Closed fist infection

Background
Wrist and hand deeper palmar dissection
  • 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
Clenched fist injury complicated by infection.
Fight bite with metacarpal neck fracture.
Infected wound on the dorsum of the left hand in front of the MP joint of the index following a fist against the teeth
  • 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, peptostreptococus

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
  • Hand infection
  • Animal bites

References
  1. Patzakis, M, et al. Surgical findings in cleenched-fist injuries. Clin Ortho Relat Res. 1987; 200:237-240.
  2. 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
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