Clenched Fist Injury

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Clenched Fist Injury

Definition

A clenched fist injury (CFI) is a bite wound on the hand, caused when a person's closed fist strikes the teeth of another person, usually in the course of a fight. CFIs are sometimes referred to as closed fist injuries or fight bites.

Description

Clenched fist injuries are most common over the metacarpo phalangeal joint. Their appearance is deceptive because they do not bleed heavily and the underlying injury is hidden by soft tissue when the patient opens his hand and straightens the injured finger. CFIs can, however, have serious consequences, including infection, cellulitis, inflammation of the bone or bone marrow (osteomyelitis ), septic arthritis, and inflammation of the sheaths covering the tendons of the hand (tenosynovitis). These may lead to permanent loss of function or amputation.

Most CFIs result in tissue injury due to the force of impact, ragged-edged tears in the skin resulting from contact with the teeth, and contamination of the wound by the bacteria in human saliva. As the patient opens his hand, the skin of the finger is pulled backward over the deeper part of the wound, thus sealing bacteria within the injured tissue. This sealing of the wound by normal motions of the finger is the reason why clenched fist injuries have the highest rate of infection of any human bite. The rate of infection of clenched-fist injuries varies from 15-50%.

Causes and symptoms

The causes of CFIs include fighting and other forms of aggressive behavior, often combined with drug or alcohol consumption.

The symptoms of clenched-fist injury include pain in the affected part of the hand and some stiffness of the injured finger with limitation of movement. If the patient has delayed getting medical treatment, there may be evidence of infection, including swelling, redness, and suppuration (a discharge of pus). The skin around the wound will be warm to the touch and fever may be present.

Diagnosis

Diagnosis of clenched fist injuries is usually made on the basis of the location of the injury and x-ray findings. The most common finding in CFI x rays is soft tissue swelling, but the x rays may also reveal air pockets in deep tissues or the joint spaces, fragments of teeth, fracture lines in the bones, or small loose bone chips. Diagnosis is often complicated by the fact that the patient will be reluctant to admit how the injury happened. The treating physician must maintain a high level of suspicion and often ask directly.

Treatment

Treatment of clenched fist injuries is complicated by several factors. One factor is the anatomical structure of the human hand, which contains many small closed spaces that make it easy for infection to spread and persist. Another is the number of disease-causing bacteria transmitted by human bites; at least 42 different species have been identified. In addition, CFIs typically do not receive immediate treatment because the patient is concerned about legal consequences. The longer the delay, the higher the chances of infection and permanent damage to the hand. Patients who wait longer than 24 hours to seek treatment or have signs of infection or damage to the tendon, joint capsule, or bones are usually referred immediately to a doctor who specializes in hand surgery.

The first step in treatment of clenched fist injury is irrigation, a procedure by which the wound is flushed with a stream of water under high pressure or with an antiseptic solution. Incision and drainage of the wound (I&D) may be required as well as debridement, the surgical removal of dead tissue and foreign objects from a wound. Careful examination of the depth of the wound is essential to proper treatment. The surgeon may need to enlarge the sides of the wound in order to make an accurate evaluation. The patient will be asked to move the affected joint through its full range of motion so that the surgeon can determine whether the tendon or joint capsule has been damaged. Following these procedures, the surgeon will pack the wound and put the hand in a splint. Bite wounds are never sutured (sewn shut) because of the possibility of enclosing bacteria inside the injury. After 24 hours, the packing will be removed and the hand reexamined for signs of infection.

If the wound has become infected, the patient is usually hospitalized and given parenteral (injectable) antibiotics. The wound is irrigated and examined to determine the extent of the injury. Cultures are taken for both aerobic (requiring air or oxygen to live) and anaerobic (not requiring air or oxygen) species of bacteria. The cultures should be taken from areas deep in the wound rather than from the surface for greater accuracy. Tetanus toxoid should be given if the patient has not been immunized within the last 10 years. The patient should also receive treatment and follow-up for the rare possibility of HIV and hepatitis transmission. Although no well-documented cases of HIV transmission by human bites exist as of 2001, the potential for transmission by this route is still present.

Infected clenched fist injuries usually contain several disease-causing bacteria, the most common being Streptococcus pyogenes, Staphylococcus aureus, Bacteroides sp., Peptostreptococcus sp., and Eikenella corrodens. Broad-spectrum antibiotics are usually given. Uninfected and relatively superficial CFIs may be treated with oral penicillin plus dicloxacillin or Augmentin. For infected CFIs, parenteral penicillin G is usually given together with nafcillin or cefuroxime. CFIs infected by drug-resistant strains of S. aureus may require treatment with vancomycin. While some human bite wounds do not require routine use of antibiotics, a 2004 study confirmed that puncture wounds, deeper lacerations and bites to the hand all have high infection rates which may be lowered by preventive use of antibiotics.

Prognosis

The prognosis depends on the patient's underlying state of health and compliance with treatment; depth of the wound; the involvement of the joint capsule or tendon; and the length of time before the wound is treated. The more superficial the wound and the faster the treatment, the better the prognosis.

Prevention

The best way to prevent clenched fist injuries is to avoid fist fights, intoxication, and association with people who practice these forms of behavior. If involved in a fist fight, people should avoid directing punches at their opponent's mouth. The next best preventive measure is to get medical treatment at once for a clenched-fist injury.

Resources

BOOKS

Jacobs, Richard A., MD. "Animal & Human Bite Wounds." In "General Problems in Infectious Diseases." Current Medical Diagnosis & Treatment 2001, edited by L. M. Tierney, Jr., MD, et al., 40th ed. New York: Lange Medical Books/McGraw-Hill, 2001.

Taylor, Mark D., MD, and Samuel E. Wilson, MD. "Bacterial Diseases of the Skin." In Conn's Current Therapy 2001, edited by Robert E. Rakel, MD and Edward T. Bope, MD. Philadelphia: W. B. Saunders Company, 2001.