What is the best course of treatment for a patient with a small fracture on their left thumb, accompanied by a nail avulsion injury, experiencing dry skin around the nail?

Management of Thumb Fracture with Nail Avulsion Injury

For a patient with a small thumb fracture and nail avulsion injury with dry skin around the nail, proper wound care with saline irrigation and amoxicillin-clavulanate antibiotic therapy is recommended as first-line treatment. 1

Assessment

• The patient has a small fracture on the left thumb with an associated nail avulsion injury that occurred on October 15 2
• The patient has been changing the dressing independently, and the skin is beginning to heal around the injured area 2
• The wound is not draining, suggesting absence of active infection, but the skin around the nail is becoming dry 2, 3
• Nail avulsion injuries with associated fractures have a higher risk of complications including infection and nail deformities 2

Treatment Plan

Wound Management

• Thoroughly irrigate the wound with sterile normal saline without additives to remove any debris 4
• Avoid using iodine or antibiotic-containing solutions for irrigation as they may impair healing 4
• Apply a non-adherent dressing to the nail bed area to protect the exposed tissue 1
• Change dressings daily using sterile technique until the area is completely healed 4

Antibiotic Therapy

• Initiate oral amoxicillin-clavulanate (875/125 mg twice daily for 7 days) as first-line therapy due to its broad coverage against common wound pathogens 1
• For penicillin-allergic patients, doxycycline (100 mg twice daily for 7 days) is an appropriate alternative 1
• Antibiotics are indicated due to the combination of open fracture and nail avulsion, which increases infection risk 4, 2

Fracture Management

• Immobilize the thumb with a thumb spica splint to protect the fracture and facilitate healing 4
• Elevate the injured hand, especially if swollen, to accelerate healing 4
• Follow up within 7 days to assess wound healing and fracture alignment 4

Skin Care

• Apply hypoallergenic moisturizing cream to the dry skin around the nail bed once daily 4
• Avoid greasy creams which might facilitate development of folliculitis due to their occlusive properties 4
• Keep the area clean and dry after moisturizing 4

Monitoring and Follow-up

• Schedule follow-up within 7 days to assess wound healing and evaluate for signs of infection 4
• Monitor for complications including:
  • Infection (increased pain, redness, warmth, drainage) 2, 3
  • Nail deformities (split nail, hook nail) 2
  • Fingertip sensitivity 2
  • Non-adherence of new nail plate 2
• Complete healing of nail bed injuries typically takes 3-4 months 3

Common Pitfalls to Avoid

• Delaying antibiotic administration, which significantly increases infection risk 5
• Using first-generation cephalosporins alone for contaminated wounds, as they have poor activity against some common wound pathogens 1
• Closing infected wounds, which can lead to abscess formation 4
• Aggressive debridement, which can impair skin closure and healing 4
• Using antiseptics or soap additives for wound irrigation instead of simple saline solution 4

Patient Education

• Explain proper wound care and dressing change techniques 4
• Advise on signs of infection that require immediate medical attention 2
• Inform that complete nail regrowth may take 3-6 months 3
• Recommend keeping the hand dry and avoiding activities that could cause further trauma to the injured area 4