After trauma, does a swollen, bruised hallux with a fluctuating mass require drainage?

Management of Post-Traumatic Swollen and Bruised Big Toe

A swollen, bruised big toe with a fluctuating mass after trauma requires drainage if it represents a true abscess or hematoma causing significant pressure, but most post-traumatic toe swelling does not require drainage and should be managed conservatively with imaging to rule out fracture.

Initial Assessment and Diagnosis

The key distinction is whether the "fluctuating mass" represents:

• A simple hematoma or contusion (most common)
• A true abscess requiring drainage
• An underlying fracture with soft tissue swelling

Physical examination should specifically assess for:

• Fluctuance indicating fluid collection versus diffuse edema 1
• Signs of infection (warmth, erythema, systemic symptoms) 1
• Point tenderness over bone suggesting fracture 2, 3
• Range of motion limitation at the metatarsophalangeal joint 2, 3

Obtain radiographs of the hallux to exclude:

• Phalangeal fractures 2, 3
• Sesamoid fractures 2, 3
• Joint dislocation 3

When Drainage IS Indicated

Incision and drainage should be performed if:

• A true abscess is present with fluctuance, erythema, and signs of infection 1, 4
• A tense hematoma is causing significant pressure and pain that limits function 4
• There is concern for compartment syndrome (rare in toes but possible) 4

For simple superficial abscesses:

• Drainage alone is usually sufficient without antibiotics 1
• Antibiotics are only needed if systemic inflammatory response criteria are present, signs of organ dysfunction, or the patient is immunocompromised 1

When Drainage IS NOT Indicated

Most post-traumatic toe swelling and bruising does NOT require drainage:

• Simple contusions with ecchymosis heal spontaneously 2, 3
• Subungual hematomas may require nail trephination rather than soft tissue drainage 2
• Diffuse soft tissue edema without a discrete fluid collection should not be incised 4

Conservative Management Algorithm

For uncomplicated post-traumatic swelling without abscess:

• Rest, ice, compression, elevation (RICE protocol) 3
• Buddy taping if stable fracture or soft tissue injury 2, 3
• Weight-bearing as tolerated with supportive footwear 3
• NSAIDs for pain control 3
• Follow-up in 5-7 days to reassess 2, 3

Critical Pitfalls to Avoid

Do not drain simple post-traumatic edema or ecchymosis:

• Unnecessary incision increases infection risk 4
• Staphylococcus aureus accounts for less than half of cutaneous abscesses; anaerobes are common in the foot 4
• Incision without true abscess can damage adjacent structures including neurovascular bundles 4

Do not miss underlying fractures:

• Hallux fractures represent nearly 10% of fracture clinic presentations 2
• Turf toe (plantar plate injury) can cause long-term dysfunction if missed 2, 3
• Sesamoid fractures require specific management and may need non-weight-bearing 2, 3

Red flags requiring urgent intervention:

• Signs of necrotizing infection (rapidly spreading erythema, crepitus, systemic toxicity) 1
• Vascular compromise 4
• Open fracture 2