Treatment

Patients presenting more than 24 h after injury may already exhibit evidence of infection, with swelling, erythema, warmth, and a purulent, often malodorous discharge. Aerobic and anaerobic cultures should be obtained from the wound prior to any irrigation or cleansing of the wound. Careful examination of the wound following irrigation and cleansing is required to inspect the tendons and joint capsules. Radiographs should be taken.

Patients who present with a fresh CFI should have careful inspection under anesthesia, as noted above, and radiographs taken. If no laceration of the extensor tendon or joint capsule is seen, the wound should be copiously irrigated; it should be left open with an appropriate dressing, the hand immobilized in a bulky dressing and elevated for 24 h, followed by reevaluation in 1 to 2 days.1819 If there is a laceration to either the extensor tendon or the joint capsule or radiographic findings (foreign bodies, fractures, or joint-space air), a hand specialist should be consulted; these patients usually require exploration in the operating room. 20 In general, non-CFI human bite wounds of the hand should also be left open after examination and irrigation.

Wounds in other locations—such as the face, head, and neck—can be successfully repaired with primary closure after copious irrigation and judicious limited debridement.2 ,22

Prophylactic antibiotics should be considered in all human bites of the hands and in bites to other locations in high-risk patients (asplenia, diabetes mellitus, and immune deficiency).17!9 Antibiotics should cover the expected mouth flora. Acceptable agents include amoxicillin/clavulanate, dicloxacillin plus penicillin, a first-generation cephalosporin plus penicillin, or a fluoroquinolone. Patients allergic to penicillin can be treated with clindamycin plus trimethoprim-sulfamethoxazole. Three to 5 days of therapy is appropriate. All patients with human bite wounds should be provided with tetanus immunization according to standard guidelines.

Patients with human bite hand wounds, particularly CFI, presenting more than 24 h after injury usually have clinical evidence of infection. Mildly infected wounds, such as those showing a localized cellulitis, in otherwise healthy and reliable patients may be managed on an outpatient basis with oral antibiotics, immobilization, and close follow-up. The wound should be explored and irrigated, left open with a dressing, and immobilized in a bulky dressing. Initial antibiotics should be administered in the ED with prescriptions for an additional 7 days given to the patient on discharge. These wounds should be reexamined in 24 h.

Moderate to severe infections manifest by fever, tachycardia, spreading cellulitis, or lymphangitis or possible involvement of deep tissue require admission for parenteral antibiotic therapy. Appropriate coverage can be provided by ampicillin/sulbactam, cefoxitin, ticarcillin/clavulanate, or piperacillin/tazobactam. Penicillin-allergic patients can be treated with clindamycin plus ciprofloxacin. Additional management includes copious irrigation and drainage (usually in the operating room), bulky dressings with daily changes, elevation, and immobilization. Delayed primary closure or healing by secondary intention is the preferred approach for the closure of hand wounds.

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