Simple Hand Laceration? I think not!

Imagine you are working a busy shift in the ED when you pick up this patient with a hand laceration.  Simple laceration, right?  Just some quick sutures and out the door, right?  Well thats what happened with this patient at an out-of-state ED.

This photo was taken several hours after the patient arrived home.  The patient was discharged with a prescription for keflex.  Do you notice the redness starting around the wound?  The patient went to the ER again, was started on IV clindamycin, and the sutures were removed.  What happened here?  Why did this simple hand laceration become almost immediately infected?

The initial photo is pretty classic.  This is a “fight bite.”  Here’s a few things to remember about treating a “fight bite.”

1.  Often times patients will not be honest about how they sustained the laceration out of fear of legal ramifications.  If you see a laceration over the knuckles, treat it as a “fight bite.”

2.  I would recommend xray for fracture or foreign body.

3.  These lacerations need irrigation with copious (at least 300cc) saline (or tap water.)

4.  Thorough examination for tendon involvement

5.  These wounds should not be closed primarily.  24-48 hour recheck should be mandatory.

6.  Antibiotic of choice is Augmentin 875mg twice a day for 7-10 days or clindamycin 450mg three times a day PLUS one of the following:  ciprolfoxacin (500mg twice daily), levofloxacin (750mg once daily), moxifloxacin (400mg once daily), or bactrim DS (two tabs twice daily.)

7.  Often times, I will give the patient a dose of IV antibiotics in the ED prior to discharge.  What are other people’s take on this?  I have no literature to support this.  I definitely would recommend giving at least the first dose of oral antibiotic in the ED prior to leaving.

The patient did well.  After the IV antibiotics, the patient was discharged on Augmentin.  There was no long-term impairment of function.

5 thoughts on “Simple Hand Laceration? I think not!

  1. I don’t necessarily treat all of these as fight bites. I do, of course, have a very clear discussion with the patient, stressing that I

    a. won’t judge them and don’t really care if they were in a fight, but
    b. will treat their wound very differently if they were (making sure to elaborate about the likelihood and seriousness of infection–hospital admission, OR, etc).

    Then I document the conversation.

    My reasoning is that if it isn’t a fight bite primary closure is the simplest, most logical course of treatment. Treating all of these wounds as though they were fight bites (keeping in mind that hitting a wall or some other inanimate object doesn’t count) leads to unnecessary ED visits and unnecessary antibiotic use (with unnecessary side effects, which for many of these antibiotics aren’t trivial). I also believe that the patient has to take some responsibility for their health care and I give them multiple opportunities to come clean.

    Agree with everything else you said about fight bites, with the possible exception of IV antibiotics for everyone. Certainly, I will if the wound is several hours old or if there are any signs of infection. Otherwise, I give them a po dose in the ED and discharge with a prescription. And the point about a thorough tendon exam (good light, bloodless field, exam through a full range of motion) is worth repeating–for all hand/wrist injuries.

  2. I usually do what Travis said, explaining to them why I need to know if it was a “fight bite”.

    These cases are scary to me as I have read couple bounceback-type “case reports” which were written up to illustrate their high risk nature both from an outcome and legal perspective. As such, I have been making my patients get rechecked the next day at least in the ED.

    Oh, and don’t forget about tetanus!

    1. I don’t use IV antibiotics. I can’t imagine their is any evidence supporting this and I think it would be quicker to just give augmentin and discharge the patient…make room for the next fight bite.

  3. In my part of the world, ALL of these go to a hand surgeon. Keeps the hand surgeons busy.

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