A 6-year-old boy is brought to the emergency department by his parents due to a dog bite. Approximately 16 hours ago, the patient was playing with the family dog in their backyard when the dog bit his left hand. The parents immediately washed the wound with soap and water and applied topical antibiotic ointment. When the child woke up this morning, he had increased pain exacerbated by making a fist. The dog is up to date with recommended immunizations. The boy has no medical issues and is current with his immunizations. Vital signs are within normal limits. On physical examination, a 2-cm × 1-cm ragged laceration is seen on the dorsal left hand. There is minimal amount of serous drainage from the wound, and no redness or streaking is seen. Full range of motion is present. The wound is copiously irrigated with normal saline. X-ray of the hand is normal. Which of the following is the best next step in management of this patient?

Question

A 6-year-old boy is brought to the emergency department by his parents due to a dog bite.  Approximately 16 hours ago, the patient was playing with the family dog in their backyard when the dog bit his left hand.  The parents immediately washed the wound with soap and water and applied topical antibiotic ointment.  When the child woke up this morning, he had increased pain exacerbated by making a fist.  The dog is up to date with recommended immunizations.  The boy has no medical issues and is current with his immunizations.  Vital signs are within normal limits.  On physical examination, a 2-cm × 1-cm ragged laceration is seen on the dorsal left hand.  There is minimal amount of serous drainage from the wound, and no redness or streaking is seen.  Full range of motion is present.  The wound is copiously irrigated with normal saline.  X-ray of the hand is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf54_8364_8f63_791a2e032454_MD0005_00 Mammalian bites with high risk for infection include those from cats or humans, on the extremities, or that are >12 hours old. Wounds with these high-risk features should be left open to heal by secondary intention. The face is an exception due to its excellent, redundant vascular supply and cosmetic importance. Mammalian bites to the face, including those from cats or humans, can be sutured unless they are >24 hours old. This child has a bite wound on his hand that is >12 hours old; therefore, it should be left open to heal by secondary intention. (Choice A) The presence of a foreign body is determined by visual inspection and a radiograph if suspicion remains high. This patient's x-ray is normal, and additional exploration of the wound is not necessary based on the mechanism of injury. (Choices B and C) Bite wounds with low risk for infection (eg, dog bite on trunk) are candidates for primary closure (eg, nylon sutures). Primary closure of a wound with a high risk for infection, such as in this patient, can increase risk by "sealing in" pathogenic bacteria, particularly anaerobes. Tissue adhesives are not typically used for any bite wounds due to increased risk of infection as well. (Choice D) Involvement of plastic surgery for wound closure is usually considered for cosmetic reasons, particularly if the wound is on the face. This wound does not require closure as it should be allowed to heal by secondary intention. Educational objective: Risk factors for infection after mammalian bite wounds include cat or human bites (except to the face), bites on the extremities, or bites that are >12 hours old. Wounds with any of these features should be left open to heal by secondary intention. References: Human and other mammalian bite injuries of the hand: evaluation and management. (http://www.ncbi.nlm.nih.gov/pubmed/25538130) Dog bites to the upper extremity in children. (http://www.ncbi.nlm.nih.gov/pubmed/26081599)

A 6-Year-Old Boy Is Brought to the Emergency Department by His