Page 98 - JSOM Winter 2017

Your anatomical knowledge leads you to suspect a digital tendon and penetrate the MCP joint. The teeth carry signifi-
nerve injury and partial laceration to the FDP tendon at the cant amounts of bacteria. These bacteria can grow in this
ring finger. You anesthetize the wound with a metacarpal joint, cause a septic joint, and lead to destruction of the joint.
block and irrigate the wound with normal saline. After apply- It is critical that the wound be carefully inspected to determine
ing a BP cuff as a tourniquet, you carefully inspect the wound if the joint is penetrated. If so, it requires a surgical washout.
and are able to visualize a deep laceration to the ring finger, Early antibiotic administration is critical. Many patients may
which appears to have injured the tendon. not reliably report the mechanism out of fear of disciplinary
repercussions. A high index of suspicion must be held for any
You consult with a higher medical authority. They recommend injuries that fit this pattern.
you close the wound with interrupted sutures and splint the
affected fingers. The splint should prevent further injury to After further discussion, the patient says he obtained the lac-
the fingers and be flexion blocking, so that the existing tear in eration during an altercation. You initiate the antibiotic com-
the tendon is not increased by forced flexion. The plan is to bination of amoxicillin and clavulanate, irrigate the wound,
electively evacuate the patient to a hand surgeon for possible and splint the hand in the position of function. The patient is
flexor tendon repair and consideration for primary digital referred to a higher level of care for a more thorough wound
nerve repair. No antibiotics are indicated. inspection and irrigation of the injury.

Patient 2 Summary
Patient 2 is a 22-year-old partner-nation special operator. He
has a laceration to his dominant hand (right) over the exten- The hand’s function is a complex interaction of an intricate se-
sor surfaces of the middle-finger metacarpal phalangeal joint ries of nerves, muscles, and tendons. These structures are very
(Figure 7). The laceration is jagged. He reports the injury oc- superficial and thus prone to injury. A good understanding of
curred after he tripped and fell on loose ground. He reports the anatomy and a careful history and systematic physical ex-
it occurred approximately 12 hours ago. He is not diabetic amination are essential to detect and treat potential injuries
and his tetanus status is current. He does smoke cigarettes. with the goal of preserving function.
He inquires if you are going to inform his chain of command
about his injury. Disclaimers
The views and medical opinion herein represent those of the
authors. They do not reflect the operation practice or views
of the Canadian Forces or other organizations. The cases are
provided to be educational and thought provoking; at no time
does the author suggest that the tactical clinicians exceed the
scope of their practice or act against the direction of their med-
ical protocols or recommendations of their medical leadership.
Figure 7 Patient 2’s injury.
Disclosure
The authors have nothing to disclose.

Author Contributions
Both authors contributed equally to the manuscript and had
final approval.

References
Examination demonstrates normal capillary refill and normal 1. Hollander JE, Singer AJ. Laceration management. Ann Emerg
two-point discrimination. He has full resisted tendon function Med. 1999;34(3):356–367.
of FDS, FDP, and extension. There is some pain with resisted 2. Hart G, Uehara DT, Wagner MJ. Emergency and Primary Care of
extension. You also notice that that this patient has some fa- the Hand. Dallas, TX: American College of Emergency Physicians;
2001.
cial contusions.
You suspect a fight bite, which is a term that describes an in-
jury sustained to the knuckles (dorsal MCP) when striking
someone in the mouth. During impact, the teeth can lacer-
ate the knuckle over the MCP. This can lacerate the extensor

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