What is the appropriate management for a patient with a stubbed right great toe, presenting with an ingrown toenail, a small superficial laceration, bruising, and no signs of infection?

Management of Stubbed Great Toe with Ingrown Toenail and Superficial Laceration

For this patient with a stubbed great toe, ingrown toenail, small superficial laceration, bruising, and no signs of infection, proceed with X-rays to rule out fracture, initiate warm saltwater soaks, and provide conservative wound care without antibiotics, as there are no clinical signs of infection requiring antimicrobial therapy.

Immediate Assessment and Imaging

• Obtain plain radiographs (three views) of the affected toe to evaluate for fracture, as you have appropriately planned, given the trauma history and bruising 1.
• This is essential to rule out bony injury that could complicate management and healing.

Wound and Infection Assessment

The absence of infection is key to your management approach. The patient lacks clinical signs of infection, which would require at least two of the following: erythema >0.5 cm around the wound, local swelling/induration, warmth, tenderness/pain, or purulent discharge 1.

• Since no signs of infection are present, antibiotics are not indicated 1.
• The superficial laceration should be cleansed and assessed for depth and any foreign material 1.

Conservative Management of Ingrown Toenail

Warm saltwater soaks are appropriate initial therapy for the ingrown toenail component 2, 3, 4.

• Recommend soaking the foot in warm, soapy water or Epsom salt solution 2-3 times daily 2, 3, 4.
• This helps reduce inflammation and softens the nail fold tissue 3.

Additional Conservative Measures

• Consider placing cotton wisps or dental floss under the ingrown nail edge to lift it away from the lateral nail fold and provide immediate relief 3, 4.
• Gutter splinting can be applied to separate the ingrown edge from the lateral fold for pain relief 3, 4.
• Correct any contributing factors: ensure proper footwear (avoid tight shoes), address hyperhidrosis if present, and educate on proper nail trimming technique 3, 4.

Wound Care for the Laceration

Appropriate wound dressing should be based on the wound characteristics 1.

• For this small superficial laceration, use a simple dressing that maintains moisture 1.
• Continuously moistened saline gauze or hydrogel would be appropriate if the wound appears dry 1.
• Do not use topical antimicrobials for this clinically uninfected wound 1.

Follow-Up and Escalation Criteria

Reassess the patient in 2-4 days, or sooner if symptoms worsen 1.

Watch for signs requiring escalation:

• Development of infection signs: increasing erythema, warmth, purulent drainage, or systemic symptoms 1.
• Failure to improve with conservative measures within 3-5 days 2, 3.
• Worsening pain or inability to bear weight after fracture is ruled out.

If Conservative Treatment Fails

Surgical intervention may be necessary if inflammation and pain do not resolve rapidly 2, 3, 4.

• Partial nail avulsion with phenol matricectomy is the most effective surgical approach for preventing recurrence of ingrown toenails 3, 4.
• This is superior to nonsurgical approaches for preventing recurrence but should be reserved for moderate to severe cases or those failing conservative therapy 3, 4.

Key Pitfalls to Avoid

• Do not prescribe antibiotics without clinical signs of infection, as the mere presence of a wound does not indicate infection 1.
• Do not perform immediate surgical intervention for the ingrown toenail in the absence of severe infection or abscess; conservative measures should be attempted first 3, 4.
• Ensure proper offloading of the affected toe to prevent further trauma during healing.
• Do not ignore the possibility of underlying fracture—the X-rays you ordered are essential before determining weight-bearing status.