December 25, 2023, 1930 hours
A few patients enter your “GP Super clinic” (because you’re ‘superman,’ after all) with only 40 minutes to go before the end of your shift. This time, it’s Christmas Day and you feel you’ve done your call of duty, and now just want to go home. The cases aren’t life-threatening, but each nevertheless demands your attention and due diligence.
The nurse tells you that a man in his 50s presents after dropping a table on his foot. “The foot is awful and bloodied and there’s not much we can do for it. He’ll need to go to the ED.” She asks you to see him first. So you do.
He tells you that a fold-away picnic table fell on his foot, an accident: the handle dropped off the table and it fell straight onto his toe. It happened about 1700 hours, and he bandaged the toe himself, only deciding to present because the bleeding was hard to staunch. He is otherwise well, takes no medications, has no allergies. He tells you, after questioning, that he last had a tetanus toxoid booster a year ago. He seems in good spirits.
The third toe is covered by a heavily blood-stained saline soak, and there is dried blood staining down the sole of his foot. You slowly remove the blood-stained gauze and find that the bleeding has stopped. The tuft of the third toe is swollen but not bruised, and resembles the colour of the rest of his foot. The toenail looks as though it may have been lifted off but remains steadfast against the nail bed; although loosened, it isn’t dislodged by your manoeuvre of removing the dressing. There is a very small, near-dried clot at the tip of the digit, but he tells you the bleeding came from the medial skin fold and nail fold at the base, rather than the tip of the digit. Rather than tender to touch, he says the toe feels numb when you compress the distal digit between your thumb and forefinger. You feel, and hear, no bony crepitus. You do nothing else.
How will you treat this man?
Leave him alone. In a way, he’s telling you he’s okay and wants to go home, now that the bleeding has stopped. Do you check his foot pulses? You can, but you don’t, because he is fit and well, and the table landed on the tip of his toe, shearing the nail off from the nail fold, as he surmises. “It’s good that it’s Christmas,” you quip. He doesn’t mind, and neither does his wife, who becomes animated, pleasantly so, during the interview. From here on you avoid making eye contact with her, because people have a way of trying to steal the show, and today, this is his.
So there you go. Any questions?
You prescribe oral antibiotics to cover for a compound injury, give him a referral for an X-ray, and provide some oral analgesia to take home. The wound is dressed carefully. You ask him to return in two days. You don’t even offer him a medical certificate, because it’s Christmas.
You arrange to review him, and his toe, in 48 hours. There, with the swelling down, you’ll look at the X-ray images yourself, examine his toe, and, if it’s only tenuously linked to the nail bed, remove the nail and replace it atop as a physical defence for the nail bed. If there are no signs of infection and no fracture, you’ll have him reviewed twice weekly for dressings until he can manage it himself, assuring him that, provided the germinal matrix isn’t damaged, new nail will grow out in due course.
A second look at the antibiotics
Writing this up later, I went back to the evidence on prophylactic antibiotics for exactly this kind of injury, and it doesn’t support what I did.
The key study is a systematic review and meta-analysis by Metcalfe et al., pooling four randomised controlled trials across 353 open distal phalanx fractures [1]. There was no statistically significant difference in superficial infection rates between patients given prophylactic antibiotics and those who weren’t, and there were no cases of osteomyelitis at all in the pooled dataset, including the 164 fractures that received no antibiotics. The review’s conclusion was direct: the focus of treatment should be on prompt irrigation and debridement, not prophylactic antibiotics.
That finding applies to open injuries. Looking back at this case, it isn’t even clear his injury met that bar. The nail was loosened but still attached, there was no crepitus, and I hadn’t yet seen the X-ray when I made the prescribing decision. If the nail bed and skin envelope were genuinely intact, the injury may not have been open at all, in which case the antibiotic question doesn’t really apply either way. One hand-surgery text puts it plainly: recent evidence suggests prophylactic antibiotics aren’t necessary unless the nail plate is actually removed [2], which his wasn’t.
In hindsight, “compound injury, therefore antibiotics” was reflexive reasoning at the tail end of a long shift on Christmas Day, understandable, but not what the evidence actually asks for. Worth naming, since the point of a case log isn’t just the calls that turn out fine, it’s the ones worth doing differently next time.
References
- Metcalfe D, Aquilina AL, Hedley HM. Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-analysis. J Hand Surg Eur Vol. 2016;41(4):423-430.
- Rozmaryn LM. Distal Phalangeal and Fingertip Injuries. In: Skeletal Trauma of the Upper Extremity.