The management of clenched fist 'fight bite' injuries of the hand

The "Fight Bite" Saline Joint Loading Test: Effectiveness in Detecting Simulated Traumatic Metacarpophalangeal Arthrotomies

Background: The saline load test is routinely used to recognize other joints' traumatic arthrotomies; however, there are currently no studies evaluating the novelty of this test for metacarpophalangeal joints (MCPJs). This study aimed to investigate the effectiveness and sensitivity of saline load testing in identifying the traumatic arthrotomies of the MCPJs using human cadavers. Methods: This was a cadaveric study of 16 hands (79 MCPJs). Traumatic arthrotomies were created using 11-blade stab-incisions, followed by blunt probing into the joint on the radial or ulnar side of the flexed MCPJs. A 3-mL syringe was used to inject intra-articular methylene-blue-dyed saline from the contralateral side. The volume at saline extravasation was recorded. Test sensitivity and factors influencing extravasation volume were assessed. Results: The mean (range) volume injected to identify arthrotomy of all MCPJs was 0.18 mL (0.1-0.4 mL). The mean volume to identify MCPJ arthrotomy of the thumb, index, long, ring, and small fingers was 0.16 mL (0.1-0.3 mL), 0.19 mL (0.1-0.3 mL), 0.21 mL (0.1-0.4 mL), 0.17 mL (0.1-0.3 mL), and 0.16 mL (0.1-0.3 mL), respectively. Cadaver age, laterality, and joint range of motion were not significantly associated with the injected volume at extravasation(P > .05, each). Injection volumes of 0.3 and 0.32 mL were required to detect arthrotomies at 95% and 99% sensitivities across all MCPJs. None of the MCPJs required > 0.4 mL to detect arthrotomy. Conclusions: Saline joint loading volumes to detect traumatic arthrotomy were similar for all MCPJs. Injection volumes of 0.32 mL is suggested for 99% sensitivity. Our findings provide the first report, to our knowledge, on intra-articular injection volumes expected to detect an arthrotomy of MCPJ. This is critical for further validation using in vivo clinical studies.

[Infections of the Hand after Bite Injuries]

Bite injuries are common. Along with the resulting complications, they represent approximately 1-2 % of all emergency department visits. In over 75 %, the hands are affected. In Northern Europe, bites and subsequent infections are mainly caused by dogs and cats but also by humans.Up to 40 % of all hand infections are caused to bite injuries. Due to the multiple and complex compartments as well as the low soft tissue coverage of functionally relevant structures, even the smallest and most superficial bite injuries of the hand lead to infections. Any bite injury to the hand may subsequently may result in a fulminant infection and, rarely, even death.The spectrum of pathogens from the oral flora of the biting animal or person is diverse and includes aerobic and anaerobic bacterial strains. Bite injuries represent a major challenge for both the injured person and the attending physician. The rate of complications has been shown to increase with delayed medical consultation, lack of medical care and inadequate wound care. In this review, we discuss the types and complications of bite wounds, their potential risk of infection, their pathogen spectrum and appearance, and their effective treatment.

The management of clenched fist injuries with local anaesthesia and field sterility

Clenched fist injury is associated with a high risk of infectious complications and is commonly managed with formal irrigation and debridement in the operating theatre. The purpose of this study was to determine outcomes associated with irrigation and debridement of clenched fist injuries under local anaesthesia using field sterility outside the operative theatre. In this single centre study, 232 patients were identified with clenched fist injury and 210 were treated with a standard protocol beginning with administration of intravenous antibiotics and then irrigation and debridement at the bedside. Primary outcome measures were the need for repeat debridement and complications. Secondary outcome measures included factors associated with the need for repeat debridement. Fifteen of the 210 patients (7%) required repeat debridement. Patients with cultures positive for gram-negative organisms had a significantly increased risk of repeat debridement. Irrigation and debridement under local anaesthesia using field sterility results in an acceptably low risk of complications or need for repeat debridement.Level of evidence: IV.

[Extensor tendon injuries of fingers in the region of the metacarpophalangeal joint (zone V)]

Due to the exposed situation of the extension side of the metacarpophalangeal joint when the fingers are bent, injuries in this region are not uncommon. The extensor apparatus lies directly below the skin and the various parts can be easily injured. Due to the complex anatomical structure, the different clinical appearances and the various forms of treatment, injuries of the extensor tendons in the region of the metacarpophalangeal joint must be examined in a very differentiated manner. The not uncommonly occurring deviation phenomenon makes all injuries in zone V suspicious and special attention must be paid to them. The alarming multitude of revision surgeries with tenolysis, arthrolysis and restoration of the balance of extensor tendons or centering show that these operations are much more demanding than the way they are appreciated in the literature and by many surgeons (beginner's operation). The article presents the surgical treatment with suture techniques and reconstruction possibilities as well as the aftercare, in addition to the special anatomy and diagnostics.

Challenging Dogma: Optimal Treatment of the "Fight Bite"

Background: The optimal treatment of human bites to the dorsal metacarpophalangeal region (ie, "fight bite") in the absence of gross purulence is controversial. Few studies have compared the outcomes of operative debridement with expectant wound care and oral antibiotics. Methods: We performed a retrospective chart review of all patients evaluated at a Level 1 trauma center over a 10-year period. We compared demographic and clinical characteristics of patients across treatment and outcome groups using the Fisher exact test. Logistic regression models were used to describe the relationships between the outcome and treatment variables. Results: We identified 115 patients with a mean age of 29 years. The mean follow-up was 51.8 days. Seventy-two (63%) patients were treated with antibiotics only. Thirty-two (28%) patients were treated with irrigation in the emergency department (ED) and expectant wound care. Eleven (9%) patients were treated with irrigation and debridement in the operating room. No demographic variables were found to correlate with the treatment selected. A 12% complication rate (major and minor) was observed. After adjusting for duration of follow-up and days to presentation, neither the treatment rendered nor the antibiotics selected influenced the rate of complications. Time to presentation >24 hours was the only variable associated with higher complication rate (P = .003). Conclusions: Not all fight bites require operative intervention. Irrigation in the ED with expectant wound care and oral antibiotics can be sufficient for patients presenting within 24 hours of injury in the absence of gross purulence.

Infections of Deep Hand and Wrist Compartments

The human hand is the most exposed part of the body to highest risk for injuries, loss of the skin integrity, and to the inoculation of bacteria, most commonly Staphylococcus aureus, Streptococcus β-haemolytic, and gram-negative. In case of an infection, the mobile anatomical structures and the synovial membranes in close proximity to each other may spread the pus towards deep spaces and compartments. Mild early infections without an abscess formation may respond to antibiotics, but at more advanced stage, erythema, swelling, stiffness, and severe pain may ensue. Abscess formation will cause debilitating pain, fever, systemic symptoms, and even sepsis. Necrotizing infections may threaten not only the limb, but also patient’s life. Therefore, an initially “trivial” hand injury should never be neglected, as it might turn into a deep space infection, which must be treated immediately with drainage, wound debridement, and i.v. antibiotics. Delay in diagnosis and inadequate initial management might rapidly lead to abscess formation, destruction of the gliding surfaces and the normal anatomy, and irreparable functional deterioration.

Closed extensor tendon rupture following neck fracture of the fifth metacarpal (Boxer's fracture): a case report

Boxer’s fractures are common injuries. This report describes a case of a rupture of both small finger extensor tendons, following a closed neck fracture of the fifth metacarpal bone. This complication has not been reported before and emphasizes the importance of good clinical examination to rule out additional damage.

[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%.

Fractures at the junction of diaphysis and metaphysis of the proximal phalanges in adults

We describe the treatment of 101 patients with 113 fractures of the proximal phalanx at the junction of the diaphysis with the proximal metaphysis. Fractures were stabilized using a single extra-articular percutaneous Kirschner wire passed lateral to the metacarpal head into the base of the phalanx base and across the fracture to engage the lateral cortex. Patients were treated semi-electively on a day surgery unit. The metacarpophalangeal joint was splinted in flexion with mobilization of the proximal inter-phalangeal joints, until the wire was removed at 24 days and the hand then freely mobilized. The mean total active movement was 230° and no patients experienced problems with significant pain. There were two pin site infections. There were no cases of angular or rotational malunion. These injuries can be successfully and safely treated using this simple technique, negating the need for close monitoring for angular displacement of the fracture, which is frequently seen with non-surgical management.

LEVEL OF EVIDENCE

IV.

[Joint infections of the hand]

Joint infections of the hand may lead to irreversible lesions and impairment of hand function due to early cartilage damage. Furthermore, persistent infections which are not treated immediately can cause osteitis and/or spread systemically. Finger joints are prone to infection due to bite wounds or crush and sharp injuries. Whereas the wrist is often affected in patients with immunosuppression or chronic diseases, such as diabetes mellitus. If diagnosis and therapy are delayed, joint damage may be inevitable. Therefore, urgent treatment of the infected joint is imperative to preserve the function of the hand. This article reviews the current diagnostics and treatment of joint infections of the hand.

Predicting serious complications and high cost of treatment of tooth-knuckle injuries: a systematic literature review

PURPOSE

The tooth-knuckle injury (TKI) is a serious and potentially costly injury seen in orthopaedic practice. The aim was to conduct a systematic literature review on the factors associated with serious complications and high treatment costs in tooth-knuckle injuries.

METHODS

MEDLINE, Scopus and CINAHL were used as the literature sources.

INCLUSION CRITERIA

Original research papers that reported on factors predicting serious complications and high treatment costs in TKIs were included. There were no restrictions placed on study size, language, study design or date of publication.

EXCLUSION CRITERIA

Case studies, case series and review articles were not included.

RESULTS

After duplicates were removed, 403 unique studies remained; after titles and abstracts were screened, 48 titles remained and were retrieved in full text. Of these, 14 titles met the inclusion criteria and were included in the data synthesis. Tenosynovitis, septic arthritis, osteomyelitis and residual stiffness were common serious complications occurring in up to 36.3, 70.0, 47.6 and 65.3 % of cases, respectively. Amputation was also common in up to 18.0 % of injuries. Treatment costs were measured by length of hospital stay and the number of debridements required. On average, patients required 3.8-8 days of admission and 1.3-2.7 debridements each.

CONCLUSION

Increased time delay from injury to treatment, deeply penetrating injuries, proximal interphalangeal joint (PIPJ) injuries and, possibly, E. corrodens infections were associated with serious complications in TKIs. Delayed treatment, inadequate treatment, PIPJ injuries and deeply penetrating injuries predicted higher treatment costs.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42016029949 ( http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016029949 ).