Punch injury self-harm in young people

Abstract

Punch injuries are a form of self-harm characterised by the intentional act of striking an object with a closed fist. We aimed to describe the characteristics and trends in young people presenting with injuries sustained via the punch mechanism. A comprehensive retrospective review of medical records was completed of all young people aged 10–18 years presenting to our Central London Emergency Department over a 12-month period. A subset of the total group was identified as the punch injury subgroup. A total of 78 punch injury presentations were identified. In this subgroup, the male:female ratio is 4.57:1; 37.18% of presentations were associated with a fracture (n = 29) and 35.90% (n = 28) of patients re-presented following another punch injury, as a victim of violence, or by other psychiatric presentation. In conclusion, a male preponderance was observed, with frequent re-presentations, often in high-risk circumstances. An opportunity for screening, including mental health, social and substance misuse, was identified. Further research is needed to enable targeted effective interventions in this group.

Keywords

Self-injurious behaviour deliberate self-harm male adolescent screening

Introduction

Young people present to Emergency Departments with a wide range of problems including mental health problems, physical injuries and self-harm, often on a background of complex social circumstances. The mode of presentation of interest here is that following ‘punch injuries’, whereby the mechanism of injury is the intentional act of striking an object or a person with a closed fist. Such acts often result in self-injury which can trigger the young person to access health services.

Punch injuries often result in physical harm to the young person. Deliberate self-harm is common in adolescents, with a prevalence in adolescent samples in the range of 16.1–18.0% (Muehlenkamp, Claes, Havertape, & Plener, 2012). Young, Van Beinum, Sweeting, and West (2007) describe a female preponderance, a finding which has been replicated elsewhere. A gender pattern has been observed whereby young women are more likely to cut themselves or take dangerous tablets, whereas young men are more likely to cut themselves or hit or punch themselves (Young et al., 2007). Van Camp, Desmet, and Verhaeghe (2011) did not identify a significant difference in prevalence or age of onset of self-injurious behaviours between the genders, but they too identified differences in methods used. ‘Punching into walls and doors’ in particular was more prevalent in males albeit not exclusively a masculine phenomenon. The authors commented that studies exploring self-injury tend to focus almost exclusively on cutting which could partly explain previous conclusions that deliberate self-harm is a predominantly female phenomenon.

Brunner et al. (2014) identified a strong association between deliberate self-harm with psychopathology and risk behaviours, including family-related neglect and ‘peer-related rejection/victimization’, related to both gender and country. The rate of self-hitting was identified as having a significantly greater occurrence in males than females.

It has been hypothesised that females may have a tendency to internalise, whereas males externalise, emotional and behavioural problems (Van Camp et al., 2011), (Kaess, Parzer, & Haffner, 2011). In this way, males may exhibit behaviours such as hitting objects with a fist as a behaviour that constitutes a transition between aggression against the outside world and aggression against the self. The male has been described as ‘fragile’ from the beginning, which, together with a social expectation for boys to be more resilient than girls, may result in boys finding substantial barriers, first in recognising emotional difficulties and subsequently accessing appropriate services for support (Kraemer, 2000).

Paivio and McCulloch (2004) report results supporting a link between a history of childhood maltreatment and self-injurious behaviour among college students, hypothesising that alexithymia, which is commoner in boys (Kraemer, 2000), may mediate this relationship, and thus emphasising the importance of understanding the social background in identifying those at risk of self-injurious behaviour.

Physical injuries sustained following punching include boxer’s fracture which is a fractured neck of the fifth metacarpal bone. Mercan et al. (2005) compared a small group of patients presenting with boxer’s fractures with other fractures and controls. Those with boxer’s fracture had more anxiety as a trait and had higher mean scores for ‘self-defeating’, borderline and antisocial personality disorders. Additionally, the boxer’s fracture group had higher scores on the anger and cynicism subscales of the Minnesota Multiphasic Personality Inventory (MMPI-2) which they suggested showed that maladaptive personality traits and anxiety symptoms are common in this group. Patients presenting with punch injuries may have a higher prevalence of psychiatric illness than the background incidence in the population (Jeanmonod et al., 2011), although this finding is not always replicated. Sönmez et al. (2010) studied patients presenting with self-inflicted wounds produced by punching glass. It was noted that higher levels of ‘psychological distress’ and ‘hostility’ were present, with ‘higher levels of anger in daily life’, although clinical psychiatric evaluation did not reveal significant psychiatric disorder in this group.

Patients presenting with boxer’s fractures have been described as frequent injury recidivists (27%) (Greer & Williams, 1999). Boxer’s fractures are often although not exclusively a result of an intentional injury (Gudmundsen & Borgen, 2009), and these predominantly male patients are at increased risk for recurrent injury (Greer & Williams, 1999; Jeanmonod et al., 2011).

In contrast to the extensive protocols and guidelines in place relating to self-harm characterised by cutting and poisoning, there is a lack of guidance, both at local and national levels, regarding appropriate management of presentations following other self-injurious behaviours such as punch injuries.

It has been hypothesised that reframing presentations following punch injuries as deliberate self-harm may support appropriate clinical assessment and enhance clinical management in a population which can often be challenging to engage.

Aim and objectives

Aim

Description of the characteristics and trends in young people presenting with injuries sustained via a punch mechanism.

Objectives

(1) To analyse age and gender distribution, (2) to investigate current clinical management, (3) to identify re-presentations to the Emergency Department, (4) to establish level of prior contact with mental health services and social care and (5) to consider practical issues arising in the Emergency Department.

Method

A retrospective review of medical records was performed using the electronic patient record system. The sample was defined as all patients aged at least 10 years and less than 18 years presenting to the Emergency Department over a 12-month period, on which occasion a hand x-ray was performed. This group is described as the ‘total group’ of patients.

Medical records were closely reviewed to obtain demographic information, details of any fractures sustained to the hand or wrist, re-presentations to the Emergency Department, history of substance use and details regarding follow-up arrangements.

A review of documentation regarding the actual mechanism of injury was then performed which enabled a subgroup of patients to be identified as having presented following a clearly documented punch injury. A punch injury was defined as sustained following an intentional act of striking an object or person with a closed fist. Cases where such documentation was equivocal or absent were excluded from the punch injury subgroup.

The ‘total group’ contains all those young people presenting to the Emergency Department requiring an x-ray of the hand during this time period. Therefore, this ‘total group’ contains all those presenting following injuries sustained by any means, including punch injuries, accidents and where mechanism of injury was equivocal.

A subset of patients resident in our local borough was identified. Patient records were reviewed to establish whether there had been any prior contact with Child and Adolescent Mental Health Services (CAMHS). Similarly, Children’s Social Care (CSC) records were reviewed to establish prior contact with the service. In all cases, it was also established whether the patient was known to services at the time of presentation to the Emergency Department.

We were advised by the National Research Ethics Service that this project is research not requiring review by a National Health Service (NHS) research ethics committee. The study was registered with the Hospital Clinical Governance Department and approved by the Caldicot Guardian.

Results

A total of 291 hand x-rays were performed in patients aged between 10 and 18 years over the 12-month period, 78 of which followed clinically documented punch injuries.

Demographics

In all, 67.70% (n = 197) of the total group (including all mechanisms of injury) are male, M:F ratio 2.10:1, mean age 13.94 years (14.10 years in males, 13.60 in females). In the punch injury subgroup, 82.05% (n = 64) of patients are male, M:F ratio 4.57:1, mean age 14.77 years (14.70 years in males, 15.10 years in females). 87.18% (n = 68) of the punch injury group were in full-time education.

In terms of locality, 51.55% (n = 150) of the total group of patients reside within the local borough. In total, seven London boroughs were represented and two patients presented from outside of London.

Physical injury

Fractures of the hand or wrist were sustained in 35.05% (n = 102) of total group. Of those presenting with punch injuries, 37.18% (n = 29) sustained a fracture, the most common of which was fractured second metacarpal (44.84% of fractures, n = 13) (Table 1); 32.05% of punch injury patients (n = 25) re-presented on another occasion with fractured hand or wrist (sustained via any mechanisms of injury).

Table 1.

Type of fractures sustained in punch injury subgroup.

Fracture type	Number of patients	Percentage of patients
First metacarpal	4	5.13
Second metacarpal	13	16.67
Third metacarpal	0	0.00
Fourth metacarpal	2	2.56
Fifth metacarpal	9	11.54
Radius	1	1.28
Ulna	0	0.00
Scaphoid	0	0.00
Multiple	0	0.00
None	49	62.82

Substance use

Documentation of an alcohol history in the medical clerking was absent in 96.56% (n = 281) of the total group and 96.15% (n = 75) of the punch injury subgroup. Documentation of enquiry regarding illicit drug use was absent in 97.94% (n = 285) of the total group and 97.44% (n = 76) of the punch injury subgroup.

The mean total number of Emergency Department attendances to date in the total group is 4.6; in the punch injury group this is 5.29. In all, 35.90% (n = 28) of patients presenting with a punch injury re-presented on another occasion following one or more of the following: a further reported punch injury (19.23%, n = 15), as a victim of violence (17.95%, n = 14) and/or a psychiatric presentation (including overdose) (7.81%, n = 5) (Figure 1).

Figure 1.

A chart to show proportion of patients presenting with a punch injury who have presented on another occasion with (1) another punch injury, (2) as a victim of violence, (3) psychiatric presentation and (4) any of the above.

The local borough subset comprised 150 young people, 45 of whom also met criteria for the punch injury subset. At the time of presentation, 20.00% (n = 9) of the young people presenting with punch injuries from this borough were already known to the local CAMHS service and 13.33% (n = 6) of cases were open to CAMHS at the time of presentation. Emergency Department records indicate clinician awareness of history of contact with CAMHS in four of these cases (8.89%).

Similarly, at the time of presentation, 53.33% (n = 24) of the local punch injury subgroup were already known to CSC, including 37.78% (n = 17) of whom were under CSC at the time of presentation. Medical records indicate Emergency Department clinician awareness of prior contact with CSC in 31.11% of punch injury group.

Follow-up

The following referrals were made for young people in the total group following the initial Emergency Department presentation: fracture clinic 37% (n = 109), general practitioner (GP) (16%, n = 48), soft tissue clinic (4%, n = 11), social services (2%, n = 7); and two patients were admitted under surgery. Referrals made for young people in the punch injury subgroup are as follows: fracture clinic 42% (n = 34), GP (13%, n = 10), social services (3%, n = 2); and one patient referred to surgeons. In all, 44% of patients presenting following a punch injury were discharged without any follow-up. With regard to liaison with CSC, a copy of Emergency Department documentation was sent to social care in 33 cases in the total group (22%), 16 of which were for those presenting with punch injuries. There were no new referrals nor documented liaison with CAMHS based on the index presentation in either group (Figure 2).

Figure 2.

Referrals made for punch injury patients compared to the total group.

Discussion

We have described a group of young people presenting with punch injuries, often sustaining physical injury and frequently re-presenting to services in alarming circumstances. It can be seen that punch injuries are a frequent mode of presentation in young people across several London boroughs with a clear male preponderance (82%) in the punch injury group which is in keeping with the literature.

Young people presenting with punch injuries often sustained fractures and follow-up arrangements appeared to focus primarily on management of physical injury (Figure 2). Few referrals were made to social care and no referrals were made to local mental health services. This is in keeping with findings by Sönmez et al. (2010) that there may indeed not always be a clear psychiatric disorder which would warrant a referral to mental health services.

The clinical management of young people presenting with self-harm may vary quite considerably. Our local protocol and National Institute for Health and Care Excellence (NICE) guidelines recommend that a young person presenting to the Emergency Department with deliberate self-harm should be admitted overnight onto a paediatric ward. However, none of the young people presenting with punch injuries in this study were admitted to the paediatric ward. A careful assessment of the nature and circumstances around such punch injury presentations would help to determine those with self-injurious intent and/or related to mental illness or maladaptive coping styles and therefore identify those which may be helpful to formulate as acts of self-harm. This would then enable the young person to be linked in with clinical pathways for further assessment and intervention as clinically appropriate.

It can be seen that re-presentations by young people with punch injury presentations were common and often occurred in alarming circumstances such as as a victim of violence, psychiatric and drug and alcohol related presentations (Figure 1). This may indicate ongoing and unresolved problems in these young people. It is interesting that although 32% of punch injury patients re-presented on another occasion with a fractured hand or wrist, only 19% were identified as punch injury presentations. Although there are several possible means by which to sustain such a fracture, this could in part indicate under-reporting or recognition of these behaviours.

It can be seen that these young people may have had contact with a wide range of professionals. These include professionals in services such as the Emergency Department, paediatrics, orthopaedics, mental health, social services, GPs and youth offending programmes. Similarly, on reflecting regarding the network around the child, majority of the sample attend school, so educational staff are amongst those in contact with these young people. A role has been identified for timely and effective communication between professionals and between services, which will be a key component to focusing future interventions.

This issue may also be considered within the wider social and political context. The political profile of antisocial behaviour was raised following Louise Casey’s (2012) report Listening to Troubled Families, which concluded that it is important to consider people and ‘troubled families’ in a fuller longitudinal manner in order to better understand the origin and development of such behaviours. Opportunities to intervene to support families were identified. Youth offending services are an example of an organisation which have established pathways to manage young people presenting with a range of problems and behaviours, including psychological intervention and packages which are tailored in order to best meet the needs of the individual and to best reduce reoffending rates and support reintegration into society.

We have identified a group that anecdotally can be particularly challenging to engage. Carefully considering the approach of the valuable Emergency Department encounter is important. The Emergency Department is an opportunity to identify and engage with these young people. By exploring the presenting circumstances and relevant background information in sufficient depth, avenues for possible intervention or further enquiry may be established. However, we must always bear in mind the demands of the Emergency Department and the high rate of changeover of many clinical staff.

An opportunity for screening for mental health and substance misuse was identified. A screening tool was introduced as a pilot to the Paediatric Emergency Department assessment card, including screening interview questions for the clinician which could also help to open a dialogue with the young person.

Limitations

Retrospective data collection relies on accurate documentation of relevant information. In some cases, insufficient information was documented, for example, regarding the absence or presence of history of substance use. This might indicate that this information was not requested by assessing clinician or alternatively that it was not documented. Since the Emergency Department records were compiled in a multidisciplinary manner, there were several opportunities to document relevant clinical information including at triage, by nursing staff and the treating clinician. A thorough review of all such areas of clinical documentation was completed.

It is likely that the punch injury subgroup identified in this study actually under-represents actual occurrence of punch injuries as these may either not have been reported by the young person or may not have been captured in the medical record. By excluding cases from the punch injury sample whose mechanism of injury was unclear, the sample was robust at the cost that some punch injury cases may have been missed.

Further investigation with regard to level of contact with mental health and social services focused solely on patients residing in the local borough due to accessibility of data. This may reflect real challenges faced by the Emergency Department in accessing relevant clinical information since patients frequently attend from different boroughs. Recommendations focus on improving connections and communication between existing services. Recognition and mobilisation of the team around the child is crucial in formulating effective interventions and management plans. The recommendations below are based following discussions with clinical teams based within the Emergency Department.

Recommendations

Clinicians should be encouraged to be curious about the young person and the circumstances leading to presentation to the Emergency Department. This will help to open a dialogue through which to identify psychosocial stressors, maladaptive coping mechanisms, signs of mental illness or substance misuse and safeguarding concerns.

It is appropriate to utilise systems in place in the Emergency Department to flag up such cases of concern for clinical team discussion such as at a weekly departmental safeguarding meeting.

Prompt liaison between services is important in order to gather relevant information during the assessment and also to formulate an ongoing plan to meet the needs of the young person. Adequate attention should be paid to ensuring that logistical factors do not become a barrier, for example, ensuring readily available contact details for mental health and social services.

A screening tool has been introduced to the Emergency Department paediatric clinical assessment card including clinical questions to support clinicians to build a fuller psychosocial and self-harm history. Clinicians should be encouraged to screen for risk factors and red flags in presentation and then act on these appropriately, for instance, by discussing complex cases with a senior clinician with a follow-up discussion within a departmental safeguarding meeting.

Footnotes

Acknowledgements

The authors are grateful for support and valuable contributions from the Whittington Hospital Emergency Department, Paediatric Department, Children’s Social Care and Safeguarding teams.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Author biographies

Cristal Oxley is a higher trainee in Child and Adolescent Psychiatry, South London and Maudsley NHS Foundation Trust.

Jane E Roberts is a Child and Adolescent Psychaitrist based at the Paediatric Mental Health Team, Whittington Hospital.

Sebastian Kraemer is a Child and Adolescent Psychiatrist and Honorary Consultant at the Tavistock Clinic

Giles Armstrong is a Consultant in Paediatrician Emergency Medicine based at the Whittington Hospital Paediatric Department.

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