Clenched fist human bite injuries

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I. C. PHAIR and D. N. QUINTON From the Leicester Royal Infirmary A prospective study has been made of 29 human bite injuries caused by the clenched fist, 27 over M.P. joints and two over P.I.P. joints. All were treated by surgical exploration, within 24 hours in 84% of cases. In 62% the wound had entered the underlying joint and in 58% the bone was injured. Significantly less morbidity was noted in those cases where there was no joint injury (P < 0.001). Early surgical exploration to identify and to treat the joint injury is recommended. Journal ofHand Surgery (British Volume, 1989) I4B: 86-87

Human bite injuries to the metacarpo-phalangeal joints caused by the clenched fist have been followed by severe complications such as septic arthritis (Chuinard and D’Ambrosia, 1977; Resnick et al., 1985) osteomyelitis (Dreyfruss and Singer, 1985; Resnick et al., 1985) and persistent infection leading to amputation (Mann et al., 1977; Schmidt and Heckmann, 1983; Dreyfruss and Singer, 1985). Recommendations on the use of antibiotics have been made by Eaton and Butsch (1970), Shields et al. (1975) Mann et al. (1977) and Goldstein et al. (1978). Peeples et al. (1980) considered that antibiotics alone were sufficient in the management of early cases provided the joint had not been penetrated, but others believed that early surgical intervention following injury would reduce septic complications (Welch, 1936; Chuinard and D’Ambrosia, 1977; Mann et al., 1977). Lister (1984) described “chondral divot fractures” of the M.P. joints which might increase the likelihood of septic complications. However, there are no prospective reports which accurately document the injury to tendon, joint and/or bone. In view of the high risk of infection, we decided to explore all these human bite wounds, taking particular note of injury to tendon or bone, in order to relate these findings to the subsequent recovery of the hand. Material and methods

Patients presenting with suspected human bite injuries adjacent to the extensor apparatus of M.P. or P.I.P. joints started a course of antibiotics (intramuscular Benzyl Penicillin and oral Flucloxacillin). The wounds were explored on the day of presentation or the following morning. When operation was delayed, the wound was cleaned and a gauze swab soaked in Betadine applied until the time of operation. Thorough debridement of the superficial and deeper structures was carried out and injured joints irrigated with saline. The extent of the injury was recorded. All wounds were left widely open to heal by secondary intention. The injured hand was immobilised on a volar slab of plaster-of-Paris, with the M.P. joints flexed to 90” and the P.I.P. joints to 20”, until deep infection had 86

resolved. Similarly, antibiotic therapy (oral Flucloxacillin and Phenoxymethyl Penicillin) was continued until clinical infection had ceased. All patients were reviewed in the Hand Clinic by one of the authors. Physiotherapy was used where indicated to manage joint stiffness. Patients were discharged when there was complete wound healing and a full range of movement of the injured joint. Statistical analysis, where quoted, was carried out by the Students t-test. Results 25 consecutive male patients whose ages ranged from 12

to 44 years (mean 25 years) with the characteristic ragged laceration over the M.P. or P.I.P. joint presenting to the Accident and Emergency Departments, Leicester Royal Infirmary, made up the study group. 16 patients gave a history that a human tooth had caused the laceration. Nine initially offered an alternative explanation, all but one of whom changed his story on confrontation, the remaining patient admitting to it later. A total of 29 wounds of 27 M.P. joints (five index, eleven middle, six ring and five little) and two index P.I.P. joints were explored, the dominant hand being injured in 16 patients. 21 patients were operated upon within 24 hours of injury, two at three days after injury, one at seven days and one at ten days. Intravenous regional anaesthesia was used in 22 patients, median nerve block in two and digital metacarpal nerve block in one. A pneumatic tourniquet was used for all procedures. Bacteriological culture of specimens taken at exploration yielded organisms in 11 out of 29 specimens : mixed coliforms in eight, staphylococcus aureus in three, haemophilus species in one and anaerobes in one. The findings at operation fell into two groups: eight patients in whom the injury was confined to the skin and 21 patients where tendon, joint capsule and/or metacarpal were involved. In the 17 patients with injury to bone there were 11 free osteochondral fragments, four metacarpal head indentations and two indentations of the metacarpal shaft. Figure 1 shows a typical osteochondral fracture found in one of the patients. THE

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The joint capsule was injured in all but three of the 21 tendon injuries, and in only one was no damage to bone discovered. Morbidity was determined by the time in days between injury and discharge. In those with damage confined to skin, it ranged from 10 to 16 days (mean 12.1 days). In those with an injury to deeper structures, it was 16-60 days (mean 30.5 days). This difference was highly significant (P
The mechanism of human bite injuries caused by the clenched fist explains the damage to deeper structures (Lister, 1984), the extensor apparatus of a tightly flexed M.P. joint affording little protection when a fist strikes an incisor tooth. This is borne out by our finding that,

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where the tendon was injured, the capsule and bone were also likely to be damaged. A similar situation exists at the P.I.P. joint. The term “chondral divot fracture” is appropriate. Although Lister (1984) said that these are “found in a large majority of human bite injuries”, no incidence was stated. Reports in the literature vary from 5.8% (Patzakis, 1987) to 30.4% (Schmidt et al., 1983). Both these series are retrospective. In our prospective series, the incidence is much higher at 58.6%. Since over one-third of our patients at first offered an alternative explanation for their injury, casualty officers should view wounds on the dorsal aspect of the M.P. joints with suspicion. Direct confrontation will usually confirm the diagnosis. The incidence of septic arthritis ranges from 15% (Shields et al., 1975) to 70% (Schmidt and Heckmann, 1973), and of osteomyelitis from 5% (Chuinard and D’Ambrosia, 1975) to 17% (Shields et-al., 1975). Our series produced one case of osteomyelitis from the 29 wounds explored, an incidence of 3.4%. We attribute this low figure to early surgical exploration and debridement. In Schmidt’s (1983) series, amputation was required in three out of five patients who developed osteomyelitis. This underlines the importance of human bite injuries. An amputation is a severe penalty for punching someone in the mouth. References CHUINARD, R. G. and D’AMBROSIA, R. D. (1977). Human Bite Infections of the Hand. Journal of Bone and Joint Surgery, 59A: 416-418. DREYFRUSS, U. Y. and SINGER, M. (1985). Human bites of the hand: A study of one hundred and six patients. Journal of Hand Surgery, 10A: 6(l): 884-889. EATON, R. G. and BUTSCH, D. P. (1970). Antibiotic guidelines for hand infections. Surgery, Gynecology and Obstetrics, 130: 119-122. GOLDSTEIN, E. J. C., MILLER, T. A., CITRON, D. M. and FINEGOLD, S. M. (1978). Infection following clenched-fist injury: A new perspective. Journal of Hand Surgery, 3 : 5 : 455-457. LISTER, G. The Hand: Diagnosisand Indications(2nd ed.). Edinburgh, Churchill Livingstone, 1984. MANN, R. J., HOFFELD, T. A. and FARMER, C. 9. (1977). Human bites of the hand: Twenty years of experience. Journal of Hand Surgery, 2: 2: 97104. PATZAKIS, M. J., WILKINS, J. and BASSETT, R. L. (1987). Surgical Findings in Clenched-Fist Injuries. Clinical Orthopaedics and Related Research, 220: 237-240. PEEPLES, E., BOSWICK, J. A. and SCOTT, F. A. (1980). Woundsofthe Hand Contaminated by Human or Animal Saliva. Journal of Trauma, 20: 5: 383389. RESNICK, D., PINEDA, C. J., WEISMAN, M. H. and KERR, R. (1985). Osteomyelitis and septic arthritis of the hand following human bites. Skeletal Radiology, 14: 263-266. SCHMIDT, D. R. and HECKMAN, J. D. (1983). Eikeneilacorrodens in Human Bite Infections of the Hand. Journal of Trauma, 23: 6: 478482. SHIELDS, C., PATZAKIS, M. J., MEYER, M. H. and HARVEY, J. P. (1975). Hand infections secondary to human bites. Journal of Trauma, 15: 3: 235236. WELCH, C. E. (1936). Human bite infectionsofthe hand. New England Journal of Medicine, 215: 901-908. Received: 26 February 1988 Mr. 1. C. Phair, Registrar in Accident Infirmary Square, L&ester LEl 5WW

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An osteochondral fracture human bite injury.

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