Management of Tip Amputations: A Case for Reduced Prophylactic Antibiotics

Hypothesis

Despite the general acceptance of management practices for tip amputations including debridement, cleansing, and local wound care, there is limited evidence regarding the specific treatment of tip amputations, including duration or type of antibiotic regimen. We predict that there is little indication for prolonged antibiotics in tip amputations, including the prevention of potential infection or revision amputations.

 

Methods

We performed a retrospective chart review of 106 patients seen by the plastic surgery hand service in a single level A trauma center between 2011 to 2016. Inclusion criteria included any fingertip amputation at the distal interphalangeal joint or beyond without any attempt at revascularization. Exclusion criteria included any bite wound. Charts were subsequently evaluated for phalynx injured, mechanism, history of smoking or diabetes, antibiotic duration, and intervention in the emergency department, with the primary outcome being infection or revision amputation.

 

Results

Demographics-wise, 84/106 (79.2%) patients were male and 22/106 (21.8%) were female. 9/106 (8.5%) had diabetes. In regards to smoking history, 73/106 (68.9%) patients were never smokers, 26/106 (25.5%) were current smokers, and 7/106 (6.6%) were former smokers. Among the 106 patients, 36 (33.9%) had a tip amputation of the MF, 28 (26.4%) of the IF, 24 (22.6%) of the RF, 17 (16.0%) of the SF, and 14 (13.2%) of the thumb. 11/106 (10.4%) of patients had multiple simultaneous tip amputations. 45/106 (42.5%) patients had tip amputations involving the dominant hand, 46/106 (43.4%) the non-dominant hand, and 15/106 (14.2%) patients either had dominance not established or not documented in their chart. 60/106 (56.6%) patients had a crush injury while 46/106 (43.4%) had a sharp injury.

Of the 106 patients, 89 (84.0%) received antibiotic treatment in the ED and 93 (87.7%) were discharged on antibiotics. Of the 93 patients discharged on antibiotics, 85 were given Keflex, 4 were given Augmentin, 2 were given Bactrim, 1 received Duricef, and 1 received Clindamycin. The average duration of antibiotics was 7.0 ± 2.3 days, ranging from 3 to 14 days. 2/106 (1.9%) patients developed a subsequent infection, most severely a superficial cellulitis. 1/2 (50.0%) of those patients who developed infections only did so after operative management of the initial injury. 10/106 (9.4%) patients required operative management after the initial injury of which 5/10 (50.0%) had revision amputations. Univariate logistic regression demonstrated that the duration of antibiotics had no significant effect on the development of infection (p= 0.521) as well as no significant effect on the need for a revision amputation (p=0.902).

 

Summary Points

There is limited evidence surrounding the treatment of tip amputations of the phalanges, particularly regarding prophylactic antibiotic use. Adverse effects related to prophylactic antibiotic use include enhanced resistance patterns, hypersensitivity or anaphylactic reactions, and clostridium difficile infection. This retrospective review demonstrates that bedside management of the tip amputations including irrigation and debridement, repair, and initial revision/completion amputations can be performed safely, and that a prolonged course of antibiotics is unnecessary.

Abbreviations: IF-index finger; MF - middle finger, RF- ring finger, SF - small finger