Forensic Evaluation of Alleged Wrist Restraint/Handcuff Injuries in Survivors of Torture Utilizing the Istanbul Protocol

Abstract

Despite being a common form of abuse, there is a paucity of literature describing shackling and wrist restraint injuries among survivors of torture. Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture presents challenges to the evaluator, especially if the injuries are remote and do not leave lasting marks nor neurologic deficits. Thorough history-taking and physical examination is critical to effective forensic documentation. Guidance is provided in The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Istanbul Protocol), the gold standard for the medicolegal documentation of torture. This guidance relies primarily on physical findings, with less direction provided on how to interpret historical evidence, or when historical evidence provided by the patient can be interpreted as highly consistent with alleged injury in the absence of current physical findings. Through a case-based review, we present diagnostic strategies for the evaluation of alleged abuse involving wrist restraints/handcuffs, focusing on skin, neurologic, and osseous injuries. We highlight key findings from both the history and physical examination that will allow the evaluator to improve the accuracy of their expert medical opinion on the degree to which medical findings correlate with the patient’s allegations of wrist restraint injuries.

BACKGROUND

The forensic evaluation of alleged survivors of torture (Figure 1) presents a unique opportunity for qualified clinicians to provide their expert opinion on the degree to which medical findings correlate with the patient’s allegation of abuse, and to communicate their findings to judiciary bodies. Effective medical documentation of torture is critical to protect individuals by bringing medical evidence to light, and for holding perpetrators accountable. Medical documentation of human rights abuses is applicable to human rights investigations, asylum claims, and establishing conditions in which statements/confessions obtained by a state are tainted by torture. Evaluations can also assist in illustrating regional practices of torture.

Figure 1.

Definition of Torture from the Convention on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment [27].

Often, physical findings from alleged abuse may be nonspecific and difficult interpret when they are remote and natural healing processes have occurred. Additionally, an implicit aim of those who carry out torture is often to minimize permanent physical marks [1,2]. Despite these challenges, the forensic examiner must strive to interpret the medical evidence - including history and physical findings - to the highest possible degree of specificity in an objective and impartial manner utilizing established methods. This requires an in-depth knowledge of torture methods, and their potential sequelae.

The international gold standard for the medicolegal documentation of torture is The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment - commonly known as the Istanbul Protocol (IP) [3]. This international standard is of critical importance when evaluating alleged survivors of human rights abuses as it provides universal guidelines for documentation, including standardized terminology. Analysis and conclusions in a medical forensic evaluation are communicated according to the evaluator’s confidence in the degree to which medical findings correlate with the patient’s allegation of abuse. The following categories are recommended: (a) Not Consistent - the lesion could not have been caused by the trauma described, (b) Consistent With - the lesion could have been caused by the trauma described, but it is non-specific and there are many other possible causes, (c) Highly Consistent - the lesion could have been caused by the trauma described, and there are few other possible causes, (d) Typical Of - this is an appearance that is usually found with this type of trauma, but there are other possible causes, and (e) Diagnostic Of: This appearance could not have been caused in any way other than that described [3].

While there is a body of literature regarding handcuff injuries related to police custody, there is currently a paucity of literature specifically describing wrist shackling and handcuff injuries among alleged survivors of torture. Handcuffs used by law enforcement are mostly metal, circular-ratcheting, and self-locking pieces. Use of plastic wrist restraints is increasingly common [4]. Prolonged restraint is a well-known form of torture, though survivors frequently report being restrained with shackles, wires, or rope, in addition to metal or plastic handcuffs [1]. Severity of handcuff injury, in addition to material used, may be impacted by total time restrained, prolonged restraint versus episodic periods, the position of arms in front of or behind the body, if the individual is lifted or pulled by the restraints, or whether the patient is suspended while restrained. In a review of 367 physical torture cases in Cairo, Egypt, describing all injuries, 68 (18.5%) survivors had positive physical evidence of trauma from handcuffs. In this study, of all 31 injuries resulting in permanent disability, 24 cases (25%) of lasting injuries were related to nerve damage from handcuffs [2]. Handcuff/wrist restraint injuries may result in abrasions and lacerations of the skin, occasionally leading to permanent scarring [4], nervous injuries involving the superficial radial, ulnar, and median nerves [5,6], and osseous injuries involving fractures to the radial styloid process [7,8], scaphoid [8,9], and even humerus. [10]. In extreme circumstances, torture involving wrist restraints can result in amputation of the hands [11].

The purpose of this article is to provide a case-based review of diagnostic strategies for the forensic evaluation of alleged abuse, outline those injuries associated with the use of handcuffs/wrist restraints, and to provide guidance for increasing the accuracy of analysis and conclusions in the medicolegal report documenting wrist restraint injuries.

CASE 1:

The patient is a man in his twenties who sought evaluation for alleged human rights abuses. He reported that his wrists were bound with rope behind his back for approximately 2.5 days. At the time, he developed pain and a tingling sensation in his right hand and swelling in his wrists which was exacerbated by movement of his wrists. He did not have any evaluation or treatment at the time of the injury.

Several years after the injury he was evaluated by an orthopedic surgeon in his country of refuge and was diagnosed with De Quervain’s syndrome given pain in the first dorsal compartment and a positive Finkelstein test. He underwent surgery for release of the first dorsal compartment of the right wrist. At the time of his forensic evaluation he reported that his hand function was slowly improving, but he still had persistent mild pain in the right wrist. Physical exam was notable for a surgical scar at the radial styloid process. Radiographs were unremarkable and no electromyography was performed. Described symptoms are consistent with both De Quervain’s syndrome and superficial radial nerve compression, which can result from wrist restraint injury. Based on the historical description of symptoms, the physical examination, and requirement of surgery for treatment, these findings in totality were highly consistent with the allegation of wrist restraint abuse.

CASE 2:

The patient is a man in his 30s who was evaluated for alleged human rights abuses. He reported multiple episodes where he was handcuffed with plastic cuffs and suspended for hours at a time. He reported that, at the time, his hands would become weak, dark in color, and numb. He endorsed multiple abrasions and lacerations to his wrists. There were periods during his detainment and after his release in which he was unable to use his hands due to weakness and loss of sensation. Following repeated episodes of alleged wrist restraint/handcuff use, he described that the abrasions to his wrists became red, swollen, and were slow to heal.

At the time of the forensic exam a few months later, the patient had persistent, slowly improving, numbness in his hands, particularly in the right. On exam, the patient had decreased sensation in the right palm and lateral hand in the median and ulnar nerve distributions. Additionally, there was decreased sensation in the ulnar nerve distribution of the left palm. There are numerous both linear and irregularly-shaped, slightly raised scars on bilateral wrists in a circumferential pattern. While median and ulnar nerve injury is consistent with wrist restraint/handcuff use, based on the totality of evidence: the historical account of symptoms, evidence of median and ulnar nerve damage, and the distinct scarring pattern observed, these findings were diagnostic of wrist restraint injury.

PHYSICAL EVIDENCE FOLLOWING WRIST RESTRAINT/HANDCUFF USE AND ITS INTERPRETATION

The forensic evaluation of any patient alleging history of wrist restraint/handcuff injury begins with a detailed account of the mechanism of injury. Important details include the style and material of handcuffs used, the duration of application-as prolonged duration increases risk of neurologic sequelae [5], and the position of the hands when restrained. Cuffing an individual behind the body, whether the wrists are maximally pronated (“back to back”) or stacked, a history of levering the individual up by the restraints, a history of perpetrators failing to loosen the wrist restraints/handcuffs, and a history of suspension, with or without feet touching the ground, while restrained causes variable risks to nervous and osseous structures. Review of symptoms during and immediately following handcuff application, including skin trauma, pain, weakness, numbness, and joint dysfunction is also essential, even if some or all of these symptoms have completely resolved at the time of assessment. A description of prior symptoms during and immediately after restraint that match a specific diagnosis can represent important evidence for the medicolegal report. The IP states “a detailed account of the patient’s observations of acute lesions and the subsequent healing process often represents an important source of evidence in corroborating specific allegations of torture or ill treatment” [3]. Finally, any persistent symptoms should be discussed in detail as these will be most important in guiding the exam and further testing. Key historical questions and examination findings are highlighted in Figure 2.

Figure 2.

Key history-taking and application of the Istanbul protocol to history and exam findings

Skin Findings

Skin markings from wrist restraint/handcuff use include wrist abrasions, ecchymoses, lacerations, and hand edema [4,6]. Of these, circumferential lesions outlining the handcuff bracelet are typical or diagnostic of alleged wrist restraint/handcuff use. The evaluator should examine the wrists carefully as scarring may only be found at bony prominences. Additionally, the patient may report lesions that immediately followed the alleged wrist restraint/handcuff abuse. These skin lesions, however, are often short-lived or may fail to occur. The absence of physical findings, therefore, cannot rule-out a history of remote wrist restraint/handcuff injury. For example, in a study of 18 patients who presented for follow up after a mean of 305 days (range 6–923 days) with neuropathy complaints from handcuff application, only 9 (50%) had skin findings (abrasions, lacerations, ecchymosis, and hand edema) suggestive of wrist compression [6]. Some examples of skin lesions from handcuff use are shown in Figure 3.

Figure 3.

Skin lesions associated with alleged handcuff injury

Neurologic Findings

Compression neuropathies are the most well documented complication of wrist restraint/handcuff application. Neuropathies of the superficial radial, ulnar, and median nerves have all been documented [5, 6]. Most nerve compression injuries from handcuffs resolve without specific therapy, but some can result in permanent disability [6,12]. Motor deficits are less common than sensory impairment but can occur. In this case, involvement of both wrists is common and deficits may persist for considerable periods of time, sometimes for years [4]. Additionally, in those survivors who are restrained and suspended, compression injury as well as axonal traction injury may result in additional deficits [1]. The type of handcuff material used has been associated with increased risk of nervous injury, with one study showing nearly double the nerve damage among individuals who were restrained with plastic as opposed to metal handcuffs [13].

Cheiralgia Paresthetica

The superficial branch of the radial nerve is the most vulnerable and commonly affected nerve in wrist restraint injury, causing a sensory neuropathy known as cheiralgia paresthetica, or “handcuff neuropathy” first described by Dr Wartenberg in 1932 [14], but initially attributed to handcuff use in 1978 [15, 16] (see Figure 4). In a study of patients who presented with hand sensory or motor dysfunction after handcuff application (n=41), 31 had injury to a specific nerve and, of these, 25(89%) had sustained injury to one or both superficial radial nerves on clinical exam or electrodiagnostic testing. While few returned for follow-up, the majority of those that did had persistent symptoms or testing abnormalities [6]. Restraining behind the body with maximal forearm pronation is associated with risk of superficial radial neuropathy (SRN), as this position causes approximation of the brachioradialis muscle and extensor carpi radialis longus tendons, pinching the superficial radial nerve where it exits between these structures in the forearm.

Figure 4.

Distribution of superficial radial nerve and area of compression leading to SRN (from: Cheiralgia Paresthetica. StatPearls Publishing. Image courtesy of Dr Chaigasame) [12].

SRN should be suspected in any patient who complains of first webspace, dorsal thumb and index finger numbness, paresthesias, or burning pain following wrist restraint/handcuffing [17]. The pain may be exacerbated by heavy use/activity of the affected hand. SRN is an uncommon disorder and, in isolation, is almost always due to external compression [18]. While this may be due to a tight bracelet or wristwatch, it is highly consistent with wrist restraint injury in the setting of appropriate history. The differential for wrist pain or numbness suggestive of SRN includes proximal nerve lesions (spinal cord, nerve root, brachial plexus disorders), and other causes of radial wrist pain, including De Quervain’s tenosynovitis (DQT), lateral antebrachial cutaneous nerve neuritis, and osteoarthritis of first carpometacarpal (CMC) joint [19]. In addition to the possibility that pre-existing CMC arthritis or DQT could become symptomatic after exacerbation with external compression, it should be noted that, while a rare etiology, a possible cause of DQT is blunt trauma to the radial wrist [20] or prolonged compression. Additionally, it should be noted that it is not uncommon for SRN and DQT to present in the same patient [19]. Thus, a diagnosis of DQT with or without SRN does not exclude handcuff/wrist restraint injury and, in some cases, might actually support it.

To evaluate for SRN and alternative causes of the numbness suggestive of SRN, physical examination should start with range of motion (ROM) testing of the cervical spine with overpressure in flexion and axial compression in side-bending [21]. C6 motor function is easiest to assess by evaluating biceps and wrist extension strength. C6 sensory dysfunction is similar to SRN neuropathy and can be mistaken by sensory symptoms alone. Should evidence of cervical radiculopathy be present, the likelihood that symptoms are caused by SRN decreases. Visual assessment of the wrist and thumb for any deformity or other signs of injury should be performed. Additionally, palpation of the distal and proximal phalanges, and interphalangeal (IP), metacarpophalangeal (MCP), and carpometacarpal (CMC) joints is required to detect deformity or joint tenderness. The patient should perform passive and active ROM of the wrist to detect positions that may reproduce symptoms. Forearm hyper-pronation and ulnar deviation will often reproduce symptoms of SRN [21].These patients will typically have a positive percussion (Tinel’s) sign where the nerve exits the deep fascia in the forearm (generally 9cm proximal to the radial styloid in the distal third of the forearm). Tapping on the irritated nerve at this location elicits a pain which often radiates distally. Patients with DQT alone would have tenderness at the radial styloid but would not have a positive percussion test in this location.

The diagnostic study of choice for SRN is electromyography (EMG), although this is not required for forensic documentation as clinical history and examination are generally sufficient. One study demonstrated that of 24 handcuff-related SRN cases diagnosed clinically, 17 (71%) also met electrodiagnostic criteria [6]. Additional testing could include plain film radiography to assist in ruling out osteoarthritis of first CMC joint.

Ulnar and Median Nerve Injuries

Neuropathies from handcuff application other than SRN can include those affecting the ulnar and median nerves and, rarely, the dorsal ulnar cutaneous branch of the ulnar nerve [5, 6, 22, 23]. Though such neuropathies can result in more significant disability than SRN due to their motor involvement, they are substantially less common than SRN in the setting of wrist restraint/handcuff use and often have good recovery [6, 24]. The proposed mechanism for these injuries is related to venous and lymphatic outflow obstruction from the hand resulting in hand edema and causing compression of these nervous structures [6]. In the absence of a comorbid SRN- providing additional evidence of external compression- the alternative etiologies for isolated median or ulnar neuropathies at the wrist are more common and include diagnoses of carpal tunnel (estimated prevalence of 2.7–6.8% in the general population) and cubital tunnel syndromes (estimated prevalence of 1.8–5.9% in the general population), respectively [25, 26].

Osseous Findings

Fractures from handcuff use have been documented in several case reports. This includes radial styloid fractures [7,8] and scaphoid fractures in the setting of resisting arrest and with the use of rigid handcuffs [8, 9]. In several of these cases the handcuffs were described as being overtightened and, in the case of scaphoid fracture, associated with the official lifting the individual by the handcuffs [9]. Hilton et al. have described a series of 5 patients with proximal humerus fractures among adolescents who were handcuffed, who may have been at increased risk of fracture due to skeletal immaturity [10].

Radial styloid fractures are common after falls on an outstretched extremity and, as such, given the rarity of fractures associated with wrist restraint/handcuff use in the medical literature, any report of a handcuff-associated fracture should be supported by additional history-taking to evaluate for risk factors for such injury, such as intense force during use of handcuffs or frailty of the subject (for example, osteoporosis). In addition, the vulnerability of a given bone during handcuff use can depend on how the handcuffs are applied to the subject [9]. Overtightening or misapplication of the cuffs can lead to fracture of the radial styloid [7].

Physical exam for suspected fracture from handcuff application includes inspection of the wrist and proximal metacarpal bone for deformity. Palpate the metacarpal bones and IP, MCP, and CMC joints for tenderness and deformity. If prior fracture is suspected, plain films of the wrist and, possibly, the shoulder may be helpful if clinically indicated by current symptoms or disability. Any complaints of shoulder pain or limitations in motion should prompt shoulder radiographs. Discussion with a radiologist can aid in proper radiographic evaluation of suspected fractures, as the appropriate type of radiograph will depend on the suspected injury. Figure 5 illustrates examples of fractures that can be sustained with use of handcuffs.

Figure 5.

Radiographic evidence of fractures associated with handcuff use. a) left radial styloid fracture. b) right radial styloid fracture. c) left scaphoid non-union with early radio-scaphoid arthritis. d) left scaphoid waist fracture

APPLICATION OF ISTANBUL PROTOCOL

The Istanbul Protocol has long emphasized the importance of physical findings and observable deficits when determining if injuries and lesions are (a) not consistent with, (b) consistent with, (c) highly consistent with, (d) typical of, or (e) diagnostic of an alleged torture experience [3]. A challenge to the evaluator in determining if alleged abuses included the use of wrist restraints/handcuffs is, often, that their use leaves no lasting physical marks and may not result in chronic nervous deficits or osseous abnormalities [1,5,6,12]. It becomes critically important, therefore, to obtain a detailed history. This includes a description of symptoms that were experienced at the time the wrist restraints/handcuffs were placed and evolution of symptoms over time, including the healing process of skin lesions and course of neurological symptoms (see Figure 2). Additionally, one must consider and inquire about other causes of symptoms and findings including a history of unrelated trauma such as falling on an outstretched extremity, self-injury such as cutting, the practice of martial arts, gaming, and prolonged repetitive activity such as nursing or holding an infant. A correlation of the degree of consistency between the history of acute and chronic physical symptoms and disabilities with the specific allegations of wrist restraint/handcuff abuse is essential to the analysis and conclusion in the medicolegal report.

With regards to skin injuries, circumferential lesions or scarring would be effectively diagnostic of handcuff use. More often, there may discrete scarring from healed lacerations over bony prominences in the bracelet distribution, and this pattern would need to be combined with history and neurological findings to assess level of consistency. Abrasions or superficial lacerations may not result in lasting scars. Neurologic deficits may also resolve in time, however, an accurate history of the type and distribution of neurologic symptoms alone, particularly if consistent with SRN, in the absence of other causes, may qualify as highly consistent with the alleged handcuff application despite lack of observable deficits at the time of evaluation. It should be noted that the finding of chronic neuropathies (ulnar or median nerve) in the absence of concomitant SRN may be difficult to classify higher than consistent with the alleged handcuff application given other common etiologies. Finally, any radiographic evidence of fracture associated with alleged handcuff use should prompt the physician to consider use of violence during the application of the handcuffs in the absence of frailty of the patient. Handcuff-associated fractures could be considered evidence which is consistent with or highly consistent with forceful wrist restraint/handcuff application, in the setting of appropriate history (Figure 2). Above all, it is the consideration of the totality of evidence in the setting of each patient’s unique history that will allow for appropriate application of the Istanbul Protocol.

RECOMMENDATIONS

A successful interaction with alleged survivors of wrist restrain/handcuff torture begins with demonstrating empathy, building trust, and avoiding re-traumatization [1]. Obtaining a detailed account of patient’s observations of acute lesions, neurological symptoms, and the subsequent healing process represents a particularly important source of evidence for documentation with regards to the use of wrist restraints/handcuffs in alleged torture. Some patients may also have official photo documentation of their injuries from a police report or hospital records from the time of injury. If authenticity can be verified, these can assist in the assessment. Utilizing diagnostic tools such as plain film radiography may help to identify healing or healed orthopedic injuries. Performing further testing, such as electromyography is usually not indicated for forensic documentation, but the patient may require referral to a specialist for further evaluation and treatment of injuries. Involving specialty expertise, such as neurology or orthopedics, may help to distinguish sequelae of torture from other neurologic or orthopedic conditions.

LIMITATIONS

While the sequelae of wrist restraint/handcuff injury have been documented for decades, rigorous evidence-based research of the physical injuries from torture, including use of wrist restraints/handcuffs is limited. Many of these injuries occur remotely from the time of evaluation making the accurate documentation of wrist restraint/handcuff injury more difficult. In addition, survivors of torture are often reluctant to come forward for fear of retribution. These factors impede the ability to determine the incidence and prevalence of such injuries. It is only with the continued work of international bodies and forensic evaluators that improvements can be made in the reporting and research of these injuries.”

CONCLUSION

The use of wrist restraints as a mechanism of torture is common. Understanding the possible injuries caused by wrist restraints/handcuffs allows the evaluator to obtain the necessary history, physical evidence, and diagnostic testing to accurately corroborate injuries with the alleged torture. There may be no observable physical findings, and symptoms may have resolved by the time of evaluation. A history of specific nerve injuries and healing is critically important to the evaluation. Even in the absence of physical findings, the level of confidence in the nexus between allegations and evidence may rise to the level of “highly consistent” for wrist restrain/handcuff abuse. In the first case, the patient’s clear description of symptoms corresponding to SRN were highly consistent with alleged torture with wrist restraints. In the second case, the patient’s median and ulnar nerve damage, as well as circumferential scarring were diagnostic of his alleged torture with prolonged and repeated use of wrist restraints. A thorough, accurate, and well-informed history and physical examination in alleged wrist restraint/handcuff injuries will strengthen the quality of evidence provided by the evaluator in the medicolegal report.