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Closed fist infection
From WikEM
Contents
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 presents 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
- Bedbugs
- Closed fist infection (Fight Bite)
- Hand cellulitis
- Hand deep space infection
- Herpetic whitlow
- Felon
- Flexor tenosynovitis
- Paronychia
- Scabies
- Sporotrichosis
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
- 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.
