Case Study: “I Fell and Hurt My Hand”

An inmate presents to the medical clinic with a laceration on his hand overlying the knuckle of his small finger.  Hand injury He insists that he fell getting off of his bunk.  He has no other injuries on examination.  What do you think happened?  How would you treat this?

Beware of this injury!  First of all, it is highly unlikely that this injury happened from a fall.  This is a “Boxer’s” type hand injury.  It occurred when the patient struck something with his fist.  When was the last time you struck the ground with your fist as you fell?  It does not happen.

More likely, this inmate struck another inmate in the mouth and lacerated this knuckle on a tooth.  What we are looking at then, most likely, is a human bite wound.  And of course the inmate might not want to admit to this and will stick to his story of falling.

The problem is that human bite wounds are notorious for getting horrific infections.  And “clenched fist” injuries tend to be the most serious of human bites.  The force of the punch commonly causes the tooth to lacerate other structures besides the skin such as the extensor tendon and may even cut into the joint itself.

Clenched-fist injuries, also called “fight bites,” are notorious for being the worst human bites. Inadequate initial management leads to significant morbidity. Misleading history, innocuous wound appearance, intoxication and lack of cooperation of the patient leading to inadequate examination, patient reluctance to admit the nature of the injury, delayed presentation, and inadequate exploration all may lead to mismanagement. Clenched-fist injuries are associated with the highest incidence of complications of any closed-fist injury and of any type of bite wound. Marx:  Rosen’s Emergency medicine, 7th Ed. Chapter 47, The Hand.

 

The proper course of action on this patient is to send him to the Emergency Department.  Most likely, he will be taken to surgery to explore the wound and to clean it out.

Have you encountered an injury such as this at your facility?  How did it turn out?  Please comment!

18 thoughts on “Case Study: “I Fell and Hurt My Hand”

    1. jeffk2996 Post author

      Thanks, Lisa! If there was no laceration, that would be a good theory. I have found that inmates usually admit to punching a wall because they don’t face discipline for that like they do for punching someone else.

      Reply
  1. Melonie

    Cleaned it up… watched the camera footage if available….and get an order for Keflex BID and wound dressing BID.. watch for S&S of infection.

    Reply
    1. jeffk2996 Post author

      Thaks, Melonie. The problem with human bite wounds is that Keflex doesn’t adequately cover the organisms in a human mouth. And often, the laceration from the tooth extends into deeper structures. So if you know or suspect that it is a human bite, it almost always should go to surgery.

      Reply
  2. Christina

    I’ve seen that exact type of injury, a guy punched his wife in the mouth before coming to jail, he told the police he hurt it working on a car. Pt was placed on antiobiotics but ended up not being able to fully extend his finger…….in the end he needed surgery and more antibiotics.

    Reply
    1. jeffk2996 Post author

      Thanks, Christina! That’s the problem with these type of hand injuries. They are easy to overlook and miss but devastating if you do!

      Reply
      1. James Ondricek RN

        I don’t recall ever sending an inmate out for surgery following a fight unless he actually broke a bone. I have had our doctor order Rocephin injections to go along with antibiotics when there was a bite or laceration, if it was known to have came from another inmate’s mouth. I also do not recall ever having a negative outcome from this, here at the Davis County Jail. I wonder what our liability would be if the hand was infected and there was a negative outcome when the inmate lied to the doctor in the first place about where the injury came from.

        Reply
  3. Divina Andres

    Hi Dr. Keller. Thanks for sharing your knowledge in Jail Medicine. Always been looking forward to your monthly posts. I would also want to ask if there is such a training for Nurse Practitioners who would like to specialize in Correctional Medicine.
    With regards to human bites with open wound, usually treat with Amoxiclavulanic Acid high dose and wound care. But for deep lacerated wounds better sending first to ER prior to booking.
    Bing, NP

    Reply
  4. Jeff D

    Someone in the public health community should consider running a PSA on this topic. “If you are thinking about punching someone in the mouth today, here’s what you should know…’

    Reply
  5. Bryan Davis

    I wouldn’t necessarily send him out emergently unless a practitioner could not evaluate the wound in a timely maner. If there is going to be a delay, then he would need an ER trip. He would definitely need a thorough eval by a practicioner to explore the wound through full range of motion, as the position of the possible tendon injury would move into view as he brings his hand back into a fist. We’d be concerned of developing tenosynovitis as well, so we’d want to irrigate she snot out of it, NOT close it, and be able to document full range of motion and then immobilize it. I wouldn’t give Keflex or Rocephin, but rather Augmentin. I’d give a tetanus booster, and likely send him to ortho for a consult. You’re absolutely right in that these wounds may not look like a big deal, because the laceration may only be 1 cm long and not gaping open, but they truly can be nasty. Another point I would make is to caution folks not to fall into the trap of assuming that there is no tendon injury just because the patient can move their finger. I have seen plenty of folks with partial tendon lacerations that maintain full range of motion.

    Reply
    1. jeffk2996 Post author

      My goodness, Bryan! Do you have experience in emergency medicine? Because your post is is a perfect description of a proper ER evaluation of such an injury, right down to looking for a partial endow laceration. The full range of motion will also sometimes show capsular tears of the MC joint that are invisible except at just the right degree of extension. I particularly liked that you would not close the wound–delayed primary closure is the way to go in this case. Many ER docs would use two antibiotics to double cover Eikenella corrodens and skin flora.

      Reply
  6. Al Cichon

    The only additional thought would be to anesthetize and explore / visualize the wound. If you can, and no tendon or other deep structure injury is revealed, that may save some transport etc.

    Incidentally, recently had an inmate who worked off-site at an animal shelter return with a ‘cat scratch’ from as feral cat. The report was ‘you might want to take a look before the person goes to work’. Clearly a cat bite on evaluation that was starting to ‘go south’ – no work, intensive (though not IV) antibiotics and symptomatic care brought it under control. Moral – beware of ‘under reporting’.

    What would you say is the liability situation if the iinmate is assessed – misrepresents the HPI and has a bad outcome – assuming that there is a good evaluatioin / documentation?

    Reply
  7. Kathleen Gittins

    I have had our doctor order Rocephin or invanz injections to go along with antibiotics when there was a bite or laceration, if it was known to have came from another inmate’s mouth. We have usually sent the inmate to the local ER but they have seldom sent the inmate to the OR. I, like James, wonder what our liability would be if there was a negative outcome when the inmate lied to the doctor in the first place about where the injury came from. I would think that very detailed, throrough charting would be helpful.

    Reply
  8. BRYAN DAVIS PA-C

    I would think our liability would not be very high in situations where a patient misrepresented the HPI. From an access to care and treatment perspective, the patient was seen and evaluated in a timely manner, and from a medical perspective, you make the most appropriate decision based on the information that is presented to you at the time of your evaluation. As long as we are evaluating and documenting appropropriately, I don’t think we can be held liable for not being mind-readers. A patient bears some responsibility in giving us the most accurate information they can and we in turn bear responsibility to examine and treat objectively. I think where we might get in trouble is if our objective findings clearly go against the subjective HPI and we fail to treat based on our objective findings. With that said, I am not a lawyer. Just my opinion. Good topic!

    Reply
  9. Al Cichon

    One additional thought (spurred by Mr. Davis) one key component to an ER HPI for trauma is ‘mechanism of injury’. There are countless times that has helped me in the jail when an individual is either over or under playing the injury. Reviewing the story presented – it seems clear that the injury is not consistent with the reported mechanism. Kind of like, seeing a clear imprint of a hand slap and being told ‘I just bumped my face on the wall’…

    Reply
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