“Clenched Fist Injury”

18 Jun

A few weeks ago we had a patient with an example of a potential pitfall in a clenched fist injury (CFI). The trauma mechanism wasn’t the classic fist vs teeth, the patient was holding a crowbar during demolition work and hit his left, non-dominant hand against a wooden post.

The intern had a first look and came back stating it was a small wound over the dorsal aspect of the 3rd metacarpophalangeal (MCP) joint with intact function, sensibility and vascularisation of the 3rd finger.

At inspection it indeed seemed to be a superficial laceration with no obvious injury of the underlying structures. But that was inspection with the fingers held straight as we usually examine the hand/fingers. On the other hand (figuratively), on inspection with flexion in the MCP-joint, which wasn’t easy due to the small size of the laceration, there was a complete transverse laceration of the extensor tendon. Only the distal part of the tendon was visible. After extending the laceration of the skin proximally, the proximal part of the tendon was found (about 1,5 cm proximal of the skin lesion). Also the radial connexus intertendinei became visible, which was intact, explaining the intact function of the finger.

This case was a perfect example of why the trauma mechanism matters. Especially in wounds over joints it is of vital importance to inspect the wound with the joint held in the same position as when the trauma occurred in order not to miss any underlying injuries.

Not only can there be tendon lesions, also the bone could be damaged or the joint capsule can be perforated. This places the patient at risk for deep infections like septic arthritis, tenosynovitis or osteomyelitis. This is especially so in the classic CFI trauma mechanism where a tooth lacerates the skin, introducing bacteria to these underlying structures.

Missing underlying injuries might also impair your treatment. Irrigation of the wound without irrigation of the joint or bone makes an infection more likely to occur. Antibiotics might not be prescribed (I would recommend a broad spectrum antibiotic, like Augmentin). Tendon lesions might not be repaired.

So … always inspect wounds over joints with the joint in several positions, especially the position in which the wound occurred. And: a clenched fist injury is not always caused by a fight!

René, EP.

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