How to treat a partial toenail avulsion (partial removal of the toenail) with pain, but no signs of infection, in a patient who has not used any pain relief or treatment, and needs a medical certificate for work?

Management of Partial Toenail Avulsion with Pain but No Infection

For this clean, non-infected partial toenail avulsion with pain, provide immediate pain relief with oral analgesics (NSAIDs or acetaminophen), perform gentle cleaning with saline, apply a simple non-adherent dressing, and advise proper footwear while monitoring for signs of infection over the next few days.

Immediate Pain Management

• Initiate oral analgesics immediately for pain control, as the patient has not yet used any pain relief 1
• NSAIDs (ibuprofen) or acetaminophen are appropriate first-line options for acute traumatic nail injury pain 1
• Pain should improve significantly within 2-4 days with proper management 2

Wound Care for Clean, Non-Infected Injury

Since the injury is clean without signs of infection, conservative wound management is appropriate:

• Clean the area gently with saline or water to remove any debris from the stair injury 3
• Apply a simple non-adherent dressing to protect the exposed nail bed 3
• The wound should be kept clean and dry, with dressing changes as needed based on drainage 3
• Avoid topical antimicrobials for this clinically uninfected wound, as they are not advocated for most uninfected wounds 3

Assessment for Potential Complications

Evaluate the injury for features that would require more aggressive intervention:

• Check if there is a subungual hematoma or abscess - if present and painful, partial or total nail avulsion may be required 3
• Monitor for signs of infection over the next 2-7 days: increasing erythema >0.5 cm around the wound, warmth, swelling, purulent discharge, or worsening pain 3
• If the nail plate is significantly loose or causing ongoing trauma to the nail bed, consider complete removal 3

Footwear and Activity Modification

• Advise wearing open-toed or loose-fitting shoes to avoid pressure on the injured toe 3, 1
• Limit standing and walking as much as possible during the initial healing phase 3
• The toe should be elevated when possible to reduce swelling and pain 3

Follow-Up and Work Clearance

• Healing typically occurs within 7-10 days for uncomplicated partial nail avulsions 2
• Reassess in 2-4 days (either in-person or via patient self-report) for signs of infection or worsening symptoms 3
• If signs of infection develop (erythema, warmth, purulent discharge, increasing pain), initiate oral antibiotics with anti-staphylococcal coverage 3
• A medical certificate for work is reasonable given the acute injury and pain, with expected return to normal activities within 1-2 weeks depending on job requirements 1

Red Flags Requiring Urgent Reassessment

• Development of purulent discharge, spreading erythema, or systemic symptoms (fever, chills) 3
• Severe, uncontrolled pain despite analgesics 3
• Signs of deep tissue involvement or abscess formation 3
• Patients with diabetes, peripheral vascular disease, or immunocompromise require closer monitoring and lower threshold for intervention 3

Common Pitfalls to Avoid

• Do not routinely prescribe prophylactic antibiotics for clean, non-infected nail injuries, as this is not indicated and may promote resistance 3
• Avoid aggressive debridement of the remaining nail unless it is clearly non-viable or causing ongoing trauma 3
• Do not delay proper pain management - inadequate analgesia is a common oversight in minor trauma 1