Contaminated hand laceration with unknown tetanus status

(a) Structured wound assessment and high-risk features (4 marks).

Assess using MEAT:

• Mechanism — a laceration from a sharp object (barbed wire) but with a crush element from the wire pull; predictable contamination with soil and organic material (the vector for Clostridium tetani spores).
• Examination — depth extends to partial extensor tendon involvement of the middle finger (visible in the wound bed); contamination with soil and grass; explore for retained foreign body (wire fragment, grass) under local anaesthesia with good lighting and image if glass or metal is suspected. Neurovascular documented and intact — radial and ulnar pulses, capillary refill under 2 seconds, symmetrical two-point discrimination on all digits; tendon tested through full active range of motion against resistance — he can flex and extend all fingers, but a partial extensor tendon laceration of the middle finger is confirmed on exploration (a hand-surgery referral finding).
• Age — 6 hours since injury; within a window where the closure decision integrates age with contamination and host rather than a rigid golden-period clock.
• Type / host — soil and organic contamination (dirty wound class); high-risk host with type 2 diabetes (HbA1c 78 mmol/mol, poorly controlled) and unknown tetanus status (likely unvaccinated, immigrated from a region with low immunisation coverage).

The high-risk features are: dirty/contaminated wound class, soil contamination (tetanus vector), hand location, partial extensor tendon injury, diabetic host, and unknown tetanus status.^[3]

(b) Management — irrigation, debridement, tetanus prophylaxis, closure decision (8 marks).

• Analgesia — local anaesthesia per the local wound-care protocol (after the neurovascular and tendon exam is documented) or a regional block given the partial tendon injury.
• Irrigation — copious normal saline before any closure decision (tap water equivalent: 3.5 vs 6.4 percent double-blind, 4 vs 3.3 percent multicentre); 20-mL-plus syringe for deep wounds.
• Debridement — excise obviously devitalised tissue to a clean margin; remove all soil, grass and any wire fragment under direct vision. Re-explore to confirm no retained foreign body (OR 2.6 for infection).
• Tetanus prophylaxis — soil-contaminated wound in a patient with unknown status. Apply the ACIP wound-management indication: Td or Tdap where Td alone was previously recommended, including catch-up from age 7 with incomplete or unknown history — with the 5-dose DTaP plus adolescent Tdap schedule as the background frame. Document the product, dose, route, site and the reasoning.
• Partial extensor tendon injury — refer to hand surgery; a partial tendon laceration seen in the wound bed is not repaired or primarily closed in the ED. The wound over the tendon is left open or managed by delayed primary closure.
• Closure decision — given the contaminated wound, the partial tendon injury and the diabetic host, this wound is NOT closed primarily. Manage by delayed primary closure — dress the wound open with a non-adherent dressing, arrange review, and close if clean at the review visit. Closing now would trap residual soil bacteria in a high-risk host and over an injured tendon.

(c) Antibiotic prophylaxis, disposition and safety-netting (3 marks).

• Antibiotic prophylaxis — indicated because this is a contaminated wound in a diabetic (high-risk host) with a partial tendon injury. per local protocol for contaminated wounds in high-risk hosts — diabetes (OR 6.7 / RR 2.70), contamination (RR 2.0) and foreign bodies (OR 2.6) each independently raise infection risk. This is NOT a bite wound.
• Disposition — refer to hand surgery (in hours) for the partial extensor tendon injury; arrange a 48-hour wound review for signs of infection (this is a high-risk wound). Treat tetanus prophylaxis as above. Check renal function and glycaemic control given the HbA1c. The wound is dressed open with a non-adherent dressing and a bandage; splint in a position of function if over a joint.
• Safety-net advice — return immediately for spreading redness, increasing pain, fever, pus, a cold or numb limb, or difficulty moving the fingers. Counsel on the risk of infection and tendon dysfunction, the need for the 48-hour review and hand-surgery follow-up, and the importance of diabetic control for wound healing.