Working Diagnosis:
Fight bite <br>Osteomyelitis of the right second metacarpal <br>Septic arthritis of the right second metacarpophalangeal joint <br>Cellulitis with abscess of right hand

Treatment:
In the emergency department he received intravenous fluids, morphine and Robaxin for pain control, Zofran for nausea and was started on vancomycin, cefepime, and Unasyn. Orthopedic surgery was consulted and performed operative irrigation and debridement of the hand. The morning after the procedure, the right index finger was found to be dusky in appearance <a href="CaseStudyImages/CS3CS2CS1Countingto9-1396.jpg" title="Case Photo #3" data-lity><b>Case Photo #3</b></a> <a href="CaseStudyImages/CS4CS3CS2CS1Counting-1396.jpg" title="Case Photo #4" data-lity><b>Case Photo #4</b></a> . Pulses in the finger were not able to be detected with doppler. Amputation of the digit was recommended, however the patient declined. The patient was amenable to repeat irrigation and debridement in an attempt to salvage the finger. <br> <br> <br>Intraoperative cultures grew streptococcus anginosus group species and prevotella intermedia, consistent with oral flora that were traumatically introduced to the hand and joint space. <br> <br> <br>During the second operative irrigation and debridement, it was made obvious the infection had destroyed local anatomy including invading the flexor tendon sheath and completely disrupting the second metacarpophalangeal joint space. There was evidence of direct injury to the metacarpal head. The finger was deemed necrotic and not salvageable. <a href="CaseStudyImages/CS5CS4CS3CS2CS1Count-1396.jpg" title="Case Photo #5" data-lity><b>Case Photo #5</b></a> Findings were relayed to the patient and his family, and he was ultimately agreeable to amputation. <br> <br> <br>The following morning he underwent a second metacarpal ray amputation with orthopedic surgery. <a href="CaseStudyImages/CS6CS5CS4CS3CS2CS1Co-1396.jpg" title="Case Photo #6" data-lity><b>Case Photo #6</b></a> A vacuum assisted closure device was placed, and the wound was definitively closed one day later.

Outcome:
He was discharged home with prescriptions for levofloxacin and metronidazole in accordance with wound culture sensitivities. He was to remain non-weight bearing to the right upper extremity until follow up occurred. He saw both his primary care physician and orthopedic surgery within one week of discharge and completed his antibiotics without issue. His wound was noted to be healing appropriately at 1 week post op wound check. <a href="CaseStudyImages/CS7CS6CS5CS4CS3CS2CS-1396.jpg" title="Case Photo #7" data-lity><b>Case Photo #7</b></a> <a href="CaseStudyImages/CS8CS7CS6CS5CS4CS3CS-1396.jpg" title="Case Photo #8" data-lity><b>Case Photo #8</b></a> He was unfortunately lost to follow up thereafter and no return to play discussions were able to be had with the patient.

Author's Comments:
In general, return to work for non-athletes status post any upper extremity ray amputation is generally 9-16 weeks(1). However, this study only evaluated return to light duty and/or work not requiring extensive upper extremity activity(1). In military populations, thumb and index finger ray amputations were found to have higher rates of digital separation and longer recovery times as compared to other finger involvement (2). Additionally, single digit amputation appears to have better outcomes than multiple digit involvement(3). <br> <br> <br>Specific data for return to play for boxers following index finger ray amputation is limited. An important consideration for boxers is single ray amputation results in an expected 15 to 30 percent loss in grip and pinch strength as compared to baseline(4). Items to consider for boxers include injury severity, hand dominance, pain level, ability to defend self, safe participation for self and others. Ultimately, return to play is a highly individualized decision assessing both physical and psychological readiness to participate in combat sport.

Editor's Comments:
Hand injuries are among the most common in boxing, and a recent U.S. data from 2014-2023 found that the hand accounted for 48.3% of boxing-related upper-extremity injuries (5). This case is a great example of why sports medicine physicians should also recognize the unique infectious risk of a “fight bite” or clenched-fist injury, in which a punch striking an opponent's teeth can inoculate the MCP joint and deeper structures with polymicrobial oral flora, potentially progressing to septic arthritis, osteomyelitis, abscess formation, tissue necrosis, and ultimately amputation if diagnosis or treatment is delayed. Boxing-specific epidemiologic data on finger amputation are extremely limited, and this case highlights how minor hand wounds can occasionally have catastrophic consequences if not treated appropriately.

References:
1. Sagiv, Paul M.D.; Shabat, Shay M.D.; Mann, Mirit M.Sc.; Ashur, Haim M.D.; Nyska, Meir M.D.. Rehabilitation Process and Functional Results of Patients with Amputated Fingers. Plastic and Reconstructive Surgery 110(2):p 497-503, August 2002. <br>2. Blazar PE, Garon MT. Ray Resections of the Fingers: Indications, Techniques, and Outcomes. J Am Acad Orthop Surg. 2015 Aug;23(8):476-84. doi: 10.5435/JAAOS-D-14-00056. PMID: 26209144.\ <br>3. Matthews D, Sukeik M, Haddad F. Return to sport following amputation. J Sports Med Phys Fitness. 2014 Aug;54(4):481-6. PMID: 25034549. <br>4. Jordan JA, Polmear MM, Wells ME, Dunn JC. Traumatic Finger Amputation in the U.S. Military. Mil Med. 2024 Jan 23;189(1-2):321-325. doi: 10.1093/milmed/usac390. PMID: 36519500. <br>5. Megafu MN, Nerenberg N, Pandya H, Guerrero O, Speechley J, Osifo SE, Tornetta P 3rd, Parisien RL, Cusano A; Investigation performed by the Scientific Collaborative for Orthopaedic Research and Education (SCORE) Group. Epidemiology of Boxing-Related Upper Extremity Injuries Presenting to Emergency Departments in the United States from 2014 to 2023. J Emerg Med. 2026 Jan;80:44-50. doi: 10.1016/j.jemermed.2025.10.003. Epub 2025 Oct 14. PMID: 41270318.

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