What's the best course of action for a patient with a partially lifted pinkie toenail due to a traumatic weight rack injury, presenting with mild swelling and redness?

Management of Traumatic Partial Toenail Avulsion

For a partially lifted pinkie toenail with mild swelling and redness following trauma, thoroughly irrigate the wound with running tap water or sterile saline, apply topical povidone-iodine 2% or antibiotic ointment, cover with an occlusive dressing, and monitor closely for signs of infection requiring medical evaluation. 1

Immediate Wound Care

The first priority is thorough wound irrigation to prevent infection:

• Irrigate the wound extensively with running tap water or sterile saline until no debris or foreign matter remains visible 1
• Running tap water is as effective as sterile saline for wound cleansing and infection prevention 1
• Remove any obvious debris from the weight rack injury during irrigation 1

After irrigation, apply topical antimicrobial treatment:

• Apply topical povidone-iodine 2% to the nail fold and surrounding tissue 1
• Alternatively, topical antibiotic ointment or cream can be used if the patient has no known allergies 1
• These agents help prevent secondary bacterial infection, which occurs in up to 25% of nail trauma cases 1

Dressing and Protection

Cover the wound appropriately to promote healing:

• Apply an occlusive dressing after topical treatment to promote wound healing and reduce infection risk 1
• The dressing protects the disrupted nail barrier that has been breached by trauma 2, 3
• Ensure the patient wears comfortable, well-fitting shoes to avoid repeated trauma 1

Critical Monitoring Parameters

Watch for signs requiring immediate medical evaluation:

• Redness spreading beyond the immediate injury site 1
• Increasing swelling or pain 1
• Foul-smelling wound drainage 1
• Fever development 1
• Purulent discharge or abscess formation 2, 3

If any of these signs develop, remove the dressing, inspect the wound, and obtain medical care immediately 1. Secondary bacterial infection can progress to acute paronychia requiring oral antibiotics or surgical drainage 2, 3.

Nail Management Considerations

Regarding the partially lifted nail itself:

• Do not attempt to remove the partially attached nail if it remains mostly adherent 1
• The attached portion provides natural protection to the underlying nail bed 4
• If the nail becomes completely detached or develops an abscess underneath, medical evaluation for possible nail avulsion is indicated 1, 3

Daily wound care should include:

• Gentle cleansing with water and mild soap 1
• Reapplication of topical povidone-iodine 2% or antibiotic ointment 1
• Fresh occlusive dressing changes 1
• Application of topical emollients to surrounding tissues to maintain skin barrier 1

Common Pitfalls to Avoid

Do not apply the following interventions:

• Avoid cutting or trimming the partially lifted nail edge, as this may worsen trauma 1
• Do not apply ice directly to the injury, as this can cause tissue ischemia 1
• Avoid tight or constricting footwear that increases pressure on the injured toe 1
• Do not ignore progressive symptoms, as delayed treatment of infection increases morbidity 2, 3

The key distinction here is that this is acute traumatic nail injury, not chronic paronychia or ingrown toenail, so aggressive interventions like phenol matricectomy or nail avulsion are not indicated unless infection develops or the nail becomes completely detached 2, 3, 5.