Clenched Fist

Clenched Fist
A clenched fist injury (CFI) is a bite wound on the hand, caused when a person's closed fist strikes the teeth of another person, usually in the course of a fight. CFIs are sometimes referred to as closed fist injuries or fight bites.
Clenched fist injuries are most common over the metacarpo phalangeal joint. Their appearance is deceptive because they do not bleed heavily and the underlying injury is hidden by soft tissue when the patient opens his hand and straightens the injured finger. CFIs can, however, have serious consequences, including infection, cellulitis , inflammation of the bone or bone marrow ( osteomyelitis ), septic arthritis, and inflammation of the sheaths covering the tendons of the hand (tenosynovitis). These may lead to permanent loss of function or amputation .
Most CFIs result in tissue injury due to the force of impact, ragged-edged tears in the skin resulting from contact with the teeth, and contamination of the wound by the bacteria in human saliva. As the patient opens his hand, the skin of the finger is pulled backward over the deeper part of the wound, thus sealing bacteria within the injured tissue. This sealing of the wound by normal motions of the finger is the reason why clenched fist injuries have the highest rate of infection of any human bite. The rate of infection of clenched-fist injuries varies from 15–50%.
The causes of CFIs include fighting and other forms of aggressive behavior, often combined with drug or alcohol consumption.
The symptoms of clenched fist injury include pain in the affected part of the hand and some stiffness of the injured finger with limitation of movement. If the patient has delayed getting medical treatment, there may be evidence of infection, including swelling, redness, and suppuration (a discharge of pus). The skin around the wound will be warm to the touch and fever may be present.
Diagnosis of clenched fist injuries is usually made on the basis of the location of the injury and x-ray findings. The most common finding in CFI x rays is soft tissue swelling, but the x rays may also reveal air pockets in deep tissues or the joint spaces, fragments of teeth, fracture lines in the bones, or small loose bone chips. Diagnosis is often complicated by the fact that the patient will be reluctant to admit how the injury happened. The treating physician must maintain a high level of suspicion and often ask directly.
Treatment of clenched fist injuries is complicated by several factors. One factor is the anatomical structure of the human hand, which contains many small closed spaces that make it easy for infection to spread and persist. Another is the number of disease-causing bacteria transmitted by human bites; at least 42 different species have been identified. In addition, CFIs typically do not receive immediate treatment because the patient is concerned about legal consequences. The longer the delay, the higher the chances of infection and permanent damage to the hand. Patients who wait longer than 24 hours to seek treatment or have signs of infection or damage to the tendon, joint capsule, or bones are usually referred immediately to a doctor who specializes in hand surgery.
The first step in treatment of clenched fist injury is irrigation, a procedure by which the wound is flushed with a stream of water under high pressure or with an antiseptic solution. Incision and drainage of the wound (I&D) may be required as well as debridement , the surgical removal of dead tissue and foreign objects from a wound. Careful examination of the depth of the wound is essential to proper treatment. The surgeon may need to enlarge the sides of the wound in order to make an accurate evaluation. The patient will be asked to move the affected joint through its full range of motion so that the surgeon can determine whether the tendon or joint capsule has been damaged. Following these procedures, the surgeon will pack the wound and put the hand in a splint. Bite wounds are never sutured (sewn shut) because of the possibility of enclosing bacteria inside the injury. After 24 hours, the packing will be removed and the hand reexamined for signs of infection.
If the wound has become infected, the patient is usually hospitalized and given parenteral (injectable) antibiotics . The wound is irrigated and examined to determine the extent of the injury. Cultures are taken for both aerobic (requiring air or oxygen to live) and anaerobic (not requiring air or oxygen) species of bacteria. The cultures should be taken from areas deep in the wound rather than from the surface for greater accuracy. Tetanus toxoid should be given if the patient has not been immunized within the last 10 years. The patient should also receive treatment and follow-up for the rare possibility of HIV and hepatitis transmission. Although no well-documented cases of HIV transmission by human bites exist as of 2001, the potential for transmission by this route is still present.
Infected clenched fist injuries usually contain several disease-causing bacteria, the most common being Streptococcus pyogenes , Staphylococcus aureus , Bacteroides sp. , Peptostreptococcus sp. , and Eikenella corrodens . Broad-spectrum antibiotics are usually given. Uninfected and relatively superficial CFIs may be treated with oral penicillin plus dicloxacillin or Augmentin. For infected CFIs, parenteral penicillin G is usually given together with nafcillin or cefuroxime. CFIs infected by drug-resistant strains of S. aureus may require treatment with vancomycin.
The prognosis depends on the patient's underlying state of health and compliance with treatment; depth of the wound; the involvement of the joint capsule or tendon; and the length of time before the wound is treated. The more superficial the wound and the faster the treatment, the better the prognosis.
The best way to prevent clenched fist injuries is to avoid fist fights, intoxication, and association with people who practice these forms of behavior. If involved in a fistfight, people should avoid directing punches at their opponent's mouth. The next best preventive measure is to get medical treatment at once for a clenched-fist injury.
Jacobs, Richard A., MD. "Animal & Human Bite Wounds." In "General Problems in Infectious Diseases." Current Medical Diagnosis & Treatment 2001 . 40th edition. Ed. L. M. Tierney, Jr., MD, et al. New York: Lange Medical Books/McGraw-Hill, 2001.
Taylor, Mark D., MD, and Samuel E. Wilson, MD. "Bacterial Diseases of the Skin." In Conn's Current Therapy 2001 , ed. Robert E. Rakel, MD, and Edward T. Bope, MD. Philadelphia: W. B. Saunders Company, 2001.
Berlet, Greg, et al. "Clenched-fist injury complicated by methicillin-resistant Staphylococcus aureus ." Canadian Journal of Surgery/Journal canadien de chirurgie 40 (4) (August 1997): 313-314.
Massachusetts College of Emergency Physicians (MACEP). P. O. Box 296, Swansea, MA 02777. (508) 643-0117. Fax:(508) 643-0141.
Antibiotic —A chemical substance produced by a microorganism which can inhibit the growth of or kill other microorganisms.
Debridement— Surgical removal of damaged tissue and foreign objects from a wound.
I&D —Incision and drainage of a wound.
Irrigation —Cleansing a wound with large amounts of water and/or an antiseptic solution.
Parenteral —Administered inside the body but outide the digestive tract.
Tetanus toxoid —Tetanus toxoid is a vaccine used to prevent tetanus (also known as lockjaw).

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This undated image obtained from Twitter on May 7, 2016 shows 16 black, female cadets in uniform with their fists raised while posing for a photograph at the United States Military Academy at West Point, N.Y. The U.S. Military Academy has launched an inquiry into the image that has spurred questions about whether the gesture violates military restrictions on political activity.
Democratic presidential candidate Sen. Bernie Sanders raises his fist to acknowledge the crowd before he speaks during an election night campaign event at the Big Sandy Superstore Arena, April 26, 2016, in Huntington, W.Va.
On Oct. 16, 1968, Tommie Smith, top center, and John Carlos, top right, extend their gloved fists in a victory stand protest against unfair treatment of blacks in the U.S. during the playing of the "Star-Spangled Banner", after Smith received the gold and Carlos the bronze for the 200-meter run at the Summer Olympic Games in Mexico City.
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Look at the history of the clenched fist as a symbol of protest and solidarity.
— -- A national debate about race and proper military behavior broke out this week after sixteen African-American West Point cadets posed with raised fists for a pre-graduation picture.
An inquiry at the academy found the cadets didn't violate any existing military rules that limit political activity. But the fists-up image led some to question if the woman expressed support for the Black Lives Matter movement, which is rooted in protests over what critics say is the excessive use of police force against African-American men. The picture, widely circulated on social media, was not intended as a political statement, according to West Point's superintendent, Lt. Gen. Robert Caslen Jr., who sent a letter to students.
He did say the cadets showed "a lapse of awareness in how symbols and gestures can be misinterpreted and cause division."
The gesture has a long history as a symbol of defiance and solidarity. Athletes have sometimes used a clenched-fist gesture as a political statement.
Here's a closer look at the gesture.
The gesture has a long history as a symbol of defiance and is often associated with both left-wing politics as well as oppressed groups.
In the 1960s, the black power movement used it as a gesture to represent the struggle for civil rights. The Black Panther Party used it as a symbol of resistance.
In one iconic image, American sprinters Tommie Smith and John Carlos raised their fists during a medal ceremony at the 1968 Mexico City Olympic Games. Later, in an autobiography, Smith said he saw it as a "human rights salute."
Sometimes a fist raised in the air is simply a fist raised in the air, even when political figures use the gesture.
When South African civil rights activist Nelson Mandela was released from prison in 1990, he and his wife both raised a fist in triumph. After 27 years in jail, he had become a symbol of the struggle against apartheid in South Africa.
Vermont Sen. Bernie Sanders has used the symbol on the presidential campaign trail this year while running for the Democratic nomination. He and others are using the fist pump to bring on cheers from voters and supporters.
Sanders has often responded to the crowd and shows his fist as if to say “fight the good fight” and often does it when he appears on stage to show solidarity with the crowd.
While raised fists have frequently appeared in the Black Lives Matter movement, it isn't the only symbol used.
It was used after the August 2014 death of unarmed teen Michael Brown in Ferguson, Missouri, to represent the "hands up, don't shoot" pose and has since been used at rallies and in social media posts.
Defenders of the West Point cadets have said the women were celebrating their impending graduation, not trying to make a political statement.
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Clenched fist syndrome: a case report

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Journal of Medical Case Reports

volume 12 , Article number: 168 ( 2018 )
Cite this article

The clenched fist syndrome/psycho-flexed hand, first described in the early 1980s, has not yet entered the major psychiatric textbooks. Curiously, the phenomenon has been illuminated mainly in journals and textbooks on hand surgery. There is a need to examine, describe, and understand this syndrome from a psychiatric perspective.
We present a case we encountered in an intensive care unit. A 60-year-old white man with schizophrenia, cerebrovascular disease, diabetes mellitus type 2, and peripheral neuropathy, developed rather acutely bilateral clenched fists in the aftermath of a traumatic dislocated hip fracture that was operated on. He later died due to complications from the surgical procedure.
While this was a complex case with some clinical uncertainty regarding the cause of our patient’s symptoms, we conclude that psychological processes were central to the development of his clenched fists. The phenomenon of clenched fists and our case are discussed with reference to the accumulated literature on psychogenic hand disorders and the International Statistical Classification of Diseases and Related Health Problems , 10th version. The nosological status appears to be obscure. This case presentation is a first step in increasing the understanding of this syndrome from a psychiatric perspective.
Medical disorders mimic psychiatric ones, and vice versa. In an often quoted article, the Canadian psychiatrist Erwin K. Koranyi wrote: “No single psychiatric symptom exists that cannot at times be caused or aggravated by various physical illnesses” [ 1 ]. The causality can go in the opposite direction as well. Often physical symptoms and signs are caused or aggravated by psychological factors or psychiatric illness. And sometimes the psychiatric symptoms are less prominent than the physical signs. In conversion or dissociative disorders, patients can have various physical signs, for example paralysis or anesthesia, and still be unconcerned about their impairment, that is, feel no or only minor subjective suffering. This phenomenon or sign of calm acceptance has been called “ la belle indifférence .” Its presence can be helpful in the diagnostic work-up although some researchers have disputed its assumed high prevalence in conversion disorders [ 2 ].
We encountered a patient with clenched hands that challenged our diagnostic skills. As the literature on the subject is parsimonious, we feel obliged to report our case to the medical community. Clinical case reports can be very useful in detecting rare disorders and generating hypotheses and may give an in-depth understanding of significant educational value. The case report genre appears to be the most appropriate method for conveying our observations [ 3 , 4 , 5 ]. The case report follows the CARE guideline
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