Board Review: Trauma/Orthopedics
50 year old male presenting to the ER with right second and third finger amputation after a table saw accident. Patient has a past medical history of HTN and DVT (on Xarelto). Vital signs are as follows: HR 120 bpm, BP 140/90, Temp 36 C, SpO2 99% on room air. On exam, the patient has an avulsion of the distal tip of the right second finger. The third digit has an obvious deformity proximal to PIP. Radial pulses 2+ bilaterally. Mild amount of bleeding from both fingers noted. IV is obtained and pain medication is given. Portable x-ray demonstrates:
What is the most appropriate choice of antibiotic for this patient?
A. Vancomycin and Cefepime
D. Vancomycin, Cefepime, and Clindamycin
Answer: C. Cefazolin
Patients with simple fingertip avulsions that do not include the bone can be repaired bedside in the ED with absorbable sutures. See the link below for further information on fingertip and nail bed injuries. Indications for emergent surgical consultation include fractures, exposed bone, complex dislocation, and obvious infections. In this case, orthopedic surgery was consulted and came to the bedside. Ultimately, the patient was taken level 1 to the OR for revision amputation. Important things to consider when acutely managing these patients include pain control and antibiotics. Pain control can be achieved with IV opiates; however, digital blocks are very effective as well using lidocaine. Occasionally the surgical team may request not performing the digital block until they are at bedside if they would like to perform a more comprehensive sensory exam. In regards to antibiotics, these injuries are considered open fractures and need to be treated with cefazolin IV. Replantation is more successful in pediatric patients although, occasionally attempted in adults. They require extensive physical therapy to improve motor and neurologic function. Stiffness is a very common side effect of these procedures. Patients typically have faster recovery with revision amputations and less complications, thus this is most commonly the intervention of choice.
Nail Basics- https://emdaily.cooperhealth.org/content/nail-basics
Russell, R. C., & Casas, L. A. (1989). Management of fingertip injuries. Clinics in plastic surgery, 16(3), 405–425.
Sindhu, K., DeFroda, S. F., Harris, A. P., & Gil, J. A. (2017). Management of partial fingertip amputation in adults: Operative and non operative treatment. Injury, 48(12), 2643–2649. https://doi.org/10.1016/j.injury.2017.10.042