Surgical management and outcomes of self-inflicted zone V wrist injuries: a narrative review
DOI:
https://doi.org/10.18203/2349-2902.isj20262492Keywords:
Self-inflicted wrist injury, Zone V laceration, Spaghetti wrist, Flexor tendon injury, Neurovascular repair, Hand trauma, Suicide attempt, Rehabilitation protocols, Functional outcomes, Patient-reported outcomesAbstract
Self-inflicted wrist injuries involving flexor tendon zone V represent a complex subset of hand trauma with important surgical, functional, and psychosocial implications. These injuries frequently involve simultaneous damage to tendons, nerves, and vascular structures, often resulting in substantial long-term disability. Despite their clinical relevance, the available literature remains fragmented, with no universally accepted definition of “spaghetti wrist” and no standardized management framework. This narrative review synthesizes current evidence on epidemiology, injury patterns, classification systems, clinical assessment, operative management, rehabilitation, complications, and prognosis in self-inflicted zone V wrist injuries. A structured literature search was conducted in PubMed/MEDLINE, Scopus, and Google Scholar for studies published between January 2005 and January 2025 in English or Spanish. Eligible publications included retrospective and prospective cohort studies, case series, case reports, and review articles addressing self-inflicted wrist injuries involving zone V. Extracted data included epidemiological characteristics, mechanisms of injury, classification systems, assessment tools, surgical and non-surgical management strategies, rehabilitation protocols, and functional outcomes. Findings were synthesized qualitatively, with emphasis on recurring themes, areas of consensus, and persistent gaps in knowledge. Available evidence indicates that these injuries predominantly affect young adults, frequently men, and are commonly associated with psychiatric comorbidity. Injury patterns typically involve the dominant hand inflicting damage on the non-dominant wrist and are characterized by multistructural involvement. Flexor tendons are almost universally affected, while neurovascular injury varies in severity and consistently emerges as the strongest predictor of long-term functional impairment. Outcome heterogeneity remains substantial, reflecting differences in injury definitions, operative techniques, rehabilitation protocols, and outcome measures. Psychiatric factors further influence recurrence risk, adherence to therapy, and return-to-work outcomes. Self-inflicted zone V wrist injuries remain a challenging and heterogeneous clinical entity. Although advances in microsurgical reconstruction and rehabilitation have improved recovery, prognosis remains guarded, particularly in patients with nerve or combined neurovascular injury. Standardized definitions, consistent outcome reporting, and integration of surgical, rehabilitative, and psychiatric care are essential to improve comparability across studies and optimize patient outcomes.
Metrics
References
World Health Organization. Practice manual for establishing and maintaining surveillance systems for suicide attempts and self-harm. Geneva: WHO; 2016. Available at: https://www.who.int /publications/i/item/practice-manual-for-establishing-and-maintaining-surveillance-systems-for-suicide-attempts-and-self-harm. Accessed on 28 April 2026.
Kisch T, Matzkeit N, Waldmann A, Stang F, Krämer R, Schweiger U, Mailänder P, Westermair AL. The reason matters: Deep wrist injury patterns differ with intentionality (accident versus suicide attempt). Plast Reconstr Surg Glob Open. 2019;7(5):e2139. DOI: https://doi.org/10.1097/GOX.0000000000002139
Jeong SH, Gu JH, Kim WK. Analysis of self-inflicted lacerations to the wrist: A multidisciplinary approach to treating. J Hand Surg Asian Pac Vol. 2020;25(1):47-53. DOI: https://doi.org/10.1142/S242483552050006X
Noaman HH. Management and functional outcomes of combined injuries of flexor tendons, nerves, and vessels at the wrist. Microsurgery. 2007;27(6):536-43. DOI: https://doi.org/10.1002/micr.20400
Cardoz Lobo I, Manek S, Bhosale K, Verma C, Devale M, Parekh A, et al. Evaluation of outcome measures of Zone V flexor tendon injury: A systematic review. Indian J Plast Surg. 2023;56(6):480-7. DOI: https://doi.org/10.1055/s-0043-1775864
Geulayov G, Casey D, Bale E, Brand F, Clements C, Farooq B, et al. Risk of suicide in patients who present to hospital after self-cutting according to site of injury: Findings from the Multicentre Study of Self-harm in England. Psychol Med. 2023;53(4):1400-8. DOI: https://doi.org/10.1017/S0033291721002956
Ersen B, Kahveci R, Saki MC, Tunali O, Aksu I. Analysis of 41 suicide attempts by wrist cutting: A retrospective analysis. Eur J Trauma Emerg Surg. 2017;43(1):129-35. DOI: https://doi.org/10.1007/s00068-015-0599-4
Yazdanshenas H, Naeeni AF, Ashouri A, Washington ER 3rd, Shamie AN, Azari K. Treatment and postsurgery functional outcome of spaghetti wrist. J Hand Microsurg. 2016;8(3):127-33. DOI: https://doi.org/10.1055/s-0036-1586487
Wang F, Zhang R, Liu S, Ruan H, Xu J, Kang Q. Severe spaghetti wrist injury: Should we expand the terminology from wrist to proximal forearm? Jt Dis Relat Surg. 2022;33(2):273-84. DOI: https://doi.org/10.52312/jdrs.2022.652
Kim JH, Yoo H, Eun S. A pilot study of 17 wrist-cutting suicide injuries in single institution: Perspectives from a hand surgeon. BMC Emerg Med. 2021;21(1):40. DOI: https://doi.org/10.1186/s12873-021-00432-4
Rodica MI, Irina CC, Octavian O, Georgescu A. Spaghetti wrist injury: Past, present, and future. J Hand Surg Glob Online. 2024;7(2):259-65. DOI: https://doi.org/10.1016/j.jhsg.2024.02.016
Hernández Pérez MF, Navalón Calzada A, Gonzalez Espinosa A. Self-inflicted wrist injuries in flexor tendon Zone V: Clinical patterns, management strategies, and outcomes. Cureus. 2026;18(2):e103658.
Jaquet JB, van der Jagt I, Kuypers PD, Schreuders TA, Kalmijn S, Hovius SE. Spaghetti wrist trauma: Functional recovery, return to work, and psychological effects. Plast Reconstr Surg. 2005;115(6):1609-17. DOI: https://doi.org/10.1097/01.PRS.0000160697.41738.EA
Rosales CP, Hansbø SE, Vaksvik T. Clinician- and patient-reported outcomes after flexor tendon repair: A 1-year prospective study. J Hand Ther. 2025;39(1):189-97. DOI: https://doi.org/10.1016/j.jht.2025.04.015
Xu H, Li J, Zhang Y, Chen Z, Wang Q. Outcome of surgical repair and rehabilitation of flexor tendon injury in zone II-V: A systematic review and meta-analysis. J Hand Surg Am. 2023;48(7):612-22. DOI: https://doi.org/10.1016/j.jhsa.2021.11.013
Newington L, Bamford E, Henry SL. Relative motion flexion splinting following zone I-III flexor tendon repair: Concepts, evidence and practice. J Hand Ther. 2023;36(2):294-301. DOI: https://doi.org/10.1016/j.jht.2022.11.004
Wang Y, Qian L, Liu ZF, Chen W, Shen X, Wu JN, et al. Risk factors after zone II flexor tendon repair: A randomized controlled trial. J Hand Ther. 2023;36(4):786-95. DOI: https://doi.org/10.1016/j.jht.2023.05.012
Tessier L, Gélinas A, Speak D, Haddad J, Lalonde A. A comparison of complication rates in flexor tendon repair performed in operating rooms versus clinic-based procedure rooms. Plast Surg (Oakv). 2025;34(1):64-70. DOI: https://doi.org/10.1177/22925503241309926
Jia Q, Chen D, Guo J, Luo X, Alimujiang A, Zhang J, et al. Risk factors associated with tendon adhesions after hand tendon repair. Front Surg. 2023;10:1121892. DOI: https://doi.org/10.3389/fsurg.2023.1121892
Mehdi Nasab SA, Sarrafan N, Saeidian SR, Emami H. Functional outcome of flexor tendon repair of the hand at Zone 5 and postoperative early mobilization of the fingers. Pak J Med Sci. 2013;29(1):43-6. DOI: https://doi.org/10.12669/pjms.291.2563
Tang JB. Outcomes and evaluation of flexor tendon repair. Hand Clin. 2013;29(2):251-9. DOI: https://doi.org/10.1016/j.hcl.2013.02.007
Puckett CL, Meyer VH. Results of treatment of extensive volar wrist lacerations: The spaghetti wrist. Plast Reconstr Surg. 1985;75(5):714-21. DOI: https://doi.org/10.1097/00006534-198505000-00018
Elliot D, Giesen T. Avoidance of unfavourable results following primary flexor tendon surgery. Indian J Plast Surg. 2013;46(2):312-24. DOI: https://doi.org/10.4103/0970-0358.118610
Atilgan N, Duman N, Colak TS, Korucu Demiryurek M. Multidisciplinary treatment and functional outcome evaluation of combined injuries of nerves, vessels, and flexor tendons: spaghetti wrist. Eur Rev Med Pharmacol Sci. 2022;26(23):8808-15.
Groth GN. Current practice patterns of flexor tendon rehabilitation. J Hand Ther. 2005;18(2):169-74. DOI: https://doi.org/10.1197/j.jht.2005.01.010
Howell JW, Peck F. Rehabilitation of flexor and extensor tendon injuries in the hand: Current updates. Injury. 2013;44(3):397-402. DOI: https://doi.org/10.1016/j.injury.2013.01.022
Cho J, Choi Y. Patterns of wrist cutting: A retrospective analysis of 115 suicide attempts. Arch Plast Surg. 2020;47(3):250-5. DOI: https://doi.org/10.5999/aps.2020.00059
Saini N, Kundnani V, Patni P, Gupta S. Outcome of early active mobilization after flexor tendons repair in zones II-V in hand. Indian J Orthop. 2010;44(3):314-21. DOI: https://doi.org/10.4103/0019-5413.65155
Bukhari AJ, Saleem M, Bhutta AR, Khan AZ, Abid KJ. Spaghetti wrist: Management and outcome. J Coll Physicians Surg Pak. 2004;14(10):608-11.
Opsteegh L, Reinders-Messelink HA, Schollier D, Groothoff JW, Postema K, van der Sluis CK. Determinants of return to work in patients with hand disorders and hand injuries. J Occup Rehabil. 2009;19(3):245-55. DOI: https://doi.org/10.1007/s10926-009-9181-4
Özgen M, Merve Aydoğan A, Uygur A, Armağan O, Berkan F, Mutlu F. Rehabilitation cost share and cost analysis of traumatic hand injuries: Our single-center results. Turk J Phys Med Rehabil. 2021;67(3):308-14. DOI: https://doi.org/10.5606/tftrd.2021.5457
Soomro GM, Kakhi S. Deliberate self-harm (and attempted suicide). BMJ Clin Evid. 2015;2015:1012.
Chin G, Weinzweig N, Mead M, Gonzalez M. “Spaghetti wrist”: Management and results. Plast Reconstr Surg. 1998;102(1):96-102. DOI: https://doi.org/10.1097/00006534-199807000-00015
Hernández Pérez M F, Navalón Calzada A, Gonzalez Espinosa A, et al. Self-Inflicted Wrist Injuries in Flexor Tendon Zone V: Clinical Patterns, Management Strategies, and Outcomes. Cureus. 2026;18(2):e103658. DOI: https://doi.org/10.7759/cureus.103658
Downloads
Published
How to Cite
Issue
Section
