Self-Harm Affects Us All: Orthopaedic Self-Harm Injuries (OSHI)
Morgan and co-authors and accompanying editorials are to be commended for their rigorous analysis and lucid presentation of an important health issue(1). However the authors appear to overlook, in their management evaluations, that physical injuries of self-harmers require clinical attention in addition to any associated mental health presenting features. This is a factor that is almost invariably neglected in the discussion of self-harm. Orthopaedic self-harm injuries (OSHIs) are exceedingly common. Tellingly Morgan et al note that 12.3% episodes of self-harm involved self-cutting(1). They go on to recognise that it may actually represent the commonest form of self-harm(1). It, in some ways, does not reflect the full clinical picture to explore primary care and mental health services, without this vital component.
Self-harm lacerations frequently require attention from orthopaedic surgeons. This is compounded by that fact that patients very commonly repeat self-harm by self-cutting(2). Hence the 68% increase in self-harm, reported by the authors, impacts not only primary and mental health care services but also on acute musculoskeletal surgical services. One single-centre study observed over a period 36 months that 15 patients were admitted a total of 73 times to their orthopaedic unit, with instances of self-harm involving self-cutting; necessitating 63 separate surgical interventions. This sequestered 416 hospital bed days. Alarmingly in 80% MRSA was isolated from wounds(3).
Self-harm does not only engage mental health services. To ensure that those who suffer from self-harm receive an appropriate and safe standard of care an inclusive and seamless approach is required, engaging all those involved in their acute care. The NICE Self-harm Quality Standard algorithm includes a limb that addresses physical injury. However this is rudimentary and skeletal compared to the comprehensive guidance provided for those who self-harm by self-poisoning(4). OSHIs pose a peculiar challenge to the treating clinician in that wounds closed with sutures or tissue adhesive often act as foci for future self-cutting or foreign body insertion(2,3,5). There needs to be a greater clinical connectedness between all those who care for patients with self-harm without exclusion of those who attend to physical injuries. This ensures that those who self-harm by self-cutting receive the same standard of care and clinical attention as those who do so by self-poisoning. The process starts by recognising the role and clinical challenges faced by those who attend to OSHIs.
(1) Morgan C, Webb RT, Carr MJ, Kontopantelis E, Green J, Chew-Graham CA, Kapur N, Ashcroft DM. Incidence, clinical management, and mortality risk following self-harm among children and adolescents: cohort study in primary care. BMJ. 2017 Oct 18;359:j4351.
(2) Bennardi M, McMahon E, Corcoran P, Griffin E, Arensman E. Risk of repeated self-harm and associated factors in children, adolescents and young adults. BMC Psychiatry. 2016;16:421.
(3) Rogers BA, Pease F, Ricketts DM.The surgical management of patients who deliberately self-harm. Ann R Coll Surg Engl. 2009 Jan;91(1):59-62
Competing interests: No competing interests