Deliberate self-harm by insertion of foreign bodies into the forearm

doi:10.1016/j.bjps.2007.04.004

Journal of Plastic, Reconstructive & Aesthetic Surgery

Volume 61, Issue 6, June 2008, Pages 700-703

https://doi.org/10.1016/j.bjps.2007.04.004 Get rights and content

Summary

Deliberate self-harm is common. It is usually by drug overdose or ingestion of other noxious substances, but self-harm by cutting or burning often comes to the attention of plastic surgeons. We report three variant cases involving insertion of paperclips, a ballpoint pen cartridge and sewing needles into the forearm.

We discuss the management considerations of each case and emphasise the importance of actively addressing the underlying psychiatric problems for all instances of deliberate self-harm.

Section snippets

Case A

A 42-year-old woman with a history of depression, personality disorder and deliberate self-harm by drug overdose and cutting was referred for non-healing wounds of her left, non-dominant forearm (Fig. 1). Over the preceding five years the self-harm included subcutaneous insertion of straightened-out paperclips. Consequently, abscesses had formed intermittently and were managed by incision and drainage with removal of the causative paperclip. Nevertheless, numerous paperclips remained embedded

Case B

A 22-year-old woman with a history of complex post-traumatic stress disorder, emotionally unstable personality disorder and deliberate self-harm who was an inpatient under Section 3 of the Mental Health Act was referred having cut the extensor aspect of her left, nondominant forearm with a pair of scissors. The laceration had breached the deep fascia but not significantly divided the underlying muscle bellies. It was irrigated and allowed to heal by secondary intention.

In addition, a punctum

Case C

A 27-year-old woman suffering chronic depressive symptoms with recurrent self-harm, under the care of community psychiatric services, was referred following an episode of cellulitis in her hands and forearms. She described repeated insertion of sharp objects including sewing needles into her forearms. The cellulitis had been treated by her general practitioner with oral antibiotics.

Examination revealed multiple old scars on her forearm and numerous chronic wounds (Fig. 4). There were no signs

Discussion

Insertion of foreign bodies is an unusual form of deliberate self-harm. Most are inserted through existing orifices, and urologists, ENT surgeons and gastrointestinal endoscopists may be involved in their assessment, monitoring and removal.2, 3 Breach of an epithelium is less common, but is reported with insertion of long thin objects through the nose into the brain4, 5, 6 or through the urethra and bladder into the abdominal cavity.7, 8, 9 Foreign bodies may also be inserted directly through

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Cited by (14)

Management of intravesical self-inflicted sharp objects in children: 10-year single-center experience
2016, Journal of Pediatric Urology
Citation Excerpt :
However, in 17% of cases no definite cause could be found [13]. Differential diagnoses of the motives behind self-inserting FBs include sexual gratification in autoerotic or consensual sexual acts [14,15], non-suicidal self-injurious behavior [16], and personality disorders or mental retardation [17]. Routine psychiatric evaluations should be offered to all patients with intentional FB insertion to avoid missing any underlying psychiatric disorders [18,19].
Intravesical foreign bodies (FBs) are rare and have interesting pathology for urologists. There has been an increase in reports of intravesical FBs in the last few decades, but they are still considered to be rare in children, especially young girls. Here we present our experience in the assessment and management of intravesical self-inserted sharp objects in children.
We reviewed the records of children with self-introduced intravesical FBs admitted to our hospital during the last 10 years. Twenty-four cases were included in this study (20 girls and 4 boys). The presenting symptoms and methods of diagnosis and treatment were reviewed.
The ages of the patients ranged from 4 to 12 years. In all cases, foreign bodies were self-inserted. All patients were subjected to KUB (kidney, ureter, bladder radiograph) and abdominal ultrasonography. Based on the KUB findings, the FBs in girls were found to be metal pins in 12, a hair clip in four, and a wooden pencil in three (Figure). In boys, a coiled electric wire was found in three, with a urinary calculus formed over one of them. There were small metallic objects in two cases (1 boy and 1 girl). Endoscopic removal of FBs was done successfully in 19 cases (18 girls and 1 boy), and open cystostomy was performed in four cases (3 boys and 1 girl).
Intravesical FBs are important considerations in the differential diagnosis of pathological lower urinary tract symptoms. They represent significant challenges to urologists. Among children, the reasons for self-insertion of FBs might reflect psychiatric disorders. Routine psychiatric evaluations should be offered to all patients with intentional FB insertion to avoid missing any underlying psychiatric disorders. In our study, psychiatric evaluations have been advised for all the affected children and their parents. Self-inserted FBs are commonly seen in adults and are rarely encountered in children. To our knowledge, this is the largest reported series of children with self-inflicted intravesical FBs. In addition, all of the FBs in this study had one or more sharp edges that made their endoscopic extraction more difficult without causing bladder or urethral damage. In children, removal of intravesical FBs represents a great challenge, as the size of the pediatric urethra may hinder safe transurethral removal. Endoscopic handling of intravesical FBs is mostly unsuccessful in boys because of the long and narrow urethra, and open cystostomy might be the treatment of choice to save the urethra. In contrast, the short female urethra renders the endoscopic removal of intravesical FBs more successful. In this study, endoscopic removal of FBs was done successfully in 19 cases (18 girls and 1 boy), and open cystostomy was performed in four cases (3 boys and 1 girl).
Although FBs in the urinary tract of children are very rare, they need to be considered during any evaluation of pathological lower urinary tract symptoms. Endoscopic management is feasible for most of these patients. The size, number, nature of foreign bodies, and any associated urinary calculi determine the treatment modality.
Finding a needle in a haystack: Ultrasound guided extraction of a sewing needle from the perineum
2015, Case Reports in Women's Health
Citation Excerpt :
The patient tolerated the procedure well and was discharged home the following day. Sewing needles have been found in the forearm, liver tissue, and cardiac tissue [1,2,3]. Needles found in extra-genitourinary areas tend be accidental, secondary to stabbing trauma, or for purposes of attempting self-harm.
"Cuts are costly": A review of deliberate self-harm admissions to a district general hospital plastic surgery department over a 12-month period
2014, Journal of Plastic, Reconstructive and Aesthetic Surgery
Self-harm, the psychiatric inpatient and the plastic surgeon
2010, Journal of Plastic, Reconstructive and Aesthetic Surgery
Management of self-harm patients: a case for a joint approach
2009, Journal of Plastic, Reconstructive and Aesthetic Surgery
Multiple zone 2 flexor tendon injuries: an act of self-harm?
2009, Journal of Plastic, Reconstructive and Aesthetic Surgery

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^☆: All three patients gave consent for publication, including for their photographs and radiographs to be reproduced. All patients had capacity to give that consent.

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Case reportDeliberate self-harm by insertion of foreign bodies into the forearm☆

Summary

Section snippets

Case A

Case B

Case C

Discussion

Surg Neurol

J Pediatr Surg

Ear stuffing: an unusual form of self-mutilation

J Nerv Ment Dis

Self-inflicted male urethral foreign body insertion: endoscopic management and complications

BJU Int

Transnasal penetrating brain injury with a ball-pen

Br J Neurosurg

Unusual self-inflicted penetrating craniocerebral injury by a nail

Neurol India

Self-insertion of urethral foreign bodies

Psychiatr Q

Case report
Deliberate self-harm by insertion of foreign bodies into the forearm☆