Orthopedic pitfalls in the ED: Fight bite

doi:10.1053/ajem.2002.31146

The American Journal of Emergency Medicine

Volume 20, Issue 2, March 2002, Pages 114-117

https://doi.org/10.1053/ajem.2002.31146 Get rights and content

Abstract

Clenched fist injuries to the mouth (“fight bite”) are notorious for being the worst human bites. These are often treated as minor injuries, without the recognition that the joint capsule, the extensor tendon, or the deep fascial spaces may have been violated and contaminated with oral bacteria. Significant morbidity can result from late presentation or inadequate initial management. The emergency physician needs to remain vigilant for complications associated with closed fist injury. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency physician in the treatment of fight bite. (Am J Emerg Med 2002;20:114-117. Copyright 2002, Elsevier Science (USA). All rights reserved.)

Section snippets

Epidemiology

Establishing the true incidence of human bite injuries is difficult because many patients who have suffered such injuries may not seek treatment for various reasons, such as embarrassment, prompt resolution of the bite injury, or fear of legal repercussions.9, 11, 12 One study from New York City determined the incidence to be 11.8/100,000 population/year.¹¹ A number of studies have found that the incidence peaks in the ages 10 to 34 years, is a male-predominated injury (4:1), and occurs most

Pathophysiology

These fight bite wounds have the highest incidence of complications of any closed fist injury and of any type of bite wound.9, 16 These injuries usually occur over the dorsal aspect of the third, fourth, or fifth MCP joints, an area which is susceptible to deep infection because the thin skin overlying the joint provides little protection to the underlying ligaments, synovium, and cartilage.² The classic injury pattern is tooth penetration of the dorsum of the hand over the third MCP joint,

Clinical presentation

Symptoms of human bite wounds to the MCP will vary based on factors such as time elapsed before treatment, severity of wound, and associated complications (eg, fracture). Typically, patients with fight bite are seen 5 to 7 days after the injury with an infected wound, swelling, erythema, pain, and a limited range of motion in the hand (Fig 1).3, 17

. Obviously infected right hand subsequent to fight bite injury. The patient was in an altercation 6 days before presentation, and now presents with

Treatment

Treatment for the patient with a delayed presentation and clinically obvious infection is straightforward for the emergency practitioner. Hand surgery consultation should be obtained, and the patient brought to the operating room for open irrigation and debridement, with subsequent admission for intravenous antibiotics.2, 9, 15, 20 The decision regarding antibiotics before surgical debridement should be made in concert with the hand surgeon, as they may prefer to obtain intraoperative cultures

Summary

All human bite wounds are potentially serious injuries and at risk for significant complications. Nowhere is this truer than with fight bite injuries to the hand. The emergency physician should aggressively seek out these wounds when evaluating patients with clenched fist injuries. Appropriate management of early wounds includes thorough exploration, irrigation, antibiotic prophylaxis, splinting, and early follow-up. Once an infection is detected, aggressive management includes consultation of

Key points for fight bite

Maintain a high index of suspicion for a fight bite wound in any patient who presents with a laceration over the dorsal MCP joint.

Do not rely on a negative history, as the patient may not be honest regarding the circumstances of the wound.

Uninfected wounds that do not violate the extensor tendon or the joint capsule may have expectant management after copious irrigation and debridement in the ED. Outpatient antibiotics and definite follow-up within 24 to 48 hours must be assured to safely

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Cited by (43)

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2022, Injury
Citation Excerpt :
However, other studies have found no significant difference in infection rates relating to delay [48]. Human bites commonly present late due to factors such as embarrassment and fear of legal consequences, and this delay increases the risk of infection [37,55]. The higher incidence of bite infection in females is likely linked to the higher rate of cat bites in females compared to males [21,44].
Bites from animal and humans represent a very small proportion of all the patients presenting to emergency departments, However, they require prompt medical and surgical intervention in order to minimise the risk of infection, that may lead to limb and life-threatening complications. In this review article we synthesise the existing literature for treatment of human and animal bites and offer practical considerations when managing bite injuries.
Mammal bite management
2016, Cirugia y Cirujanos
Las mordeduras de animales son un problema importante de salud pública: se estima que el 2% de la población es mordida cada año. La mayoría de las mordeduras son de perro y los factores de riesgo incluyen niños pequeños, hombres, ciertas razas de perros y perros no adiestrados. El riesgo de infección posterior a las mordeduras difiere entre las especies animales y depende de la dentición de los animales y de la flora oral.
Las mordeduras de animales siguen siendo una causa importante de morbilidad en pacientes de todas las edades y han causado varias muertes infantiles prevenibles. Estas heridas comúnmente se infectan. Si la herida lo requiere, se debe realizar valoración quirúrgica temprana. El uso de antibióticos solo se recomienda para las heridas por mordedura de alto riesgo.
Animal bites are a major public health problem, it is estimated that 2% of the population is bitten each year. Most bites are by dogs and the risk factors include young children, men, certain breeds of dogs and untrained dogs. The risk of infection after bites differs between animal species and depends on the animal teeth and oral flora.
Animal bites are still a major cause of morbidity in patients of all ages and have caused several preventable childhood deaths. These wounds often become infected. If the wound requires it, early surgical evaluation must be performed. The use of antibiotics is only recommended for high risk bite wounds.
Clenched fist injury complicated by septic arthritis and osteomyelitis treated with negative pressure wound therapy: One case report
2016, Chinese Journal of Traumatology - English Edition
Citation Excerpt :
The patients mostly hid the true cause of the injury as in our case. The typical injury pattern of the clenched fist injury is tooth penetration of the dorsum of the hand over the third MP joint.1 In our case, the wound was situated well over this joint.
We reported a 30 years old man who suffered a bite wound of the right hand in a fight. Two days after the injury, he was admitted in emergency because of stab wound above the head of the third metacarpal bone. He presented the swelling, redness, pain and fever. Primary revision confirmed only partial lesion of the extensor apparatus. During the following days, we recorded a deterioration of local findings and magnetic resonance imaging revealed osteomyelitis and septic arthritis of the third metacarpophalangeal joint. The wound was then revised several times using negative pressure wound therapy in combination with intravenous antibiotics. After resolution of clinical and laboratory findings, the wound was finally closed by delayed primary suture. Clenched fist injury is a medical emergency that requires immediate surgical revision. We treated clenched fist injury with the development of septic arthritis and osteomyelitis with negative pressure wound therapy and obtained good outcomes.
Acute fight bite
2013, Journal of Hand Surgery
Citation Excerpt :
Prophylactic antibiotics are typically given for all fight bite injuries with the exception of those with minimally superficial wounds or those that present 72 hours or more after injury without clinical signs of infection.9,10 The human mouth contains as many as 50 species of bacteria, with the most common species being Staphylococcus aureus, followed by Streptococcus species, Corynebacterium species, and Eikenella corrodens.7,9,10 Based on this microbiology, rather than any high-level clinical evidence, patients are typically started on broad-spectrum antibiotics and combination therapies, such as cephalosporins or a combination of gentamicin and a penicillinase-resistant penicillin.
Hand and Wrist Injuries
2012, Emergency Medicine: Clinical Essentials, SECOND EDITION
Hand injuries and infections
2011, Emergency Medicine Secrets

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TherapeuticsOrthopedic pitfalls in the ED: Fight bite*,**

Abstract

Section snippets

Epidemiology

Pathophysiology

Clinical presentation

Treatment

Summary

Key points for fight bite

Natural course of human bite wound: Incidence of infection and complications in 434 bites and 803 lacerations in the same group of patients

J Trauma

Human bites to the hand: Twenty years of experience

J Hand Surg

Human fight bite wounds of the hand

J Hand Surg Br

Bite wounds: Early treatment and prophylaxis against infectious complications

Postgrad Med

Infectious disease issues in the emergency department

Clin Infect Dis

Medical-legal problems in the emergency department related to hand injuries

Emerg Med Clin NA

Emergency department evaluation and treatment of hand injuries

Emerg Med Clin NA

Treatment of infected clench-fist human bite wounds in the area of metacarpophalangeal joints

J Hand Surg Am

Current management of human bites

Pharmacotherapy

Infections of the hand

Emerg Med Clin NA

An epidemiological study of the human bite

Public Health Rep

Human bites

Postgrad Med

Therapeutics
Orthopedic pitfalls in the ED: Fight bite*,**