What is the appropriate technique for removing a splinter and managing infection risk, including antiseptic care, tetanus prophylaxis, and indications for antibiotics or referral?

Splinter Removal and Wound Management

Removal Technique

For superficial splinters, expose the entire length by incising the skin along the long axis of the splinter, then lift it out with forceps under direct visualization. 1

Basic Removal Approach by Splinter Type

• Superficial horizontal splinters: Make an incision over the entire length of the splinter along its long axis, then grasp and remove with forceps 1
• Subungual splinters: Cut a V-shaped wedge from the nail with the point at the proximal tip of the splinter, grasp the exposed end, and remove carefully without pushing it deeper into the nail bed 1
• Deep or elusive splinters: Consider imaging (ultrasound using waterbath technique) for precise localization before attempted removal 2

When to Refer

• Refer immediately for splinters located near nerves, tendons, blood vessels, or vital organs 1
• Refer when the splinter cannot be adequately visualized or localized despite imaging 1

Wound Cleansing and Antiseptic Care

Cleanse the wound with sterile normal saline only—iodine or antibiotic-containing solutions are unnecessary and not recommended. 3

• Remove superficial debris during cleansing, but avoid aggressive deep debridement that could enlarge the wound or impair closure 3
• Clean technique (rather than sterile technique) for dressing application does not increase infection rates and is clinically acceptable 4

Tetanus Prophylaxis

Administer tetanus toxoid (0.5 mL intramuscularly) if the patient's immunization is outdated or status is unknown. 3

Critical Timing Consideration

• For patients with high-risk wounds (contaminated, deep puncture wounds from soil exposure), tetanus toxoid should be given if the last booster was more than 5 years ago 5
• For clean minor wounds, tetanus toxoid is indicated if the last booster was more than 10 years ago 5
• Common pitfall: A 79-year-old woman developed generalized tetanus after a contaminated agricultural wound because she did not receive tetanus prophylaxis despite her last booster being 7 years prior—this represents a failure to recognize the 5-year threshold for high-risk wounds 5

Clinical Context

• Tetanus follows anaerobic wound infection, typically with 3 days to 3 weeks incubation period 6
• The majority of cases (75%) present initially with trismus (lockjaw), and 70% develop reflex spasms that characterize disease severity 6

Antibiotic Prophylaxis

Routine prophylactic antibiotics are NOT indicated for simple splinter removal in immunocompetent patients with clean wounds. 3

When Antibiotics ARE Indicated

• Infected wounds at presentation: Start empiric antibiotics targeting skin flora (Staphylococcus and Streptococcus species) 3
• Contaminated wounds with retained organic material (wood, thorns, vegetative matter): These should be removed immediately before inflammation or infection develops, but prophylactic antibiotics may be considered 1
• Immunocompromised patients: Consider prophylaxis even for minor wounds 3

Specific High-Risk Scenarios Requiring Antibiotics

• Animal bite-related splinters or contamination: Use amoxicillin-clavulanate (covers Pasteurella multocida and anaerobes) or, if penicillin-allergic, a fluoroquinolone plus metronidazole 3
• Post-splenectomy or asplenic patients with any animal bite or contaminated wound: Mandatory 5-day course of co-amoxiclav (or erythromycin if allergic) due to susceptibility to Capnocytophaga canimorsus 3

Wound Closure Decisions

Do not close infected wounds—leave them open for healing by secondary intention. 3

• For clean wounds seen within 8 hours of injury, primary closure is controversial; approximation with Steri-Strips followed by delayed primary or secondary closure is prudent 3
• Facial wounds are an exception and may be closed primarily by a plastic surgeon after meticulous wound care, copious irrigation, and prophylactic antibiotics 3

Follow-Up and Monitoring

Arrange follow-up within 24 hours (by phone or office visit) to assess for signs of infection. 3

Red Flags Requiring Immediate Re-evaluation

• Pain disproportionate to injury severity, especially near bones or joints (suggests periosteal penetration, osteomyelitis, or septic arthritis) 3
• Progressive erythema, warmth, swelling, or purulent drainage 3
• Fever or systemic symptoms 3
• Hand wounds require particularly close monitoring as they are more prone to serious complications than wounds in fleshy areas 3

Management of Established Infection

• If infection develops despite appropriate initial care, consider hospitalization 3
• Infectious complications requiring prolonged therapy include septic arthritis (3-4 weeks), osteomyelitis (4-6 weeks), and subcutaneous abscess 3

Key Pitfalls to Avoid

• Do not attempt removal of deep splinters near neurovascular structures in the office setting—refer these cases 1
• Do not push subungual splinters deeper while attempting removal 1
• Do not forget tetanus prophylaxis, particularly the 5-year rule for contaminated wounds 5
• Do not use iodine or antibiotic solutions for wound cleansing—sterile saline is sufficient and preferred 3
• Do not rely on prophylactic antibiotics alone for retained organic foreign bodies—removal is essential 1