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%)

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
  • May also have systemic symptoms such as fever, lymphadenopathy, etc.

Differential Diagnosis

• Hand and finger fractures

Hand and finger infections

• Bed bugs
• Closed fist infection (Fight Bite)
• Hand cellulitis
• Hand deep space infection
• Hand-foot-and-mouth disease
• Herpetic whitlow
• Felon
• Flexor tenosynovitis
• Paronychia
• Scabies
• Sporotrichosis

Look-Alikes

• Digital mixoid cyst

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)
• 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

• Amoxicilin-clavulanate 875mg PO BID x 5-7days OR
• Clindamycin 450mg (5mg/kg) PO q8hrs daily x7 days PLUS
  • Ciprofloxacin 500mg PO q12hrs x 7 days OR
  • TMP/SMX 2DS tabs (5mg/kg) PO q12hrs

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