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Restraint Techniques, Injuries, and Death: Handcuffs

Article · December 2016

DOI: 10.1016/B978-0-12-800034-2.00325-6

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Restraint Techniques, Injuries, and Death: Handcuffs
JJ Payne-James, Forensic Healthcare Services Ltd., Southminster, UK; Barts and the London School of Medicine and Dentistry,
London, UK; and St George's Hospital, London, UK
r 2016 Elsevier Ltd. All rights reserved.

Abstract

Handcuffs of many types are widely used as a means of restraint and control. The general form is of two
wrist pieces joined to limit movement of hands and upper limbs. The wrist pieces are applied around the
wrist. Simple application should cause no sequelae. A struggle by the prisoner, or force applied to the
handcuffs by whoever has applied them, can result in a range of injury from none to severe, including
nerve damage and fracture.

Introduction tight. The commonest injuries are blunt force injuries of

reddening, abrasions, and bruising, particularly to the
Three main means of handcuffing individuals exist: radial and ulnar borders of the wrists. These may be seen
traditional handcuffs with two wrist pieces connected by as imprints of the cuffs on the wrist (Figure 3). Super-
a short chain (see Figure 1); rigid cuffs whereby the two ficial cuts, from the edge of the cuff, may be present
wrist pieces are connected by a bar and cannot move in in the same locations. In rare cases fractures of the
relation to each other (see Figures 2(a) and (b)); and forearm bones may occur. Figure 4 shows the wrist
plasticuffs – in effect larger size cable ties which are easy and forearm of a subject who struggled after application
to store and easy to apply but less secure than the first of the handcuff. He sustained an ulnar styloid fracture.
two types. In some cases commercial cable ties may be Numbness or hyperesthesia in the distribution of the
used and can create some of the injuries described par- cutaneous nerves distal to the applied cuff is not un-
ticularly neuropathies. The fixed connecting bar of the common. Specific handcuff neuropathies may be caused
rigid handcuffs allows controlled application of force and single or multiple nerves may be affected, the extent
across the wrist to gain control. Once applied, simple being determined by a number of factors including
pressure against the wrist allows the single bar of the the tightness of compression, the length of time com-
cuffs to release over the top of the wrist and close with a pression has occurred, and the degree of resistance of the
ratchet mechanism. If the individual is noncompliant detainee.
and continues moving the handcuffs can progressively In most cases the damaged nerves fully recover within
tighten causing increasing pain and potentially increas- a few weeks. Persistence of symptoms may require nerve
ing the risk of neurological and skin damage. conduction studies.
It is rare for handcuffs to cause fractures of the wrists
secondary to the use of handcuffs. However, they should
be considered when there is marked tenderness, loss of
Clinical Effects
movement, or extensive bruising. The most vulnerable
A number of injuries may be caused by handcuff ap- parts of the wrist are the styloid processes, particularly
plication. Soft tissue injuries may be produced by on the ulna.
movement of the wrist within the handcuff, movement
of the handcuff on the wrist or by the handcuff being too
Neurological Injury

Cook (1993) identified handcuff neuropathy as the most

common neurologic problem acquired by US prisoners
of war during Operation Desert Storm. Neurologic
deficits were exclusively sensory in all those affected
and began to resolve shortly after their release from
captivity. Some individuals expressed concern that these
injuries could be career-threatening.
Scott et al. (1989) reported two cases in which the
ulnar nerves were affected, but the radial nerves were
normal or only minimally affected. This serves to em-
Figure 1 Standard chain-linked handcuffs. phasize a broader clinical spectrum of handcuff injury.

Encyclopedia of Forensic and Legal Medicine, Volume 4 doi:10.1016/B978-0-12-800034-2.00325-6 127

128 Restraint Techniques, Injuries, and Death: Handcuffs

(a)

(b)

Figure 2 (a) Rigid bar linked handcuffs – KwikCuffs®. Note the ratchet on the cuffs. Increased struggling or movement tightens the cuffs further.
(b) KwikCuffs® applied – movement of upper limbs substantially restricted.

Figure 4 Injuries caused by handcuff application where subject

struggled – the full range of blunt force injury including reddening,
bruise, abrasion, laceration, and underlying ulnar styloid fracture.
Figure 3 Cuff imprint on wrist after application for 430 min.

Significant disability may result. These cases also involve The superficial radial nerve was affected in eight hands
alcohol intoxication, which may predispose patients to and the median nerve in two. Neurologic deficits per-
this type of injury because of overly aggressive appli- sisted as long as 3 years after handcuffing. Nerve
cation of restraints motivated by the patient’s aggressive conduction studies helped to exclude malingering and
behavior. other diagnoses. All patients had been intoxicated when
Stone and Laureno (1991) noted compressive neuro- handcuffed or had been arrested with force. They con-
pathy due to tight application of handcuffs in 5 patients. sidered that the handcuff mechanism, which allows
Restraint Techniques, Injuries, and Death: Handcuffs 129

increased tightening after application, is an un- Summary

recognized factor in these neuropathies.
Grant and Cook (2000) conducted a prospective Handcuffs are applied in a wide variety of lawful and
27-month study at a large, urban, teaching hospital of unlawful settings – police, prison, security, military, and
all patients with a complaint of hand numbness, weak- torture. All handcuffs cause compression injury at the
ness, or paresthesias attributed to overtightened hand- site of application. Increased tightening or aggression
cuffs. Forty-one patients were evaluated clinically, and from those applying and those being handcuffed will
electrodiagnostic testing was performed on 18. In the increase the risk of injury. Most injuries will resolve
group with electrodiagnostic testing, neuropathies due over 24 h. A small proportion will sustain more serious
to overtightened handcuffs were detected in 22 super- injuries, including neuropathies and fracture, each of
ficial radial, 12 median, and 9 ulnar nerves. The cor- which may have long-term clinical and practical impli-
relation between clinical and electrodiagnostic findings cations. Handcuffs should be applied for as short a time
was best for superficial radial neuropathies, some of as possible and be tightened only to the extent that they
which were severe. Median and ulnar nerve injuries were achieve the restraint or control needed.
generally mild. Similar clinical findings were obtained in
the group without electrodiagnostic testing. Handcuff-
related injury to the most commonly affected nerve, the See also: Restraint Techniques, Injuries, and Death: Baton.
superficial radial, can be severe and permanent. Restraint Techniques, Injuries, and Death: Conducted Energy
Scott et al. (1989) also reported two cases in which Devices. Restraint Techniques, Injuries, and Death: Irritant
the ulnar nerves were affected, but the radial nerves were (Incapacitant) Sprays. Restraint Techniques, Injuries, and Death: Use
normal or only minimally affected. They pointed out of Force Techniques
that the cases both involved alcohol intoxication, which
may predispose patients to this type of injury because
of overly aggressive application of restraints motivated
by the patients' aggressive behavior. References
Chariot et al. (2001) studied the frequency of com-
pression neuropathies following handcuff application. Chariot, P., Ragot, F., Authier, F.J., Questel, F., Diamant-Berger, O., 2001. Focal
neurological complications of handcuff application. Journal of Forensic Sciences
Twelve of 190 (6.3%) consecutive subjects kept in police 46 (5), 1124–1125.
custody presented with distal neurological symptoms Cook, A.A., 1993. Handcuff neuropathy among U.S. prisoners of war from Operation
possibly related to handcuff application. The duration Desert Storm. Military Medicine 158 (4), 253–254.
of handcuffing was significantly longer in patients with Ghaleb, S.S., Elshabrawy, E.M., Elkaradawy, M.H., Nemr Welson, N., 2014.
Retrospective study of positive physical torture cases in Cairo (2009 & 2010).
neurological symptoms. They concluded that prolonged Journal of Forensic and Legal Medicine 24, 37–45. [Epub 2014 Mar 29].
handcuffing associated with reduced conscious level and doi:10.1016/j.jflm.2014.03.005.
acute alcohol intoxication could be predisposing factors Grant, A.C., Cook, A.A., 2000. A prospective study of handcuff neuropathies. Muscle
& Nerve 23 (6), 933–938.
to handcuff neuropathy.
Scott, T.F., Yager, J.G., Gross, J.A., 1989. Handcuff neuropathy revisited. Muscle &
In a study of 367 torture victims (Ghaleb et al., 2014) Nerve 12 (3), 219–220.
in Cairo during the years 2009 and 2010, 68 of the Stone, D.A., Laureno, R., 1991. Handcuff neuropathies. Neurology 41 (1), 145–147.
subjects had typical handcuff injuries, which were blunt
trauma in nature around wrists or ankles, which repre-
sented 18.5% of the population.

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