FRCS (Tr & Orth) Oral Examination: Abbreviated Fight Bite Case Presentation
A 28-year-old man presents 72 hours following an injury to his left hand. He seems evasive about the history but finally admits to being involved in a fight.
1. Can you describe the picture and the underlying injury?
This clinical photograph shows a wound over the metacarpophalangeal joint of the index finger of the left hand. The injury is most likely a 'fight bite' wound caused by a penetrating tooth injury. The wound may extend down to the underlying joint, which could potentially cause septic arthritis, extensor tendon damage, osteochondral injury, or associated fractures or osteomyelitis in neglected injuries.
Fight bite wounds are common injuries that result from hand-to-hand or fist-to-tooth contact. This type of wound is caused by crushing tissue between the teeth and underlying bone, leading to a penetrative injury. Because of the high prevalence of oral flora in the human mouth, these wounds have a high risk of infection. The underlying injury can involve soft tissue, such as skin and subcutaneous fat, as well as deeper structures including bone and joint. A fight bite is considered a surgical emergency.
2. How would you assess the patient in the emergency department?
In the emergency department, I would take a full history from the patient, including hand dominance, occupation, past medical history, and tetanus immunisation status. I would also ask the patient if they knew the person they punched and if their bloodborne virus status is known. An examination should be performed to assess the wound's severity, look for signs of cellulitis, obvious purulence, tendon rupture, and septic arthritis. A request for plain radiographs should be performed to assess underlying fractures and retained tooth fragments. Signs of sepsis should also be assessed through observation and inflammatory marker tests (white cell count and CRP).
A comprehensive assessment of the patient's wound is necessary in an emergency department following a fight bite. The assessment should include a thorough history to evaluate the patient's risk of infection. An examination of the wound is necessary to determine the wound's severity and assess for signs of cellulitis or sepsis. Radiographic imaging should be used to check for underlying bone involvement or foreign bodies. A tetanus vaccine should be administered if necessary. Prompt surgical referral is necessary for most fight bite injuries.
3. How should this injury be managed?
A fight bite wound warrants operative management due to the potential risk of developing septic arthritis. Before starting broad-spectrum intravenous antibiotics according to local microbiology guidelines (co-amoxiclav would be the antibiotic of choice in my unit), a wound swab and deep tissue samples should be taken. Gram-negative bacteria should also be covered with the antibiotics, as Eikenella corrodens is often implicated in a fight bite. The infection is typically polymicrobial, but the most commonly cultured organism from a fight bite is Staphylococcus aureus. I would photograph the wound, cover it with saline-soaked swabs and a non-adherent dressing, and take the patient to theatre for a debridement under general anaesthesia with an arm tourniquet. If the tendon is ruptured, primary repair should be avoided at this time, and deep tissue samples should be sent at the time of surgery with the commencement of intravenous antibiotic therapy. The joint should be inspected, irrigated with copious volumes of normal saline, and partially closed with sterile, non-adherent dressing.
Fight bite wounds necessitate surgical management due to the risk of septic arthritis development. Physicians should order a wound culture and take deep tissue samples before administering broad-spectrum antibiotics. A combination of anti-staphylococcal and gram-negative coverage antibiotics should be used. Fight bites necessitate enhanced physician suspicion due to the high risk of infection. Treatment options are dependent on the wound and injury severity. Prompt wound closure, combined with appropriate antibiotic treatment and surgical intervention, reduces the risk of infection, septic arthritis, and other complications.
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