Closed fist infection

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Background

  • Also known as a "Fight Bite" or "Reverse Bite Injury"
  • Result of striking another individual's teeth with clenched fist
  • Although may appear benign, significant morbidity can result from late presentation or inadequate initial management
  • Complications are frequent and include joint violation (68%), tendon injury (20%), and fracture (17%)[1]

Clinical Features

  • Laceration over dorsal aspect of MCP joint (most commonly third, fourth, and/or fifth MCP joints)
  • Many patients present 5-7 days after injury with healing wound, pain/swelling, erythema, limited ROM[2]
    • May also have systemic symptoms such as fever, lymphadenopathy, etc.

Differential Diagnosis

Hand and finger infections

Evaluation

Work-up

  • Hand x-ray to evaluate for fracture, tooth fragments

Evaluation

  • Clinical diagnosis, based on history and physical exam
  • Need to maintain high clinical suspicion due to frequent delayed presentation

Management

  • Copious irrigation
  • Tdap (if >10 years since last booster[2])
  • Wound left open to heal by secondary intention
    • May require loose approximation if gaping

Antibiotics

Prophylactic antibiotics should be initiated for all but the most superficial wounds Requires polymicrobial coverage for: S. aureus, Strep Viridans, Bacteroides, Coagulase-neg Staph, Eikenella, Fusobacterium, Cornebacterium, Peptostreptococcus

Disposition

  • Admit with IV antibiotics and hand surgery consultation if:
    • Delayed presentation, evidence of local infection, systemic symptoms
  • Otherwise, discharge with PO antibiotics, close follow-up, and strict return precautions.

See Also

References

  1. Patzakis, M, et al. Surgical findings in cleenched-fist injuries. Clin Ortho Relat Res. 1987; 200:237-240.
  2. 2.0 2.1 Perron,A et al. Orthopedic pitfalls in the ED: Fight bite. The American Journal of Emergency Medicine. Volume 20, Issue 2, March 2002, Pages 114–117