What assessments are indicated for an elderly woman with a dog bite to the right arm and palm, who has limited hand and finger movement due to pain?

Assessment of Elderly Woman with Dog Bite to Right Arm and Palm

This patient requires immediate evaluation for deep structural injuries (neurovascular and tendon damage), wound infection risk, and rabies/tetanus prophylaxis status, as limited hand and finger movement strongly suggests underlying tendon, nerve, or joint involvement that may require urgent surgical exploration.

Critical Initial Assessment Components

1. Neurovascular Examination

Perform detailed neurovascular assessment immediately, as physical exam abnormalities are highly predictive of surgical findings:

• Nerve function: Test sensation in all nerve distributions (median, ulnar, radial). Any sensory deficit or neuropraxia indicates 69% likelihood of actual nerve damage requiring repair 1
• Vascular status: Assess radial and ulnar pulses, capillary refill, and hand perfusion. Any abnormal vascular exam has 100% correlation with arterial injury 1
• Document all findings precisely - these guide surgical decision-making

2. Tendon and Motor Function Assessment

Test active range of motion for each finger and wrist joint individually:

• Inability to actively flex or extend fingers suggests tendon injury
• 77% of patients with abnormal tendon exam have confirmed musculotendinous damage at surgery 1
• Pain limiting movement is NOT sufficient - you must differentiate true motor weakness from pain-related guarding
• Examine for flexor tenosynovitis signs (Kanavel's signs): fusiform swelling, flexed posture, pain with passive extension, tenderness along flexor sheath

3. Wound Characteristics Documentation

Document specifically:

• Depth of penetration: Dog bites cause crush injuries and can penetrate to muscle, tendon sheath, joint, or bone 2
• Location (palm wounds have higher infection risk due to closed spaces)
• Size and contamination level
• Time since injury (>24 hours significantly increases infection risk 3)

4. Imaging Studies

Obtain plain radiographs (3 views minimum) of the hand and wrist immediately 4:

• Rule out fractures (15.9% rate in adult dog bites 5)
• Identify retained foreign bodies (teeth fragments)
• Assess for joint involvement
• Do NOT delay imaging - fractures and foreign bodies alter management

Consider CT without contrast if:

• Radiographs equivocal but high suspicion for fracture
• Complex injury requiring surgical planning 4

MRI is NOT indicated acutely unless radiographs normal but persistent concern for occult fracture after initial management

5. Infection Risk Assessment

Examine for signs requiring immediate surgical intervention:

• Purulent drainage
• Spreading erythema
• Fluctuance suggesting abscess
• Crepitus
• Systemic signs (fever, elevated WBC if obtained)
• Hand infections from bites can progress rapidly - low threshold for admission 3

6. Rabies and Tetanus Evaluation

Determine rabies risk 6:

• If dog is healthy, domestic, and available: confine and observe for 10 days
• If stray/unavailable: initiate rabies post-exposure prophylaxis immediately (HRIG + vaccine series)
• Do not delay prophylaxis if dog cannot be observed

Tetanus status:

• Administer tetanus toxoid if >5 years since last dose for contaminated wounds
• Give tetanus immunoglobulin if unvaccinated or unknown status

Red Flags Requiring Urgent Surgical Consultation

Immediate hand surgery consultation indicated for 1, 7:

• Any sensory or motor deficit on exam
• Diminished or absent pulses
• Suspected tendon injury (inability to actively move fingers)
• Joint involvement
• Fracture
• Signs of compartment syndrome
• Deep space infection

Common Pitfalls to Avoid

1. Assuming pain alone explains limited movement - always test active motion to exclude tendon injury
2. Delaying antibiotics - start amoxicillin-clavulanate prophylaxis immediately for all bites, especially hand injuries 8
3. Underestimating depth - small puncture wounds can cause severe deep structure damage 7
4. Missing the 24-hour window - patients presenting >24 hours have significantly higher complication rates and often require admission 3
5. Inadequate neurovascular documentation - this is medicolegally critical and guides surgical decisions

In elderly patients specifically, consider 9:

• Decreased physiologic reserve
• Anticoagulation status (affects bleeding risk and timing of procedures)
• Nutritional status (affects wound healing)
• Frailty assessment (influences surgical candidacy)