremely debilitating.

Table.

Data on men arrested and handcuffed

Case No	Age (years)	Violent/ resisted arrest	Consumption of drugs or alcohol	Skin breach	Fracture	Nerve injury	Neuro- physiological examination	Outcome
1	37	Yes	Yes	None	None	Superficial radial—bilateral and right median	Confirmed lesions	Median nerve explored, nerve conduction tests recovered but symptoms persist
2	23	No	Yes	Severe bruising	Radial styloid	Superficial radial—bilateral	Confirmed lesions	Full recovery
3	69	Yes	Yes	Lacerations, extensor carpi ulnaris tendon pain	None	Ulnar—dorsal sensory branch	Failed to attend	Still unable to grip or work 1 year after injury
4	46	Yes	No	None	None	Ulnar and superficial radial	Confirmed lesions	Required ulnar nerve exploration
5	25	Yes	No	None	Scaphoid	None	Not performed	Required fixation
6	27	Yes	Yes	None	None	Superficial radial	Failed to attend	Failed to attend follow up
7	32	Nil	Nil	None	None	Superficial radial—bilateral	Confirmed lesions	Function returned to normal at 2 years but still had sensory symptoms
8	46	Nil	Yes	Grazes	None	Bilateral median nerve injury	Not performed	Failed to attend follow up
9	45	Possible	Nil	Local abrasions and swelling	None	Superficial radial—bilateral	Confirmed lesions	Improving at 10 weeks then stopped attending
10	34	Nil	Nil	Local scarring	None	Superficial radial—bilateral	Confirmed lesions	Still symptomatic at 5 weeks
11	38	Nil	Nil	None	None	Superficial radial	Not performed	Full recovery