Management of Dog Bite Puncture Wound to the Palm
Do not close this puncture wound to the hand—leave it open, irrigate thoroughly, provide prophylactic antibiotics with amoxicillin-clavulanate, and update tetanus immunization. 1, 2
Wound Closure Decision
Primary closure is contraindicated for puncture wounds to the hand. The IDSA guidelines explicitly state that puncture wounds should not be closed, and hand wounds carry a higher infection rate than other locations when closed. 1 This is critical because:
- Puncture wounds are independent predictors of infection with an odds ratio of 4.1 3
- Hand location is the highest-risk anatomical site for serious complications 4, 2
- Closing wounds of the hand may be associated with infection rates higher than other locations 1
Immediate Wound Management
Copious irrigation with sterile normal saline using a 20-mL or larger syringe is essential. 2, 5 The wound management algorithm includes:
- Thorough cleansing with soap and water, followed by irrigation with normal saline 1, 2
- Exploration for tendon, bone, or joint capsule penetration—critical in palmar hand wounds 2, 5
- Debridement of any necrotic tissue if present 4, 2
- Assessment for foreign bodies 2, 5
Antibiotic Prophylaxis
Prophylactic antibiotics are strongly indicated because this meets multiple high-risk criteria: hand location, puncture wound, and presentation within 24 hours. 2, 3
First-Line Antibiotic Choice:
- Amoxicillin-clavulanate 875/125 mg twice daily for 7-10 days 2, 5
- This provides coverage against the polymicrobial flora typical of dog bites: Pasteurella species (50%), Staphylococcus aureus (40%), Streptococcus species (40%), and anaerobes 2
Alternative Options (if penicillin allergy):
- Doxycycline (excellent activity against Pasteurella multocida) 2
- Moxifloxacin as monotherapy 2
- Clindamycin plus a fluoroquinolone 2
Critical Pitfall to Avoid:
Never use first-generation cephalosporins, macrolides, or penicillinase-resistant penicillins alone—they have poor activity against Pasteurella multocida, which is present in 50% of dog bite wounds. 2
Tetanus Prophylaxis
Administer tetanus toxoid if the patient has not received vaccination within 10 years; Tdap is preferred over Td if not previously given. 1, 2 For dirty wounds like dog bites, a booster is indicated if >5 years has elapsed since the last dose. 1
Rabies Consideration
Assess rabies risk and consult local health officials. 1, 2 If the dog cannot be observed for 10 days or is stray/unwanted, postexposure prophylaxis with immune globulin and vaccination on days 0,3,7, and 14 may be indicated. 1, 5
Follow-Up and Red Flags
Instruct the patient to return immediately if any of the following develop: 4
- Increasing pain, swelling, or redness
- Purulent drainage
- Fever or chills
- Decreased range of motion of fingers or wrist
- Lymphadenopathy
Hand wounds warrant particularly close monitoring because they can lead to serious complications including tenosynovitis, septic arthritis, or osteomyelitis requiring 3-6 weeks of antibiotics. 2, 6
Common Pitfall
The infection rate for puncture wounds that are not closed is only 2.6%, but this increases dramatically to 5.2% overall when wounds are inappropriately managed. 3 The combination of puncture wound morphology and wound closure increases infection risk with an odds ratio of 3.1 for closure alone. 3 Therefore, leaving this palmar puncture wound open is the single most important decision to prevent infectious complications.