An inmate presents to the medical clinic with a laceration on his hand overlying the knuckle of his small finger. 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!