What should I do for a 16-year-old patient with hand pain after punching a wall?

Evaluation of Hand Pain After Punching a Wall in a 16-Year-Old

Immediately assess for "fight bite" (human tooth laceration over the metacarpophalangeal joint), which is a surgical emergency requiring urgent hand surgery consultation due to high risk of deep infection, septic arthritis, and tendon injury. 1, 2

Critical Initial Questions

Mechanism and Timing

• Exact location of impact: Specifically ask if the knuckle contacted the wall versus palm or other area 3, 2
• Time since injury: Delays >24 hours significantly increase infection risk if there's a break in skin 1, 2
• Was this actually a wall or another person's teeth?: Patients often misrepresent fight bites as "punching a wall" due to legal/social concerns 2

Skin Integrity Assessment

• Any break in the skin over the knuckles, even tiny?: A small puncture wound over the metacarpophalangeal (MCP) joint is a fight bite until proven otherwise and requires immediate antibiotics and hand surgery referral 1, 2
• Swelling, erythema, warmth, or drainage: These indicate infection, particularly concerning if the wound is over a joint 1, 2

Functional Assessment

• Can they make a full fist?: Inability suggests fracture, tendon injury, or compartment syndrome 4, 5
• Pain with specific finger movements: Test each finger's flexion/extension individually to identify tendon injuries 4, 6
• Numbness or tingling: Indicates potential nerve injury requiring immediate consultation 4, 5
• Which specific knuckle hurts most: The 4th and 5th metacarpals (ring and pinky finger knuckles) are most commonly fractured in "boxer's fractures" 2

Physical Examination Priorities

Inspection

• Visible deformities: Rotational malalignment of fingers when making a fist, depression over knuckle, or abnormal finger cascade 4, 2
• Swelling pattern: Diffuse hand swelling suggests crush injury or compartment syndrome 5
• Small lacerations over MCP joints: These are fight bites requiring surgical exploration 1, 2

Palpation

• Point tenderness over metacarpal heads or shafts: Indicates likely fracture 3, 2
• Compartment assessment: Tense, swollen hand with pain out of proportion suggests compartment syndrome—a surgical emergency 5
• Joint stability: Assess collateral ligaments of each MCP and interphalangeal joint 7, 4

Range of Motion Testing

• Active flexion/extension of each finger: Loss of active motion with intact passive motion indicates tendon injury 4, 6
• Grip strength: Compare to contralateral hand 7, 8
• Cascade sign: When making a gentle fist, all fingers should point toward the scaphoid; deviation indicates rotational fracture deformity 2

Neurovascular Examination

• Two-point discrimination: Should be <6mm at fingertips; increased distance indicates digital nerve injury 4
• Capillary refill: Should be <2 seconds in each fingertip 4, 5
• Sensation in radial, median, and ulnar nerve distributions: Document precisely which nerves are affected 4, 5

Red Flags Requiring Immediate Hand Surgery Consultation

• Any laceration over an MCP joint (fight bite) 1, 2
• Open fracture 4
• Vascular compromise (pale, cool finger, absent capillary refill) 4, 5
• Nerve injury (numbness, loss of two-point discrimination) 4, 5
• Flexor tendon injury (inability to flex finger) 4, 6
• Compartment syndrome (tense swelling, pain with passive stretch, pain out of proportion) 5
• Fracture-dislocation 4
• Rotational deformity (fingers don't align properly when flexed) 2

Initial Imaging

• Plain radiographs are mandatory: Obtain posteroanterior, lateral, and oblique views of the hand 7, 3
• Special oblique views for 2nd metacarpal base: This area is difficult to visualize on standard films due to overlying structures 3
• Comparison views of opposite hand: Consider if growth plates are a concern in this 16-year-old 1

Management Based on Findings

If Fight Bite Suspected

• Start IV antibiotics immediately: Ampicillin-sulbactam or piperacillin-tazobactam for inpatient; amoxicillin-clavulanate for outpatient 1
• Avoid first-generation cephalosporins, macrolides, and clindamycin: Poor coverage of Eikenella corrodens (oral flora) 1
• Urgent hand surgery referral: These require surgical exploration and irrigation 1, 2
• Update tetanus: If not current within 5 years 1

If Simple Closed Injury Without Red Flags

• Immobilize in ulnar gutter splint: For suspected 4th/5th metacarpal fractures 2
• Thumb spica splint: For suspected 1st metacarpal or scaphoid injuries 2
• Elevation above heart level: Critical for first 48-72 hours to prevent swelling 1
• Ice application: 20 minutes on, 20 minutes off for first 48 hours 1
• Follow-up within 24-48 hours: Either with primary care or hand surgery depending on severity 4, 2

When Severity is Uncertain

• Immobilize and refer next day: This is appropriate when diagnosis is doubtful 4
• Do not dismiss as minor: Even small injuries can have serious underlying structural damage 6

Common Pitfalls to Avoid

• Assuming "punched a wall" means no human contact: Always directly ask about fighting 2
• Missing rotational deformities: These require surgical fixation even if radiographs show "acceptable" angulation 2
• Underestimating crush injuries: Minimal skin disruption can hide severe deep tissue damage 5
• Delaying antibiotics for suspected fight bites: Infection develops rapidly in these injuries 1, 2
• Missing extensor tendon injuries: Small lacerations over joints can cause complete tendon division 6