A small puncture wound, particularly from a human or cat bite, may involve significant injury to the tendon, joint capsule, or articular cartilage. The most common cause of human bites is a tooth-induced injury to the metacarpophalangeal joint as a result of a punch to the mouth (clenched fist injury). The oral flora of humans includes Eikenella corrodens, staphylococci, streptococci, and anaerobes. Patients with clenched fist injuries tend to wait hours or days after the wound occurs before seeking medical attention, which increases the severity of the infection. Animal bites usually contain multiple potential pathogens, including Pasteurella multocida (particularly in cat bites), staphylococci, streptococci, and anaerobes. Serious complications include infectious arthritis and osteomyelitis.
Erythema and pain localized to the bite suggest infection. Tenderness along the course of a tendon suggests spread to the tendon sheath. Pain worsening significantly with motion suggests infection of a joint or tendon sheath.
The diagnosis is clinical, but if the skin is broken, x-rays should be taken to detect fracture or teeth or other foreign bodies that could be a nidus of continuing infection.
Treatment includes surgical debridement, with the wound left open, and antibiotics. For outpatient treatment, empiric antibiotics usually include monotherapy with amoxicillin/clavulanate 500 mg po tid or combined therapy with a penicillin 500 mg po qid (for E. corrodens,P. multocida, streptococci, and anaerobes) plus either a cephalosporin (eg, cephalexin 500 mg po qid) or semisynthetic penicillin (eg, dicloxacillin 500 mg po qid) for staphylococci. In areas where MRSA is prevalent, trimethoprim/sulfamethoxazole, clindamycin, doxycycline, or linezolid should be used instead of a cephalosporin. If the patient is allergic to penicillin, clindamycin 300 mg po q 6 h can be used. The hand should be splinted in the functional position and elevated (see Fig. 3: Splint in the functional position (20 wrist extension, 60 metacarpophalangeal joint flexion, slight interphalangeal joint flexion).).
Noninfected bites may require surgical debridement and prophylaxis with 50% of the dose of antibiotic used to treat infected wounds.
Last full review/revision March 2013 by David R. Steinberg, MD
Content last modified September 2013