In a 76-year-old man three days after a grinder injury with a red, throbbing distal phalanx and several subcutaneous pus collections, is treatment with oral amoxicillin-clavulanate and scheduling hand‑surgeon review the next day sufficient?

Immediate Surgical Drainage is Required—Oral Antibiotics Alone Are Inadequate

Your current management is insufficient and places this patient at risk for serious complications including osteomyelitis, septic arthritis, and potential digit loss. The presence of multiple loculated pus collections in the distal phalanx requires urgent surgical drainage, not just antibiotics and next-day referral 1.

Why This Requires Immediate Intervention

Hand wounds with purulent collections are surgical emergencies that demand same-day drainage. 1

• Loculated pus collections will not resolve with antibiotics alone—the most important therapy for any soft tissue infection with purulent material is to evacuate the infected material through incision and drainage 1
• Hand infections are particularly serious because the confined anatomical spaces can lead to rapid progression to deeper structures including tendons, joints, and bone 1
• Pain in the distal phalanx near bone should raise concern for periosteal penetration, which can progress to osteomyelitis requiring 4-6 weeks of therapy 1

Critical Actions Needed Today

This patient requires surgical consultation and drainage within hours, not tomorrow. 1

Immediate Steps:

• Contact the hand surgeon urgently for same-day evaluation and drainage rather than waiting until tomorrow 1
• The infected wound should be opened to evacuate all purulent material—this is the cornerstone of treatment 1
• Do not delay surgical intervention while waiting for antibiotics to work, as this increases risk of complications 1

Antibiotic Management:

• Amoxicillin-clavulanate is an appropriate empiric choice for traumatic wound infections, as it covers both aerobic and anaerobic organisms commonly found in contaminated wounds 1, 2
• However, antibiotics are adjunctive to surgical drainage, not a substitute for it 1
• Consider IV antibiotics if the patient develops systemic signs (temperature >38.5°C, heart rate >110 bpm, or erythema extending >5 cm beyond the wound) 1

Key Complications to Prevent

Delayed drainage significantly increases the risk of:

• Septic arthritis of the distal interphalangeal joint (requiring 3-4 weeks of antibiotics) 1
• Osteomyelitis of the distal phalanx (requiring 4-6 weeks of antibiotics and potentially bone debridement) 1
• Flexor tenosynovitis (a surgical emergency requiring immediate drainage) 1
• Compartment syndrome of the digit leading to tissue necrosis 1

Common Pitfalls to Avoid

• Do not assume oral antibiotics will sterilize loculated pus—purulent collections require physical drainage 1
• Do not wait for "demarcation" in an evolving infection with systemic signs—this is appropriate only for dry gangrene or nonsevere infections 1
• Do not underestimate hand infections in elderly patients—the 76-year-old age increases risk for poor outcomes 1
• Ensure tetanus prophylaxis is current given the traumatic mechanism 1

Wound Closure Considerations

The original sutures may need to be removed. 1

• Infected wounds should not remain closed—they require drainage and healing by secondary intention 1
• The guideline explicitly states that infected wounds should not be closed and that early suturing (<8 hours after injury) is controversial 1
• If infection has developed despite closure, the wound must be opened to allow drainage 1