From the Guidelines
Preoperative antibiotics are strongly recommended for a nail gun injury to the foot, with cefazolin or clindamycin being the preferred choices, as stated in the 2023 AAOS clinical practice guideline summary 1. The use of antibiotics in this context is crucial due to the high risk of infection associated with contaminated wounds.
- The preferred antibiotic regimen is a first-generation cephalosporin such as cefazolin (1-2g IV for adults) administered within 60 minutes before surgical debridement.
- For patients with beta-lactam allergies, clindamycin (600-900mg IV) is an appropriate alternative, as recommended in the guideline 1. The antibiotic coverage should be continued postoperatively for 24-48 hours depending on the extent of contamination, tissue damage, and presence of any retained foreign bodies.
- Tetanus prophylaxis should also be administered if the patient's immunization status is not up to date, although this is not explicitly mentioned in the provided guideline 1. Additionally, thorough surgical debridement of devitalized tissue and removal of any foreign material are essential components of treatment alongside antibiotic therapy to prevent infection in these puncture wounds, as implied by the guideline's discussion on initial wound management and prevention of surgical site infection 1.
From the Research
Nail Gun Injuries and Preoperative Antibiotics
- Nail gun injuries can result in deep penetrating wounds, often contaminated with foreign particles, which may increase the risk of infection 2.
- The use of preoperative antibiotics in patients with nail gun injuries is a common practice to prevent infection, especially in cases where there is a high suspicion of wound contamination 3, 2.
- A study of 88 nail gun injuries to the extremities found that infections were relatively rare, but were more likely to occur in patients who presented later than the day of injury 3.
- The majority of nail gun injuries can be treated with simple emergency room removal of the nail, local debridement, and a short course of antibiotics, unless there is intra-articular or neurovascular involvement 3.
Choice of Antibiotic
- The choice of antibiotic for preoperative prophylaxis in patients with nail gun injuries is important, especially in patients with penicillin allergies 4.
- Cefazolin is a commonly used antibiotic for surgical prophylaxis, but its use in penicillin-allergic patients is controversial 4.
- A study found that the use of cefazolin in penicillin-allergic patients was safe and did not increase the risk of adverse events 4.
Treatment of Nail Gun Injuries
- The treatment of nail gun injuries typically involves removal of the nail, debridement, and irrigation of the wound 3, 5, 6.
- In some cases, surgical exploration may be necessary to assess for tendon, nerve, or joint involvement 6.
- A study of 55 cases of nail gun injuries to the hand found that 25% of cases had tendon, nerve, or joint involvement at operation, but none of the injuries required more than meticulous wound toilet 6.