Case 6

27 yr old male

Claims he accidentally knocked against edge of table.
'Just stitch it up for me, doc.'
How would you approach this case?

Answer : Fight Bite

This laceration is sustained when one punches another individual in the mouth with a clenched fist, with the victim's teeth cutting the perpetrator's hand around the metacarpophalangeal joint (MCPJ), as shown :

• All wounds around MCPJ should be considered fight bites until proven otherwise
• Characterized by innoculation of organisms and rapid spread - cellulitis, septic arthritis, tenosynovitis, osteomyelitis, abscess
• Usually polymicrobial
• Initial presentation may be deceptively unremarkable

Management

• Examine all wounds in flexion and extension so as not to miss extensor tendon injuries
• Wounds should not be closed initially
• All wounds should be explored, irrigated and debrided
• Tetanus prophylaxis
• Xray to exclude foreign bodies (e.g. teeth fragment)
• Antibiotics to cover both oral and skin flora
  

Disposition

• Outpatient only if : early presentation, no infection, no comorbidity (e.g. diabetes), no evidence of bone/ joint/ tendon involvement --> refer to Ortho/ Hand surgeon for early review
• All others - admit for definitive wound care and IV antibiotics

This case also illustrates the sad-but-true fact that our patients do not tell us the truth all the time, or even most of the time. Haven't we all at some time or another rolled our eyes at the patient who swallowed 40 Paracetamols because 'the headache won't go away', or the teenage Juliet with 8-9 lacerations on her wrist because she accidentally cut herself opening a can of sardines?

Often patients do not tell us the truth because it is embarrassing, but sometimes also because they are afraid of the medicolegal implications. Do we press them, and how hard do we press?
Personally I usually ask them a direct question once, e.g. 'Did you cut yourself on purpose?'. If they deny there's usually no point persisting, because it only puts them on the defensive and your patient-doctor relationship goes out of the window. As long as it does not affect the medical management, I would just document the negative response to my direct question, and proceed to treat the patient.

In some cases the patient eventually comes around and admits to what really happened. I had a patient with wrists lacerations who, on review a few days later, admits that she had cut herself deliberately after quarreling with her bf. I was then able to refer her forward for counseling and psychiatric review.

I guess the only time when I would really try as much as possible is when I strongly suspect deliberate abuse (e.g. child/ elderly/ spouse), when my inaction or failure to find out the truth may inadvertently lead to greater injuries or even loss of life. Luckily these cases don't happen that often!