[Surgical therapy for hand infections. Part I]

[Trauma surgical relevance of bite injuries by animals and humans]

Bite injuries require differentiated treatment due to the deeply inoculated polymicrobial pathogen spectrum, possible concomitant injuries and pronounced soft tissue damage. Dog bites are the most common bite injuries but are less complicated to heal than human and cat bites. The location of the bite greatly depends on the age and the size of the bite victim as well as the type of bite perpetrator. In every case detection of the pathogen should be carried out to provide the best possible adapted treatment in the event of an exacerbation. The primary antibiotic treatment should be empirical with amoxicillin + clavulanic acid or ampicillin + sulbactam and, if necessary, adjusted according to the antibiogram. Depending on the findings, surgical treatment includes excision of the bite canal and a customized wound debridement. It is important to check the vaccination status of those involved and if indicated, to carry out postexposure prophylaxis for tetanus and rabies.

[Surgical treatment of bites]

OBJECTIVE

Thorough and profound debridement for acute bite injuries while sparing nerves, vessels and tendons.

INDICATIONS

Acute traumatic and late presented bite injuries.

CONTRAINDICATIONS

General contraindication for anesthesia or surgery.

SURGICAL TECHNIQUE

Extensive flabellate local anesthesia/general anesthesia, wound irrigation using 0.9% NaCl or antiseptic solutions, removal of avital tissues, wound debridement, wound edge excision, anew extensive irrigation, drainage if necessary, wound closure where applicable (except older or punctual deep injuries), bandage, elastic wrapping and immobilization. If necessary, plastic surgery with coverage of remaining defects.

POSTOPERATIVE MANAGEMENT

Immobilization with initially daily wound evaluation, removal of drainage/loop on postoperative day 2; if necessary, antibiotic therapy with amoxicillin and clavulanic acid in high-risk wounds (e.g., puncture wounds, joint or bone involvement, extensive soft tissue squeezing), suture removal on day 10-12 after surgery.

RESULTS

Of 142 bite injuries that were treated and retrospectively evaluated, 46% were caused by dogs and 32% by cats. Patients were on average 44 years old; 55% of all dog bites affected women, but 67% of all cat bites. In 48% of the cases, general anesthesia was necessary. The postoperative infection rate was 6.3%.

Animal and Human Bite Wounds

BACKGROUND

30,000 to 50,000 injuries are caused by bites in Germany every year. Dog and cat bites are common, human bites relatively rare. 25% of the victims are under age 6, and 34% are aged 6 to 17.

METHODS

This review is based on pertinent literature retrieved by a selective search and on the authors' clinical and scientific experience.

RESULTS

In small children, most bite wounds are on the head and neck; in older children and adolescents, most are on the limbs. Bite injuries range from trivial ones needing no medical intervention to major soft-tissue defects with the loss of functionally important structures. A bite can transmit unusual pathogens from the saliva into the wound. The risk of infection after a bite is 10-20%, and about 30-60% of the infections are of mixed aerobic-anaerobic origin. Prophylactic antibiotics are recommended only for wounds that are considered at high risk of infection in view of their type and location, the species of the biting animal, and the characteristics of the patient.

CONCLUSION

Structured surgical management of bite wounds is the most important factor in the prevention of infection. High-risk wounds must be differentiated from trivial ones. Interdisciplinary management is advisable for wounds on the hands and face.

Bite injuries to the hand: microbiology, virology and management

Bites to the human hand, be it from a pet, a stray animal or even a fellow human, may often have dire consequences for the person suffering the insult. Bites by mammals are a common problem and they account for up to 1% of all visits to hospital emergency rooms, in the UK. Clenched fist injuries to the mouth ('fight bite') are notorious for being the worst human bites. Bite injuries of the hand and their related infections must be monitored vigilantly and managed proactively, by experts in this field of surgery. In this review article we discuss the associated microbiology and virology of these injuries as well as their management.

Common nail disorders

Brittle nail, simple chronic paronychia, and onycholysis represent three of the most prevalent nail disorders. Brittle nails are characterized by increased fragility of the nail plate due to damage to the nail matrix or changes to nail plate cohesion, caused by internal and/or external factors. Simple chronic paronychia represents an inflammatory process of the lateral and/or proximal nail folds of the fingernails or toenails often preceded by damage to the cuticle. Onycholysis describes the detachment of the nail plate from its nail bed, often attributable to dermatologic conditions, infections, drug therapy, or trauma.

Tetanus following replantation of an amputated finger: a case report

Introduction

Tetanus is an infectious disease caused by tetanus toxin produced by Clostridium tetani and induces severe neurological manifestations. We treated a patient who developed tetanus during hospitalization for replantation of an amputated finger. To the best of our knowledge, this is the first published case report of such an entity.

Case presentation

A 49-year-old Japanese man had an amputation of his right middle finger at the distal interphalangeal joint region in an accident at work. His middle finger was successfully replanted, but his fingertip was partially necrotized because of crushing and so additional reconstruction with a reverse digital arterial flap was performed 15 days after the injury. Tetanus developed 21 days after replantation of the middle finger, but symptoms remitted via rapid diagnosis and treatment.

Conclusions

In replantation after finger trauma with exposure of nerve and blood vessel bundles, concern over injuring nerves and blood vessels may prevent irrigation and debridement from being performed sufficiently; these treatments may have been insufficiently performed in this patient. It is likely that the replanted middle finger partially adhered, and Clostridium tetani colonized the partially necrotized region. Even when there is only limited soil contamination, administration of tetanus toxoid and anti-tetanus immunoglobulin is necessary when the fingers are injured outdoors and the finger nerves and blood vessels are exposed. The drugs should be administered just after replantation if the finger has been amputated. However, if clinicians pay attention to the possibility of tetanus development, treatment can be rapidly initiated.

[Bite injuries of the hand]

Bite injuries of the hand have a clearly increased risk for infection compared with other regions. Surgical treatment of the wound is indicated, and the debridement must be done thoroughly and with consideration of the wound closure. Antibiotic therapy may be indicated in addition to the surgery if signs of infection exist. Antibiotics alone are not a suitable treatment. Common complications in cases of deficient primary therapy are flexor tenosynovitis, purulent arthritis, and phlegmons of the dorsal hand. These are emergencies and need immediate surgical intervention.