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Traumatic Amputation of Finger From an Alligator Snapping Turtle Bite

  • Robert D. Johnson
    Correspondence
    Corresponding author: Robert D. Johnson MD, The University of Oklahoma Health Sciences Center, Section of Pediatric Emergency Medicine, 940 NE 13th Street, 2G-2300, Oklahoma City, OK 73104
    Affiliations
    University of Oklahoma Health Sciences Center, The Children’s Hospital, Section of Pediatric Emergency Medicine, Oklahoma City, OK
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  • Cynthia L. Nielsen
    Affiliations
    University of Oklahoma Health Sciences Center, The Children’s Hospital, Section of Pediatric Emergency Medicine, Oklahoma City, OK
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Published:April 22, 2016DOI:https://doi.org/10.1016/j.wem.2016.02.003
      Legend states that the alligator snapping turtle (Macrochelys temminckii) should be handled with extreme caution as it has jaw strength powerful enough to bite a wooden broomstick in half. Tales of bite injuries from what is the largest freshwater turtle in North America exist anecdotally, yet there are few descriptions of medical encounters for such. The risk of infection from reptilian bites to the hand in an aquatic environment warrants thorough antibiotic treatment in conjunction with hand surgery consultation. We present the first case report of a near total amputation of an index finger in an adolescent boy who had been bitten by a wild “gator snapper.”

      Key words

      Introduction

      The alligator snapping turtle (Macrochelys temminckii), also known as the “gator snapper,” is the largest freshwater turtle in North America (Figure 1).
      • VanDeWalle T.
      • Collins S.
      Turtles in Your Pocket: A Guide to Freshwater and Terrestrial Turtles of the Upper Midwest.
      It inhabits the deeper waters of lakes, swamps, and river systems that drain into the Gulf of Mexico (Figure 2). It is readily distinguished from the common snapping turtle (Chelydra serpentina) by its large head and 3 distinct rows of prominent spiked scutes running the length of its carapace.

      Fuller P, Somma LA. Macrochelys temminckii. USGS Nonindigenous Aquatic Species Database, Gainesville, FL. 2015. Available at: http://nas.er.usgs.gov/queries/FactSheet.aspx?SpeciesID=1227. Accessed November 25, 2015.

      Like many aquatic Chelonians, it is a predator that responds unpredictably and with aggression when handled.
      • Vigani A.
      Chelonia (tortoises, turtles and terrapins).
      Southern folklore weaves tales of the turtle’s bite as being powerful enough to split a broom handle in two, and the traumatic amputation of fingers from an alligator snapping turtle bite has been purported in legend as well as in the lay press.
      • Goode G.B.
      Natural history of useful aquatic animals, section 1.
      • Holt E.G.
      Alabama reptiles.
      • Shufeldt R.W.
      Turtles, terrapins, and tortoises of the United States: an important branch of the Reptilia.
      Figure 1.
      Figure 1Macrochelys temminckii. Courtesy of the US Fish and Wildlife Service.
      Figure 2.
      Figure 2Map of Macrochelys temminckii distribution. Courtesy of the US Geologic Survey; August 22, 2015.
      We present the case of a 15-year-old boy who sustained a near total amputation of his second digit from an alligator snapping turtle (M temminckii) bite, which required emergent antibiotics and surgical formalization. The circumstances in which the event occurred share many characteristics of previously reported wildlife encounter–related injuries in the Southern United States,
      • Kaar C.R.
      • Plikaitis C.
      • Germino K.W.
      • Nakanishi A.K.
      Catfish noodling forearm injury requiring urgent surgical treatment: a case report and review of the literature.
      but in this case with permanently disfiguring sequelae. Wounds to the hand from wild animal bites as well as those sustained in aquatic environments are notorious for producing infections that are polymicrobial, highly pathogenic, and potentially life-threatening.
      • Noonburg G.E.
      Management of extremity trauma and related infections occurring in the aquatic environment.

      Kimberlin DW, ed. Recommendations for care of children in special circumstances—bite wounds. In: Red Book: 2015 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2015:205–210

      • McNamara R.
      • DeAngelis M.
      Laceration repair with sutures, staples, and wound closure tapes.
      Aggressive management of such trauma including wound care and antibiotic prophylaxis is implicated. This is the first case of such an injury we know of to be reported in the medical literature.

      Case Report

      A 15-year-old right-hand-dominant boy was transferred to our Pediatric Emergency Department from a community hospital for a traumatic injury sustained the same evening in late April. A self-described naturalist, he spotted an alligator snapping turtle in a stream near his home with an estimated 76-cm width by personal report as the specimen was held relative to his torso. He positively identified the species as M temminckii based on specific features including 3 distinct rows of spikes on the carapace. He had lifted the animal from its aquatic environment and endured the near total loss of his left index finger when the turtle snapped at him suddenly with a single bite during his attempt to photograph the animal. He stated that the turtle consumed his finger and neither the turtle nor the digit could be recovered. He applied direct pressure and sought immediate medical attention while achieving hemostasis. At an outside facility he was given a tetanus booster and a dose of cefazolin (1 g) before transfer to our institution.
      He arrived with vital signs significant for tachycardia (pulse, 115 beats/min) and a complaint of pain, but was otherwise hemodynamically stable (blood pressure, 124/86 mm Hg; temperature, 36.8°C; respiratory rate, 18 breaths/min; oxygen saturation, 98%). Physical examination revealed an obvious amputation of his left second digit with only the most proximal 1 cm remaining of the proximal phalanx (Figure 3, Figure 4). The extremity was otherwise neurovascularly intact with a slight range of motion limitation in the remaining digits seemingly because of local edema and pain. Radiographic examination revealed an intact metacarpophalangeal joint and an impressively precise, transverse amputation at the proximal phalanx and no other fracture or foreign body (Figure 5, Figure 6).
      Figure 3.
      Figure 3Injury photograph of the hand. Courtesy of J. Andrew Jensen, MD.
      Figure 4.
      Figure 4Injury photograph of the hand, preoperatively. Courtesy of J. Andrew Jensen, MD.
      Figure 6.
      Figure 6Radiograph of the hand (lateral view).
      Orthopedic hand service was consulted, and the patient was treated with intravenous (IV) fluids and fentanyl, which provided adequate analgesia. Antibiotic therapy was initiated, consisting of ampicillin/sulbactam (3 g), gentamicin sulfate (60 mg), and levofloxacin (750 mg). The wound was copiously irrigated with normal saline solution and dressed loosely with Xeroform, Kerlix, and an ACE bandage pending formalization, and the patient was admitted for operative intervention, which took place the next morning. Surgical revision was determined to be the only option for repair as the digit was lost. The proximal phalanx was refined, and skin edges were reapproximated around the remaining bony stump. Operative course was without complication, and the patient was discharged on the day of surgery. During the next 8 weeks, the patient reported difficulty with activities of daily living secondary to handled objects becoming caught on the remaining stump or simply falling through his hand. As a result of these complications, the patient elected to undergo Ray amputation of the second metacarpal as an additional procedure. Although not a common procedure, it is stated to often improve hand function especially in the setting of a functionless, residual digit.
      • Jebson P.J.
      • Louis D.S.
      Ray amputation with and without digital transposition.

      Discussion

      The alligator snapping turtle is among the largest of nearly 300 Chelonians, and individuals may reach a mass of 113 kg.
      • Riedle J.D.
      • Shipman P.A.
      • Fox S.F.
      • Leslie Jr, D.M.
      Status and distribution of the alligator snapping turtle, Macrochelys temminckii, in Oklahoma.
      Although widely distributed in the Southern United States, the species is considered “vulnerable” owing to low population densities, and being aggressive predators, human interaction with them is discouraged.
      • Ernst C.H.
      • Lovich J.E.
      Turtles of the United States and Canada.

      Tortoise & Freshwater Turtle Specialist Group. 1996. Macrochelys temminckii. The IUCN Red List of Threatened Species. 1996. Available at: http://www.iucnredlist.org/details/12589/0. Accessed November 30, 2015.

      If animal handling is necessary, creature-specific methods are suggested by veterinarians for the protection of both the handler and animal: the alligator snapper is held with gloved hands on specific, lateral portions of the carapace away from the head, followed by the turtle being allowed to bite down on an object such as a PVC pipe (Figure 7).
      • Vigani A.
      Chelonia (tortoises, turtles and terrapins).
      Figure 7.
      Figure 7Illustration of proper handling. Courtesy of Animal and Wildlife Immobilization and Anesthesia. 2nd ed. Ames, IA: John Wiley and Sons; 2014.
      Unfortunately, children are more likely to be bitten by animals and sustain more severe injuries when bitten.
      • Marano N.
      • Galland G.G.
      The pre-travel consultation: counseling & advice for travelers, animal-associated hazards.
      As many as 1% of all pediatric visits to emergency departments during summer months are for treatment of bite wounds, many occurring on the hands.

      Kimberlin DW, ed. Recommendations for care of children in special circumstances—bite wounds. In: Red Book: 2015 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2015:205–210

      • McNab I.S.
      Hand infections.
      Finger amputations from bite injuries are thankfully rare, with frequencies of 0.75% among all finger injuries reported for persons 15 years of age and older.
      • Conn J.M.
      • Annest J.L.
      • Ryan G.W.
      • Budnitz D.S.
      Non–work-related finger amputations in the United States, 2001–2002.
      In a review of isolated finger injuries in 283 children, only 6% were reported as amputations with none occurring at the proximal phalanx, making this case especially unusual.
      • Doraiswamy N.V.
      • Baig H.
      Isolated finger injuries in children—incidence and aetiology.
      Because of the vulnerability of multiple, small compartments and joints, bites to the hand are considered to be at especially high risk for infection.
      • Evgeniou E.
      • Markeson D.
      • Iyer S.
      • Armstrong A.
      The management of animal bites in the United Kingdom.
      It is generally accepted that the bacteriology of bite wounds sustained from exotic animals is inclusive for the oral flora of the creature.
      • Goldstein E.J.
      Bite wounds and infection.
      As many as 90% of turtles are known to harbor Salmonella species as a component of their enteric microflora, making the handling of both pet or wild turtles an infection risk from either casual contact or bite injuries.
      • Chiodini R.J.
      • Sundberg J.P.
      Salmonellosis in reptiles: a review.
      • Lamm S.H.
      • Taylor Jr, A.
      • Gangarosa E.J.
      • et al.
      Turtle-associated salmonellosis. An estimation of the magnitude of the problem in the United States, 1970–1971.
      • Mermin J.
      • Hoar B.
      • Angulo F.J.
      Iguanas and Salmonella marina infection in children: a reflection of the increasing incidence of reptile-associated salmonellosis in the United States.
      • Warwick C.
      • Lambiris A.J.
      • Westwood D.
      • Steedman C.
      Reptile-related salmonellosis.
      In addition, wounds occurring in aquatic environments expose victims to a milieu of invasive aerobic and anaerobic bacteria, and such wounds often yield halophilic bacteria and waterborne pathogens such as Vibrio, Plesiomonas, and Erysipelothrix organisms, notwithstanding other reptile-associated zoonoses including Mycobacteria, Pseudomonas, Aeromonas, and Proteus species.
      • Noonburg G.E.
      Management of extremity trauma and related infections occurring in the aquatic environment.

      Grange, JM, Davies, PDO. Disease caused by environmental mycobacteria. In: Warrell DA, Cox TM, Firth JD, Ogg GS, eds. Oxford Textbook of Medicine. 5th ed. Oxford, UK: Oxford University Press; 2010:section 7.6.26

      • Abrahamian F.M.
      • Goldstein E.J.
      Microbiology of animal bite wound infections.
      Immediate care of an amputation injury requires direct pressure to the extremity. Care of the amputated digit(s) warrants the digit(s) to be wrapped in moist gauze and placed in a sealed bag on ice but not in direct contact with such to avoid causing a frostbite injury and to increase the chance of a successful revascularization or replant procedure.
      • Roushdi I.
      • Cumberworth J.
      • Harry L.E.
      • Rogers B.A.
      Power tool injuries to the hand and wrist.
      Small lacerations and punctures may be treated on an outpatient basis; however, debridement of wound edges may be necessary to allow for adequate irrigation, which should be performed under high pressure, a modality that requires appropriate analgesia in the emergency department or potentially operating room to be performed effectively.
      • Evgeniou E.
      • Markeson D.
      • Iyer S.
      • Armstrong A.
      The management of animal bites in the United Kingdom.
      As a result, this type of injury should be managed aggressively with early consultation of a hand surgeon.
      • Cheung K.
      • Hatchell A.
      • Thoma A.
      Approach to traumatic hand injuries for primary care physicians.
      All bite wounds warrant consideration of tetanus status regardless of the offending species involved. It is suggested that 3 to 5 days of broad-spectrum, empiric antibiotic therapy be given for high-grade, open injuries, to be started in the emergency department. For gram-positive coverage, administration of a first-generation cephalosporin given IV every 8 hours until 24 hours after wound closure, with levofloxacin and gentamicin for gram-negative coverage, is recommended.
      • Yaffe M.A.
      • Kaplan F.T.
      Agricultural injuries to the hand and upper extremity.
      Unfortunately, clinical trial data are lacking and fluoroquinolones are not approved for this indication in children, for which either ampicillin/sulbactam or piperacillin/tazobactam, in conjunction with gentamicin, is recommended.

      Kimberlin DW, ed. Recommendations for care of children in special circumstances—bite wounds. In: Red Book: 2015 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2015:205–210

      To address the risk of clostridial contamination in the setting of certain outdoor injuries, ampicillin, penicillin, or doxycycline has also been encouraged.
      • Angoules A.G.
      • Lindner T.
      • Vrentzos G.
      • Papakostidis C.
      • Giannoudis P.V.
      Prevalence and current concepts of management of farmyard injuries.
      • Zalavras C.G.
      • Marcus R.E.
      • Levin L.S.
      • Patzakis M.J.
      Management of open fractures and subsequent complications.
      • Diaz J.H.
      • Lopez F.A.
      Skin, soft tissue and systemic bacterial infections following aquatic injuries and exposures.
      For penicillin-allergic patients, vancomycin with a fluoroquinolone provides excellent coverage.
      • Yaffe M.A.
      • Kaplan F.T.
      Agricultural injuries to the hand and upper extremity.
      Patients with overtly infected wounds, which may range from cellulitis to life-threatening necrotizing fasciitis, should undergo wound cultures and be started on antibiotics in the emergency department often to be continued in an inpatient setting as wound severity dictates, possibly for 10 to 14 days of therapy.
      • Finkelstein R.
      • Oren I.
      Soft tissue infections caused by marine bacterial pathogens: epidemiology, diagnosis, and management.

      Levine BJ, ed. EMRA Antibiotic Guide. 16th ed. Irving, TX: Emergency Medicine Residents Association; 2015:78–79

      Conclusions

      The management of animal bites, including those from reptiles, should begin with a customary Advanced Trauma Life Support (ATLS) style assessment. Immediate goals include those necessary to achieve hemostasis, resuscitation via fluids and blood products, and analgesia. A thorough physical examination is required to assess for injuries to soft tissue, vasculature, and nerves as well as to evaluate for the presence of foreign bodies, fractures, and dislocations. This should be augmented with radiographs or ultrasound.
      Animal bites, when powerful enough to sever bones and enter joint capsules, require expeditious use of IV antibiotics, and the bacterial milieu known to exist in the setting of injury necessitates a broad approach to antibiotic coverage. Surgical consultation and operative intervention are integral in minimizing infectious risk and maximizing future function. Our patient presented with a unique injury previously suggested in folklore with complete loss of an index finger from a large alligator snapping turtle. This case confirms legend and reaffirms the wisdom that such animals are best left undisturbed.

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