Shackling Ulcer: an Upper Extremity Ulcer Secondary to Handcuffs

A 42-year-old man with post-traumatic stress disorder presented for a mental health emergency. He was placed in custody when police identified an outstanding warrant for arrest and shackled with metal cuffs to the hospital bedframe. Physical examination of the limbs on hospital day 2 revealed a linear, circumferential stage 2 pressure ulcer of the wrist at the shackle site (Fig. 1). The patient was diagnosed with a shackling ulcer. The treating team requested the custody officer loosen the handcuff ratchet teeth. The patient was monitored for infection and underwent local wound care with hydrocolloid dressings.

Fig. 1.

Linear, circumferential stage 2 pressure ulcer of the wrist at the shackle site during physical examination on hospital day 2

Shackling refers to restraint using a mechanical device to control the movement of a prisoner’s body. Shackling can reduce mobility, impede examination, limit safe positioning, and impair healthcare provider empathy towards incarcerated patients.^1–3 Case reports have described overtightening of handcuffs resulting in local tissue damage, fractures, and compressive neuropathies.⁴ While typical hospital restraint regulations mandate the least restrictive form that protects patient and staff safety, no such guidelines govern hospital shackling.⁵ As shackles are placed for nonmedical reasons, treating clinicians should carefully examine incarcerated patients with wrist and hand symptoms, and request an alternate means of securing an incarcerated patient when medically necessary.

Declarations

Conflict of Interest

The authors report no conflicts of interest.